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“The pharmacist of tomorrow is going to be unrecognizable to most of us. He might not be a vending machine, but he’s not going to be that quiet old white-haired guy up behind the counter, either.”  –  Jim Ammen

Part of the team… 

Harnessing the power of a pharmacist’s knowledge and expertise to control healthcare costs and improve patient outcomes has been a difficult process. Those promoting the transformation of the role of the pharmacist from the traditional dispenser of medications to a dispenser of information have always been confronted with the question of “who will pay for these services”. Fortunately, since the implementation of Medicare-D, the value of pharmacists providing cognitive services, including medication therapy management MTM services, has become more widely recognized.

But even with this increased recognition, the profession of pharmacy is still facing a sort of ‘identity crisis’. “Pharmacists see themselves as having nine different identities” according to a recent @ChemistDruggist article, thus suggesting they play a ‘flexible role’ in healthcare but remain uncertain of the future.

It’s been a long time coming…

The decade long push for recognizing pharmacists as healthcare providers is finally seeing results. Recent legislation in California became law when Governor Jerry Brown signed the pharmacist provider status bill (SB 493) recognizing pharmacists as healthcare providers. I’m sure other states will be looking at similar legislation in the near future. But will the new legal recognition as providers get pharmacists a seat at the healthcare team table?

“Pharmacists are working more closely with patients and healthcare colleagues in hospitals, outreach teams, patients’ homes, residential care, team graphichospices, and general practice” reports the Royal Pharmaceutical Society @rpharms in ‘Now or Never: Shaping Pharmacy for the Future’. In the U.S. the team based care approach continues to get a foothold with pharmacists participating in patient centered medical home models, accountable care organizations and in collaborative arrangements with other healthcare providers. But we have a long road ahead until we’ll actually see a majority of pharmacists participating as a member of the healthcare team on this level.

It all makes sense…

There are areas where it’s been shown pharmacists can contribute as a first string member of the healthcare plan team. Take medication non-adherence for example. The cost of non-adherence and compliance to prescribed medication therapy has been reported to be well over $290 billion annually in the United States. This is often a direct reflection of the lack of a patient’s understanding of their particular disease state and how their medication therapy can control or improve their particular condition. This is a great example where having a pharmacist on the care plan team makes a great deal of sense, especially at any point of transitional care.

A major component of the patient care plan consists of properly treating the patient’s disease state with appropriate drug therapy. When there is a breakdown, pause or discontinuation of medication therapy by a patient, i.e. lack of medication adherence or compliance, one can almost always predict a breakdown in overall patient care. This can result in increased hospital re-admissions, lack of disease control, increased complications and of course, increased healthcare costs.

Including a pharmacist in the patient care plan process can improve patient outcomes, especially during transitional care. About 1 in 5 Medicare patients who leave the hospital are readmitted withing 30 days. “We know that people who have medication discrepancies, or are not adhering to what the health care team thought they were adhering to, have at least double the risk of becoming a readmission” reports Jane Brock, MD, of the Colorado Foundation for Medical Care. 

Pharmacists should be given the role of patient care managers and  should be performing services such as medication reconciliation, checking for potential adverse drug reactions, performing patient education and other patient oriented services such such as MTM whenever there is a transition inlogo_white medical care. They should also be directly involved with follow-up services to ensure adherence and compliance to drug therapy and report this back to the patient care plan team. Compliance to drug therapy is critical in chronic diseases such as diabetes, hypertension or heart disease and community pharmacists are in an ideal position to fulfill this role. 

Moving forward…

I’ve written before on the topic of pharmacists “being the healthcare provider”. As PROVIDERS of services (including MTM services) and EDUCATORS to help patients understand their medications and medical conditions, pharmacists will be recognized as a resource to ensure continuity through the transitions of healthcare, thus changing patient’s lives, improving outcomes and saving healthcare dollars.

So again I say “Be the Provider” and take an active roll as part of the patient care planning team.

“The pharmacist of tomorrow is going to be unrecognizable to most of us. He might not be a vending machine, but he’s not going to be that quiet old white-haired guy up behind the counter, either.”  —  Jim Ammen as quoted on QuoteSea.

W.C. Fields in The Pharmacist, 1933

The profession of pharmacy is rapidly changing in the 21st century. Gone are the days past when there was a pharmacy on nearly every corner in town and the Rexall brand was known in every household. Independent druggists were first line caregivers in the community, often prescribing medications for illness and ailments when patients could not see a physician. Community pharmacists were seen as a pillar of society… independent, highly visible in the community and usually considered well off financially.

Hospital pharmacies, on the other hand, were usually found in the basement, with an existence almost unknown to physicians, nurses and patients alike. The hospital pharmacy existed, in the mind of many people, solely to perform the dispensing and delivery of prescription medications as ordered by the physician. And likewise, the hospital pharmacist often had an image to match. Their salaries even lagged behind those pharmacists in a community setting until fairly recently. But hospital pharmacist stepped up to the challenge.

Times are a changin’…

Hospital pharmacists began performing many clinical functions supporting the delivery of care in addition to the delivery of drugs. An increasing level in the sophistication and number of pharmaceuticals required an increasing level of knowledge and sophistication on the part of pharmacists as well. While the community pharmacist was still counting by fives and ‘lickin and stickin’ labels, hospital pharmacists were taking on greater roles in drug delivery and patient centric clinical functions. Adding to that the increasing numbers of chemotherapeutic agents, radiopharmaceuticals, biopharmaceuticals, nuclear pharmacy and technological advances in drug delivery have made hospital pharmacy a specialty at the very least.

We now see community pharmacists suffering from numerous attacks on their livelihood. Increasing numbers of third party payers, decreasing margins and higher stress and demand in the prescription filling process have fueled the frustration of many pharmacists:

“The word out in the pharmacy community is that the small pharmacist was sold down the river by the drug companies and the PBMs (pharmacy benefit managers)” — Doug Larson

“I’ve been a pharmacist for 40 years now, and Monday morning I didn’t want to come to work because I knew what would await me. Basically, we’ve got a travesty on our hands” — Charles Pace

“It’s every independent pharmacist’s worst nightmare. There isn’t one component that’s working. It’s so extensive that it’s hard to imagine it’s going to get fixed — Todd Brown   (all quoted from QuoteSea/pharmacists)

These and many other unrepeatable quotes and comments are being heard daily from pharmacists who are overworked and under appreciated, being pushed along towards burnout and increasingly locked into the ‘golden handcuffs’ of the chain pharmacy bullies of the industry. Is it any wonder community pharmacists are complaining?

“I’ve tried to maintain an uneasy balance between your friendly unassuming neighborhood pharmacist and Anthony Perkins in ‘Psycho‘ – Roger Bart, (check the date) September 29, 1962!!

Anthony Perkins as 'Norman Bates' - 'Psycho' 1960

Many of the remaining independents are on the verge of financial ruin. Those who work in chain drugstore settings are frustrated, confused and tired of the ongoing abuse they receive. It’s amazing that we don’t have more pharmacists going postal or psycho as a result of the stressful conditions they work in.”

What will it take to bring about the necessary change in the profession? Payment for cognitive services or medication therapy management services is a step in the right direction. Recognition as healthcare providers by healthcare, governmental and third party payers would also help change this environment. But what will be the driving force to secure the future of community pharmacy?

You Are!

We, who want to be the pharmacists of tomorrow, are going to have to step up and take the lead toward securing the profession. We can’t count on professional associations and lobbyists to do it for us. Many of our professional associations are being managed by non-pharmacists (and we complain about non-pharmacists in corporate managerial positions). New pharmacists coming into the ranks must be prepared to recognize the opportunities that exist. And like the rest of us, they also need to stand up for what is morally right for the profession. We all need to take a lead on providing care that is patient oriented and always look out for the patient’s interests, even when it might be contrary to the ‘business as usual’ profit driven policies of corporate pharmacy. Doing so will win their confidence and secure their advocacy for the services you provide them. If your patients are being served appropriately and their needs taken care of you can be sure their voice of support will be heard.

Step up and do the ‘next right thing’ when it comes to taking care of your patients. Look forward to and expect the changes to take place, but only after you have done your part. Our future will be what we make it to be. Each of you in the profession of pharmacy has an obligation to stand for what you believe. After all, if you don’t, who will?

I’ve been in the profession of pharmacy for over half my lifetime. I’ve seen the ins and outs of what happens in independent, hospital, nursing home and chain pharmacies. There are many problems that have plagued pharmacists over the years that have made it difficult at times to practice real, patient oriented pharmacy.  Unfortunately patient care sometimes takes a backseat to all the headaches and stress involved in the prescription filling process.

For most pharmacists the profession has evolved to a hectic paced, overworked environment. Many are filling hundreds of prescriptions each day, dealing with difficult insurance issues and coordinating the prescription filling process understaffed and over-pressured. There are almost always issues and disputes between the overworked support staff. And then there are the interactions with cantankerous customers or the nurse ‘know it all’ that really makes a pharmacist’s day.

All of this can lead to a pharmacy professional that is run ragged by the shear volume of the workload. We often have ‘management’ that thinks they know a better way to fill prescriptions more efficiently to give us time to counsel with our patients. We even have customers that want to weigh in on how to fill prescriptions better. After all, we’re just putting pills in a little bottle that came out of a bigger bottle, right? Oh, and don’t you dare put the blue pills in Mrs. Smith’s bottle that should contain pink pills. We’re still expected to be exacting and perfect in all we do. No wonder so many pharmacists are bald or balding due to the natural phenomenon of pulling one’s hair out.

But even with all this going on, your pharmacist should still be able to satisfy your need for personal pharmacy services. If not, you may need to consider finding a new pharmacist.

Here are three valid reasons why you should consider firing your pharmacist:

1.  Your questions don’t get answered properly. 

Yes the pharmacist is always busy, but they’re still obligated to answer your questions. We’re not talking about questions like “what aisle are the toothpicks on” or “do you know when you will be getting more toothbrushes in stock”. In most states pharmacists are obligated to answer your questions when you pick up a prescription. If your questions can’t be answered at that time, your pharmacist should schedule a time to sit down with you uninterrupted. If you can’t get the answers you need you should fire your pharmacist.

2.  You can’t get a prescription filled in a reasonable amount of time.   

Here again, pharmacies are usually a busy place. But that’s no excuse for a pharmacist to tell you to come back tomorrow for your antibiotic. I’ve witnessed pharmacists telling a mom or dad with a sick child the prescription will be ready in 3 hours… or even longer. A 24 hour pharmacy recently told a young mother with a prescription from the E.R. to come back after 3 a.m. There were no other patrons in the pharmacy when she arrived 4 hours before that. What’s he doing? Taking a 4 hour break or something? Prescription refills are a different story but if you can’t get your new prescription in a reasonable length of time you should fire your pharmacist.

3.  Your pharmacist ignores you or fails to recognize you as a patient. 

There may be more than one pharmacist at a pharmacy location. And every one of them will know by sight some of the customers at that store. We don’t always recognize all of the good customers, but we all seem to know who the bad customers are.  It’s easy to remember Jane Doe because she is the one who never remembers to call in her refill for birth control pills. We all remember John White who repeatedly complains that we shorted him on his Vicodin. But it’s difficult to remember those ‘regulars’ who rarely complain or make a scene.  Regardless, it is unacceptable for a pharmacist to ignore or fail to recognize a customer, good or bad. If you don’t get greeted in a cordial and respectable manner you should fire your pharmacist.

The bottom line: 

If you are still unsatisfied with the service you receive and your pharmacist is as generic as most of the pills on his shelves or breathes negativity with every other word you should find a new pharmacist. One who is willing to go out of his way to ensure you understand your medications. One who will see to it the staff can take care of customers in a reasonable amount of time. And one who will recognize you with a smile on his/her face even though they don’t remember your name.  They’re out there and ready to assist you in transferring your prescriptions to their pharmacy with a promise and commitment to provide the service you deserve.

Twitter’s @ThePharmerGuy recently posted on his blog ‘Another Day Behind the Pharmacy Counter…’ asking the question:  Why Can’t Pharmacists Prescribe?  He details a very good argument as to why pharmacists should have prescription authority.   My thoughts on this topic follow below:

I totally agree it’s past time for pharmacists to be given prescribing authority, at least on a limited basis. There are so many instances where a pharmacist could make the decision to appropriately select and prescribe from a limited formulary of medications for a number of common disease states.

Pharmacists receive more intensive training and are more qualified to make decisions regarding appropriate medication therapy than most nurse practitioners or physicians assistants I know, and probably more qualified than many MDs as well.

Prescribing authority is given to MDs, NPs and PAs, in my opinion, after receiving basic training algorithms to assist them in making prescribing decisions based on their diagnosis. They don’t receive near the training or knowledge base in pharmacology, pharmacokinetics, adverse drug reactions and drug interactions that should be used in the drug prescribing process. They are also somewhat dependent on and easily swayed by the influence of pharmaceutical sales and marketing efforts, something which pharmacists are able to sort through by throwing out the hype and making better clinical decisions based on rational therapeutic approaches.

And, from what I have seen, most prescribers are easily swayed by their patients as well. All of the direct to consumer pharma advertising has created a patient population who go the the doctor with their expectations of what should be prescribed… and sometimes get upset when they don’t get what they want!

Pharmacist prescribing would expedite patient care and lower the cost of care by facilitating or streamlining the process of finding the correct medication and dose to reach and maintain therapeutic goals. This would tie in very well with a medication therapy management type of pharmacy practice that monitors new medications and makes changes or adjustments quickly and efficiently based on patient response to therapy.

All this would help to reduce costs associated with patient medication therapy,improve and streamline the process of reaching therapeutic goals, aid in assisting, educating and counseling patients to ensure compliance and adherence to drug therapy and improve patient outcomes.

The PharmD vs. BSPharmacy status for prescribing authority will need to be addressed in some manner. Pharmacists were making decisions regarding appropriate medication selection and use decades ago. It wasn’t until the prescriber and dispenser functions began to change that pharmacists  began to lose the authority to ‘prescribe’ all but those medications given OTC status. Generally speaking, most RPhs have as much knowledge and decision making skills when it comes to prescribing as those who prescribe the prescription orders they fill and dispense. Same with PharmDs.

Yes, it is time for pharmacists to be given prescribing authority, if even on a limited basis. I would expect that this authority would be expanded after a year or two of monitoring said prescribing authority based on the positive outcomes we would see.

Starting a personal health record PHR is easier than you might think.  Store your personal health records in digital format… tools are available to assist you. Google Health, No More Clipboard and Microsoft Health Vault are just a few of the many available tools.  Learn how to gather your health information and build your personal health record.  Click the link below for more information:

Why You Should Start a Personal Health Record

 

Starting and keeping a personal health history is probably easier than you think. Although this might look like a daunting task at first, it is really quite easy once you get started. 

Begin by organizing all of the health information you have at home. Gather all information from:

  • Files at home containing information from physician visits or hospital admissions
  • Pertinent information that might be contained in billing records from physician or hospital visits
  • Identification cards or immunization records prepared by health care providers
  • Information provided by your pharmacy or with the prescriptions you receive
  • Information contained in insurance billings or other documents
  • All other sources or pertinent records containing relevent personal and family health history   

Once you have this information in a single location you are ready to begin building a personal health record (PHR).  You are also entitled to copies of all personal health information maintained by your physician or health care provider. You will want to discuss with them what information they have on file and how to obtain copies for your records as well.

Learn more about obtaining your health information from health care providers by reading Dave deBronkart’s ( @ePatientDave on Twitter  )  blog article entitled      “Gimme My D*** Data “.    

Managing your health information is like balancing your checkbook….it will become easier if you work on maintaining and updating your information regularly.

Gather information, organize it and share it on a regular basis with your health care providers.

 Most people don’t realize that it is unusual to find a complete record of all of their personal health information.  Our personal health information is not usually found in any single location or even in consistent format.   As we gather complete and accurate personal health information for our families and ourselves we create a personal health record or PHR.   This PHR is a resource that will help us take an active role in the quality of our health care.   It is important to gather and share this information with our health care providers to fill in the gaps that exist in our medical records.

Your personal health record (PHR) should be a collection of important information about your health (or the health of someone you are caring for) which you actively gather, maintain and update.  The information that your PHR should include (but is not limited to):

  • Personal identification (name, birth date and demographics) 
  • Emergency contacts 
  • Names and contact information of your physician, dentist, eye doctor, and any other specialists
  • Health insurance information
  • Living wills, advance directives, or medical power of attorney
  • List and dates of significant illnesses, injuries and surgical procedures
  • Current medications and dosages
  • Herbal supplements and pertinent dietary information
  • Drug allergies or sensitivity and other allergies 
  • Pertinent family history information
  • Important test results; eye and dental records
  • Organ donor authorization

Having access to your personal health information in an emergency can be critical.   Your emergency personal health record (ePHR) can provide lifesaving information necessary for your medical treatment.

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