Hospital and health-system pharmacy continues to evolve and expand its perspective in managing the drug therapy of the patients we serve. We started by placing all our resources in developing and implementing unit dose and IV admixture systems to serve our inpatients. Later, many of us added or expanded our ambulatory services to serve our employees, discharge patients and clinic patients. Disproportionate-share drug pricing for outpatients gave us the incentive to expand these programs. Some health-systems expanded their service to their communities by operating retail pharmacies, either through contracts with retail pharmacy operators or by establishing their own pharmacies. Now the third wave of pharmacy service development is upon us, namely the development of ambulatory injectable services. Such programs require our best clinical and administrative knowledge and skills.

As the articles in this issue convincingly illustrate, there is much more to managing ambulatory injectable drugs than reconstituting a vial of a drug. Our challenges include:

1. Making every effort to assure our patients that we can provide ambulatory injectable drugs in an error-free environment. The drug must be the right one for the patient; the dose must be correct and adjusted for clinical parameters, if they apply; preparation, distribution and administration also must be proper. This is complicated by the fact that the source of some of these drugs may be specialty pharmacies, thus reducing our control in their distribution. Whether we provide the drug or not, concern for counterfeit supplies of these drugs entering our hospitals is real. Such drugs are targets for illicit providers because of their high costs. We must be forever vigilant in this regard.
2. Improving our cost management effectiveness. Costs can be controlled if we purchase the drug under group purchasing organization (GPO) contracts, if applicable, or under 340 B pricing, if we qualify. Waste should be minimized by proper admixture and storage. Because some of these drugs are administered according to clinical parameters, careful management of ambulatory drug therapy is important. Otherwise, we will be mixing drugs that will not be administered to patients. Pharmaceutical company indigent programs and drug waste replacement can be effective ways to manage costs.
3. Increasing revenue. This is a particular conundrum. Inpatient drug revenue is controlled by reimbursement by case or per diem. Traditional outpatient prescription reimbursement is either with cash paid by the patient or by online adjudication. With ambulatory injectable drugs, reimbursement seems more designed to not pay hospitals for therapy provided than to pay hospitals. Revenue cycle management is new to our lexicon. Yet, if we do not aggressively master this subject, we risk leaving millions of dollars on the table in the form of billing problems or the famous "rejects." We must be the institutional experts in this area and not leave this to the billing department, which typically is unskilled in ambulatory drug billing and reimbursement. We must be constant learners in this area and monitor various web sites (see other articles for web site addresses) and other sources that can help us manage these turbulent waters. We must be ready to develop a pro-forma in this area to demonstrate to the hospital's senior management and trustees that we can be entrepreneurial and contribute to our hospital's fragile bottom line. We can be invaluable in working with physicians in supporting them and their patients. Since many of these patients have chronic diseases and can be devoted to our institutions, they can take advantage of our ambulatory and inpatient services to our mutual benefit.

As health-system pharmacists, we need to extend our responsibility for patients' drug therapy across the continuum of care and actively manage the chronic and acute care drugs given by ambulatory infusion. This will require the application of both clinical and administrative skills. Clearly, we are well equipped to manage this patient and institutional need.