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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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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, 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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