So yet again, another set of cases reported of contaminated food products leading to food-borne illness.

http://www.cnn.com/2010/HEALTH/05/13/lettuce.recall/index.html?hpt=Sbin

Now it is lettuce. Last time it was spinach, jalapenos, and tomatoes. When will the country realize that this large scale corporate agribusiness, while providing wildly inexpensive food in massive quantities may be causing harm to our population’s health?

We know very well that large populations in small quarters are at higher risk of disease spread (nursing homes, prisons, day cares, etc.). So it should not be surprising that these large “cattle farms”, for lack of a better term, are potential hotbeds for disease. I think it is time for consumers to fight back for a safe food supply and for the rights of small farmers.

I think it is time for me to start eating more organic and locally grown food and I encourage others to join me!

(Check out the movie “Food Inc.” for quite a shocking expose on the american food production industry.)

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Like countless other health professions students and medical personnel, I have at prior time taken a trip down to Latin America to help provide medical care to a patient population with under-served health needs.

As spring turns into summer, and more medical personnel make their pilgrimage to provide service, it gives me opportunity to reflect on the system this all takes place within.

My first issue is with mission trips whose primary goal is something other than providing health care. This specifically refers to religious mission trips. Now, I have no problem with religion, unless taken to the extreme, it is a great help to a great number of people. However, I believe the right to be healthy belongs to all people regardless of religion. I fundamentally disagree with using medicine as a way to sell ones beliefs or to convert a culture to your belief system. Simply put, medical care should be provided because health is a basic human right. It should not be used as a tool, or a hook, for some other purpose.

However, thinking back on my own experience, provides an even more general outlook on the whole system.

When i went on my mission trip, yes, we provided a good deal of medications. We diagnosed and treated some infections, some diarrhea, and yes, even some infectious diarrhea.

However …
When I returned home, I could not help but think: “What happens the next time these patients get an infection? Or diarrhea?” What happens if the business of importing volunteers drys up?

The communities I visited were completely dependent on international volunteers for health care. The local health care system was anemic. If that stream of volunteers was interrupted, the area’s health would suffer.

Yes, these trips are a tremendous way to train students as, for better or for worse, many times they are free from many of the regulations, burdens, and expectations of healthcare in the developed world.
But … have we really improved these people’s health care in any meaningful, lasting way?

What I suggest is we change the lens through which we view the goal of medical mission trips. Let us model them more-so like the peace corps. Instead of setting goals to measure it by as teaching experience and treating “X” number of illnesses. Let us judge the effects by how much of a lasting impact was made in the communities that we visit.

Why not clean up the water supply so that less people get diarrhea and infections to begin with?

Why not teach local health workers how to diagnose and treat common ailments?

Why not help create clinic spaces and create a medical infrastructure from which to build on?

Why not create a medication distribution system that can get people medicines that they need and train people within each community to educate people on the use of these common medications?

I think if we start to view some of these activities from a more global perspective, we can see how some of the activities we support as a developed country, may not be what those who are still struggling to develop really, truly need.

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What happened in our society to doing something simply because it is the right thing to do to improve the quality of people’s lives in our community?

We are clawing our way out of this large financial crisis because corporate greed led big business to ignore what was the responsible approach to lending.

We have had millions of people that are uninsured and millions more that are suffering being under-insured in healthcare in our society for decades. The rest of the world saw it as being in society’s best interest to make sure that affordable health care was available to all citizens so that they could live happy, healthy, productive lives. Why then has it taken us as a society to even make a step in the direction of what is in society’s best interest?

Gone are the days where we had politicians that we could look up to that made the right decisions not because it was good for their political career, but because it was the right thing to do. Teddy Roosevelt breaking up the trusts, FDR taking us to war to fight a sweeping wave of injustice, and those who followed, the creation of social security and Medicare.

Today, however, public policy is determined by what lobby’s can get them the most votes or can contribute the most campaign contributions.

As pharmacists I believe that we need to lobby our own employers, especially those who work for the large pharmacy corporate giants, to change focus from product distribution to clinical disease management services. We need to lobby for marketing based on the quality of our medication knowledge and management skills rather than the distribution convenience and efficiency. If we do not undertake this challenge, our profession could be in jeopardy …

I am not sure what the answer is. I hope this blog and others like it can, in some small way, help to mobilize a grass roots effort to stimulate people to think of the larger picture. Think of not what is best for one’s current interests, but what one sees as in the best long-term interest for the future of our community.

A man named John Kennedy once said: “Ask not what your country can do for you, but what you can do for your country”.  Maybe … Just maybe … if we focus on our community first, that effort may yield a better environment for our future that could pay us back ten-fold.

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So there was some interesting breaking news this week from the American Medical Association (AMA) who seemingly has deemed it within their purview to define and describe the scope of practice for every other health professional group.

The reference and details of this story can be found at the ACCP website:

http://www.accp.com/announcements/amaresponse.aspx

This month was pharmacy’s turn to have its own scope of practice determined by the professional association for another profession …

Why does the AMA feel that it can determine what the role of every other health profession is? The American Pharmacist’s Association does not define the scope of practice of physicians, nurses, respiratory therapists, and so on … Though those in the AMA, whom most (if not all) have never practiced or studied pharmacy, feel that they have the authority to define the entirety and boundaries of what pharmacists are qualified to do.

Not only have they defined for us what our role is, they do not make that definition available to us. They define the roles of every health profession but only make those documents available to AMA members.

I am thankful we have our  pharmacy organizations to send corrected facts to them regarding the practice of our profession.

But … this does provide opportunity to examine how some in the medical establishment view pharmacists:

1. The response letter suggests that the original document suggests that pharmacy involvement in medication management services is simply to compensate for the increasing utilization of technology and automation in the dispensing process. (1) As health care professionals, are not pharmacists creating medication management services to help patients live healthier and longer?

2. The recommendation document further states the below statement is mentioned by the AMA:

“To protect patients’ health and safety, physicians considering entering into CPAs with pharmacists should assess whether the education, training, and expertise of a pharmacist adequately equips him or her to initiate, monitor, and/or modify
therapeutic regimens prescribed by physicians,” (2)
Pharmacists get much more training, education, and practice with therapeutic, pharmacologic regimens than do most physicians. This sounds like a warning to physicians to avoid collaborating with pharmacists and utilizing pharmacists in a team-based approach to care. There is a wealth of research showing the pharmacists are more than capable of assisting in the modification of therapeutic regimens for chronic diseases. These modifications almost universally show a significant benefit to patients from this team-based approach to medical care. And I can provide citations to those who would like :).
3. The recommendation document also states the following is stated:
“To provide comprehensive CDTM [comprehensive drug therapy management], the pharmacist must secure the consent of all the physicians who prescribe medications for the patient,” (2)
Is not drug therapy the specialty of pharmacists? Do we need to seek permission from all other providers for a patient before educating patients about their medication therapy? Or before proactively seeking ways to optimize a patient’s therapy?
Granted, we are not able to see the original document, thus all of these impressions are garnered from pharmacy’s response to it. But it shows a disturbing tone. Why can we not continue moving towards team-based care utilizing each profession’s strengths? Why is medication therapy management seen as a threat rather than a benefit to society?

Let me know what you think!
References:
2.

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So, after a short sabbatical from writing, it is time once again to think about the tough issues facing advancing our profession.

Today, somehow, I began thinking about medical information release forms. I know, not very stimulating thoughts!

But wait …

Why, when we are providing medication services to patients (comprehensive medication reviews, diabetes management services, hypertension management services) to help them live longer and healthier and with less medication related complications, do we need to specifically obtain permission to access information that would help us take better care of our patients?

When I work in a hospital setting, it is the standard of care for other hospitals, clinics, or pharmacies to graciously share relevant medical information to assist in caring for the patient.

When I work in community pharmacies, we graciously provide medication use information to physicians without any extra hassle to help them take better care of our patients.

Yet, when as pharmacists we request information for use in our patient care services, oftentimes, other healthcare practitioners refuse to provide that information or demand obtaining consent for each piece of information.

Under HIPPA, it is not a disclosure of protected health information to provide medically necessary information to another healthcare provider involved in the care of the patient.

So why then are we treated differently as pharmacists?

Are we viewed as health care providers? How can we change our image?

When setting up new cognitive pharmacy services, should we be practical and take this image into account, or stick to the principle that we are healthcare providers and design our services around the bi-directional sharing of information?

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So one thing I have come to realize in my short time so far in pharmacy is that as a whole, we are terrible marketers. Now I am not saying that I am any better, but at least I think I am aware enough to realize it may be a problem. There has been quite a few times when co-workers have told me “That is a great ideal, but this is the real world” or “You need to consider that patients don’t expect that from you” and a whole set of variants on that theme.

A true marketer would never just accept clients’ expectations and give up on a product/service. Their whole job is to create a strategy with which to change clients’ expectations so they desire that product/service.

We need to learn from them as a profession. No one is just going to accept that we know how to manage chronic diseases. No one is just going to accept that we can help patients quit using tobacco, or educate them fully on their medications, or properly manage the progress of treatment. So we have two choices: (1) Give up, (2) Attempt to change expectations so that patients believe and desire us to fulfill those roles.

How best can we market our services beyond our product dispensing functions?

I think we need to get pharmacists more active in community events, senior centers, etc to get the word out of new services we are creating. We need to find physician champions to show the public that we work WITH the rest of the medical team. We need our professional organizations to undertake more aggressive mass media campaigns such as  nursing has done. We need the large corporate players in the pharmacy market to begin to place value on knowledge-based pharmacy services. And lastly, we need all of our pharmacy providers to start seeing themselves as health-care providers rather than subservient to the rest of the medical team.

How do you think we can best market our profession and change patient expectations?

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I hope everyone had a great holiday season and has gotten back safely from all of their trips this season.

So this holiday season I was out of the country for several weeks and while I was there I, unfortunately, had the opportunity to experience some of their medical system first-hand. The first thing that struck me when I entered this pharmacy in Asia was that, “Hey, this looks like a health-care environment!”. Where were the sodas? Where were the salty snacks? Where were the gifts, the trinkets, the candies, the photo section, the cosmetic section? What was this pharmacy? It was a counter with a pharmacist preparing medicines behind it and a few limited OTC medications near the waiting area out front.

Do I think this was a perfect pharmacy environment? No, it was a little small. This lead to minimal privacy at the counter. A sit down desk might be better than a retail-ish looking counter. However, it would be a large environmental improvement to many of the pharmacies we are seeing here now which tend to look more like a convenience store than a health-care provider office.

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So the holiday season is upon us.
(Happy Holidays to everyone by the way!)

And like every holiday season, much of it revolves around retailing. Pharmacies are not just pharmacies anymore. Pharmacies have become grocery stores, antique shops, greeting card shops, candy stores, clothing stores, and a place to by a whole variety of knick-knacks.

What message does it say about pharmacy if the smallest part of the store is the actual pharmacy?

In my opinion pharmacies should be purely places to purchase healthcare related items as well as healthcare services. I think sometimes we focus so much on the front end that we don’t have any more resources or energy to focus on developing pharmacy services which could both enhance the business as well as benefiting patients and the profession.

Have pharmacies become too ‘retail’?
Should we scale back more to an apothecary model of the past?

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So pretty much every pharmacy I have been at refers to its “clients” as customers. Any signage or promotional materials lists them as customers. Rarely do pharmacy personnel seem to see those we serve as patients.

cus·tom·er (kŭs’tə-mər) n.
1. One that buys goods or services

customer. (n.d.). The American Heritage® Dictionary of the English Language, Fourth Edition. Retrieved December 08, 2009, from Dictionary.com website: http://dictionary.reference.com/browse/customer

Patient (pā’shənt) n.

1. One who receives medical attention, care, or treatment.

patient. (n.d.). The American Heritage® Dictionary of the English Language, Fourth Edition. Retrieved December 08, 2009, from Dictionary.com website: http://dictionary.reference.com/browse/patient

So are we providing medical attention or care to our clients? Or are we simply selling them goods and services. Are we medical professionals or are we vendors peddling goods?

Despite what some other pharmacy blogs might lead you to believe, patients are not stupid. If the environment tells them they are a customer and if the staff believes they are and treats them as a customer, they will begin to play the role of a customer. Along with that role comes set expectations for nothing beyond a transaction of currency for goods and the expectation of convenience and speed that goes along with that schema.

Our profession must change if it is to survive. Gone are the days when pharmacies can survive off of the profit margins on prescription drug reimbursements alone. However, before the profession can change, we need to change patient expectations. And before patient expectations will change for pharmacists, pharmacists’ own expectations of themselves must change. We must view patients as patients and combat the image that they are simply customers involved in a transaction. We must believe that we are providing medical care for a patient over time and then convey that image to our patients. I believe this is the first step in change, and it begins with us. Changing our profession individually may be a challenge, but if as a profession we decide to change this mindset I believe we can begin to see some substantial changes in patient expectations.

Let me know what you think …

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So …, I have been at several different pharmacies so far, all of them having different dispensing software. What is the common thread between them?

1. None of them have a place to record a patient’s tobacco use status:

Pharmacists are in a perfect position to record a patient’s tobacco use status and routinely follow-up with them on it using motivational interviewing skills. What other health care provider sees their patients as regularly as we do? Thats right, no one! However, when I decided I wanted to start making these interventions for patients I ran into a dilemma. I have no where to easily flag someone as a tobacco user. So how am I going to allow pharmacists to follow-up on subsequent visits without annoying the patient by asking them about their status every time?

This is quite a simple fix. The developers of these programs should put one more field in, then that field can be populated upon intake for new patients. In the absence of this happening, how can we pro actively, effectively screen and assist our patients?

2. There is no reliable way to input any documentation. What happens when I discover the patient uses tobacco and I want to note that in the system, also note the patient gets half of their prescriptions from Walmart for $4, uses 3 herbal products, and uses aspirin OTC? Well, lets document it in the notes field of our dispensing software. But wait, I only get 2 lines to document this in. How can I possibly get all of this necessary patient information in a legible manner in 2 lines of text?

Pharmacy computer systems need to advance. I believe there are some pharmacists out there who would expand their roles and provide even better patient care if the technology provided to them were to allow them these functions to make it easier. We should not need to keep extra paper charts, index card systems, or similar method if we have a database already which could be expanded to include the totality of relevant data for patient care.

Will pharmacy dispensing system providers ever realize this need and help pharmacies implement pharmaceutical care by making these changes?

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I hope everyone in the U.S. had a fantastic holiday weekend!

So, last week, in the most recent issue of the Archives of Internal Medicine, there was a new article detailing a study that had been done to look at the benefits of using physician-pharmacist co-management of patients in the management of hypertension in the primary care setting.

Carter BL, Ardery G, Dawson JD, et al. Physician and pharmacist collaboration to improve blood pressure control. Arch Intern Med. 2009;169(21):1996-2002.

In this study they had clinical pharmacists in 6 sites.(1) In three sites, pharmacists were passive and only answered questions for physicians if they arose. In the other three sites, pharmacists provided direct patient care in the form of follow-up appointments with the patient and recommendations for therapy when appropriate.

They found that in the intervention group (pharmacist care), significantly more patients’ blood pressure was controlled 63.9% versus 29.9%.(1) This trend was maintained whether or not you also considered the patients with diabetes. They also found that the group with pharmacists involved in follow-up had significantly decreased systolic blood pressure compared to the control group.

I think this study further reinforces previous studies that pharmacists are very good at managing such conditions as hypertension and other related ailments. This is a role that we can step into. However, I do not see these studies showing the benefit of clinical pharmacists in these settings really gaining much popular attention in the profession, which confuses me. This is exciting stuff!

This shows that a pharmacist participating in patient care in primary care settings can have a significant health benefit for patients. This even provides evidence for me that we could even see some similar effects from enhanced pharmacist follow-up, monitoring, counseling, and recommendations from pharmacists in community pharmacies. There is no reason that this same type of patient care service could not be done collaboratively from a community pharmacy (as evidenced by the Asheville projects).

So why does research of this nature not get as much attention as maybe it deserves?

Does this research open up new roles for pharmacists in patient management?

Can pharmacists do this type of thing in the community pharmacy setting?

Let me know what you think!

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Well, here comes another pre-holiday debate!

So, I have been at a number of pharmacies thus far, as I don’t have a single pharmacy to call my home. But I make sure that I counsel every patient on every prescription, new, refill, OTC, everything. And no matter where I work, I hear patients tell me, “Its just refills”, or “I never have to talk to X pharmacist about my medications”.

But how are we supposed to figure out whether a medication is working appropriately for our patients if we don’t counsel them on refills?

So my question today is:

Is it possible to change patients expectation about counseling and the role of pharmacists (or pharmaceutical care) if not all pharmacists in a practice are sending a consistent message about the importance of consultation and pharmacist monitoring??

I think that if Joe the pharmacist works T/Wed/Th and Joe doesn’t really consult very much because he wants to make the pharmacy more convenient, but he is a very nice guy and patients like him. (After all he doesn’t make them talk). Then Mary the pharmacist works M/F and she consults every patient thoroughly, will the inconsistency in the pharmacy practice make it difficult for Mary to practice utilizing more cognitive skills/services?

There are pockets of pharmacists doing some great things with pharmaceutical care. I also believe there are many out there that desire to, but because of inconsistency between providers in their organization find it much more difficult to get any progress going.

So, is there value in consistency of values within a pharmacy organization?

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So everyone these days seems to be so worried about the H1N1 influenza virus. Now, I know any time a new infectious microbe comes onto the scene that it could be dangerous. But it is on the national news daily, everyone is talking about it around the water cooler at work, and one case in a community causes a panic.

I get it, it is new, its sexy. The new bad guy with all of the gadgets gets the attention.

But …

What about obesity? Obesity kills or leads to the early death of more people in this country in one year than H1N1 will kill in the next 50 years. I received a link to this article through an e-mail list serve this week:
Estimated county-level prevalence of diabetes and obesity

Looking at the graphic: We have states with >30% obesity rates?

And when you look at the states that are doing well, they are ranked 0-26.2%. Is there really much of a difference between 26.2% and 30%?

When I was rotating through the hospital setting, especially when I was working in cardiology, more often than not, the patients were definitely on the heavier side. Now that is just an observation, but the literature definitely does support a link between obesity and metabolic syndrome, diabetes, and heart disease.

When are we as a society going to recognize this as a problem and call for more noticeable and health critical nutritional information labeling on unprepared and prepared foods? When are we going to get sodas, candy, and unhealthy lunches out of schools?

This definitely also links into the recent health care reform topics. What better way to lower costs and utilization in the health care system than to lower one of the primary risk factors for diabetes and heart disease and consequently their long-term complications?

What can the pharmacy profession do to help combat this epidemic?

What are pharmacists currently doing to help improve this situation?

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So, I have always considered pharmacists practitioners and health care providers. However, recently, I hear colleagues speak about “sending a fax to the patient’s health care provider”. I see legislation which defines “practitioner” as a physician, physician’s assistant, or nurse.

Are not we not practicing a profession? We refer to our role as “practicing pharmacy”. So why then do even many in our own ranks not consider ourselves “practitioners”?

I certainly think I am providing health care to patients when I educate them on a new medication and how to help fit it into their lives. I view myself as providing health care to patients when I am checking their blood pressure or assessing how well they are managing their diabetes. And I certainly view myself as providing health care when I am doing a comprehensive medication review, medication reconciliation, or rounding on an inpatient unit. Why then do many in our profession segregate ourselves from the “health care provider” group and term?

I think there are many people in this profession providing health care. Now if truly all a pharmacist is doing is checking to make sure the right product is in the vial and asking “any questions?”, then maybe a few are not providing health care. However, there are many (I would argue most) that are and until we acknowledge ourselves as health care providers we will never be able to expect patients and other providers to see us as one.

We need to start being more confident about talking about the services that we offer our patients. Modesty over whether we are health care providers and practitioners does not help our profession move forward. As a profession we need to first start seeing ourselves collectively as health care providers, then we can move forward with filling out the spectrum of patient care services that will fulfill our role in that area.

I have been told many times that “the real world is different” and that I need to adjust to expectations about the pharmacists role from patients and prescribers. I would argue that if we can see our profession adding more value to the health care system than we currently do, we should try to adjust “the real world” to be more comfortable with higher expectations of us.

So, Do you consider pharmacists health care providers or practitioners?

How can we better fulfill our roles as providers in the health care system? Or are we doing all that we can?

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So these are both two issues that I care very much about. I whole-heartedly believe in the ability of the pharmacy profession to help patients, and I equally believe that our planet has never faced a challenge so large as the global warming challenge that is facing it currently.

So what do these things have in common?

I think all pharmacists should be environmentalists, and here is why. Our over-reliance on fossil fuels is raising our CO2 production higher than at any other time in the earth’s history. This leads, eventually, to all the disastrous effects on our weather, temperature, glaciers, and wildlife populations. Furthermore, we are quickly approaching the point at which we have used up more than half of the fossil fuels accessible on this planet. And since the planet is no longer creating oil at any measurable rate, as oil gets more rare, the price of fossil fuels and their derivatives will have to increase.

And where do many of the pharmaceutical products that our patients rely on come from?? Oh yeah! Petroleum products! A-ha there is the link. If fossil fuels reach a point where the market sees them as more rare, the cost of petroleum based products should increase. Leading to drug prices higher than the already high prices we currently see.

So instead of saving our earth’s petroleum reserves for pharmaceuticals and other products which maintain life and quality of life, we are burning them up and putting them into the air killing the planet and leading to more respiratory disease. It is definitely a more long-term issue, but that is why I believe all pharmacists should be environmentalists.

Are there any other connections between global warming and our profession?

What impact would moving to alternative energy sources instead of coal plants and internal combustion vehicles have on the prevalence of respiratory disease?

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So in effort to get this thing up-and-started, another idea for the day.

So the House passed a health care reform bill, but I do not see anything in it that significantly moves our profession forward. Yeah, it provides the opportunity for CMRs and MTM services, but it is not anything more than current Medicare Part D MTM provisions repackaged (and I don’t see too many community pharmacies taking advantage of those).

In fact, when “practitioner” is defined in integrated care models, I do not even see pharmacists listed (unless I am missing it). I think pharmacists can have tremendous impact in primary care environments helping to manage various chronic disease states that have high medication utilization. And we can provide some of those services at lower cost to the system than many of those services are being provided today. We could lower both direct and long-term costs to the system.

Why doesn’t the current health-care reform debate utilize the clinical skills of pharmacists to a greater extent??

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So I just read a new article detailing the potential interactions between PPIs and Plavix released this past July:

Norgard NB, Mathews KD, Wall GC. Drug-drug interaction between clopidogrel and the proton pump inhibitors. Ann Pharmacother. 2009;43(7):1266-1274.

It seems there is growing evidence to support that the concurrent use of PPIs and Plavix can put patients at increased risk for a recurrent cardiac event. Most trials with omeprazole show a decrease in clopidogrel effectiveness; however, there seems to be some limited evidence that pantoprazole may not be quite as bad (but nothing too convincing!).

What are your thoughts? There may be a clear role for the hospital pharmacist. Is there a role for the community pharmacist to have an impact here??

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So, some people I have talked to worry about robots and computers taking over pharmacy practice. I think they may in some circumstances.

A robot can fill faster than I can. A robot can count more accurately than I can. A computer can remember more drug interactions than I can. And do you really need a $100k/year pharmacist to do a basic final check on the prescriptions. I think a trained $14/hour technician could do quite well.

So what is the answer?!

I think this is a golden opportunity to start learning how to market MTM type skills and more ambulatory care pharmacist functions. Instead of using automation to increase to an increasingly larger maximal prescription volume, we should use that increase in efficiency to make time for clinical services in the outpatient setting.

So how will automation affect pharmacy?

Will it be its death knell or a stimulus to a greater role in our patients’ care?

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Hello everyone,

I believe we are in a great profession and we have very much that we can offer patients and the health care system. I wanted to create a place in which to help spur development of a new reformed pharmacy system where we have one focus: The Patient

Many of the pharmacy blogs I see posted on the internet portray negative images of our profession through the venting of events that we experience every day. I want to create a little corner of the internet where we can focus on the positives of our profession and on the things that we can change to provide a more satisfying profession.

So welcome and I hope you enjoy!

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