“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.

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Can you hear me now?

You can call it selective hearing, being preoccupied or just not interested in listening to somebody when they’re trying to tell you something. In my case, it was also losing my hearing in the frequency range of my wife’s voice. never listenShe would often complain that I never listen to her. She returned one evening from a craft fair or bazaar with a painted block of wood, wrapped with a ribbon, and handed it to me. It had the following inscription:

“My wife says I never listen to her… at least I think that’s what she said.” 

Later I discovered our lack of communication was only partially due to my progressive hearing loss. I say “partially” because I now know I was guilty of not giving her my full attention when she spoke to me. I struggled with my hearing (and listening) until a few years later when I suffered profound loss of hearing in both ears.

Though my total loss of hearing was devastating when it happened, regaining my hearing through the process of receiving a cochlear implant has taught me some very important lessons about the difference between hearing and listening.

Hearing is not the same as listening.

The rehabilitation process of regaining my hearing through the miracle of a cochlear implant was hard work. I would struggle to hear at times, knowing I needed to understand the words being said.

But because I was concentrating so much on hearing the words in a conversation, I found myself lacking in the area of listening to the conversation. My brain was so focused on hearing that I didn’t have time to listen at first. Likewise, if our minds and concentration are focused elsewhere, we’re going to miss most of the conversation.

Using more than just your ears.

Listening is not only hearing what is being said, but what is not being said or only partially being said. There are so many nuances to a conversation that one can’t hear unless they truly engage in listening. Body language, facial expression, verbal and non-verbal messages can only be pick up if one is fully engaged, both hearing and listening.

So now you might be asking yourself “what does this have to do with healthcare?”

Time allotted:  8 minutes per patient.

The New York Times recently published an article referencing a study which confirmed “new doctors are spending less time with patients than ever before.” I’m sure this translates over to many of the physicians who’ve been in practice for a number of years as well. Physicians (and pharmacists for that matter) are being bogged down in paperwork and other tasks not directly associated with patient care.

Pharmacists have been under this pressure for years. Even With OBRA mandating patient counseling on all new prescriptions, most pharmacists find it difficult to  get 30 seconds to counsel a patient at times. And I’m sure that physicians and pharmacists are not the only healthcare professionals who are lacking the time to spend listening to patients.

“The opposite of talking isn’t listening. The opposite of talking is waiting…”
~ Fran Lebowitz

So here’s a few tips that would improve the delivery of healthcare from a listening perspective:

  • Stop talking – let your patients tell their story
  • Get ready to listen – remove distractions (including laptops, etc.)
  • Be patient – put them at ease and let them share their concerns
  • Listen for what’s not being said – listen with your eyes as well
  • Be empathetic – try to understand the patient’s point of view

Unless we put forth the effort to prepare ourselves to listen it probably isn’t going to happen.

No time, no time, no time…

One might argue the case of  this new generation of healthcare practitioners being different than past generations due to time constraints. Circumstances may change over time. But the framework for building good relationships with other people hasn’t changed much, if at all, for centuries.

If we want to improve healthcare we must improve the communication and interaction with patients… many who are more informed and engaged in their health and medical conditions than ever before.

So what happened to the sign?

It still sits on our kitchen windowsill, over 15 years later, as a daily reminder to us all.

I was immediately intrigued when I read @PhilBaumann ‘s thought provoking post titled ‘140 Health Care Uses for Twitter‘.

Twitter evolution via @mashable
(nursing caps added)

I’ve observed many of the 140 uses Phil mentions over the last couple of years while following and tweeting on Twitter.  But some of the ideas he came up with were totally new to me, if not ‘off the wall’ in some respects. Phil comments: “there’s potency in the ability to burst out 140 characters, including a shortened URL”… and he’s right!
Twitter is potent medicine!
He also cautioned about several additional issues health care tweeters face including patient privacy, legal and HIPAA concerns.

But if we focus on what Phil suggests, to “be imaginative, determined and innovative” in our approach to using Twitter (and other social media) as a powerful adjunct ‘healthcare tool’, we’ll find even more possibilities and ways to improve patient lives.

As a pharmacist the gears in my head started turning right away after reading #29 – Prescription management, including pharmacy refill reminders.  I thought I would expand on a few uses for Twitter that pharmacists might employ in their practice in the future.

Phil already mentioned the first one on my list, #29a prescription refill reminders. I would add #29b “your prescription is ready” reminders and #29c “we’re waiting for your doctor to authorize a refill” reminders. There may be others that fall into similar, logistical type categories as these.

Here’s a few more I thought of that expand on and utilize the pharmacists professional expertise:

#29d:  Patient Medication Education-

This is an area any pharmacist on Twitter can leverage, after all, pharmacists are medication experts.  Most of my tweets on any given day will have some component of patient education, although some more than others. One patient education plan could be to target specific disease states or patient populations to help them understand their disease and how to manage it properly. Another plan could be to educate patients on drugs and drug interactions as well.

#29e:  Medication compliance and adherence-

Lack of adherence to prescription medication therapy cost the U.S. $317.4 billion in 2011 and we can expect that figure to continue to rise until we find solutions to the problems surrounding the issues of compliance. Pharmacists who find a way to improve medication reminder programs for their patients will not only save healthcare dollars but improve patient lives. Twitter and/or texting could be leveraged to improve patient compliance.

#29f:  Medication safety and drug interaction alerts and reminders- 

Twitter could be utilized by pharmacists to notify patients of medication safety issues and potential drug/drug or food/drug interactions that could be problematic. There are over 2 million cases of adverse drug interactions annually in the U.S. resulting in over 100,000 deaths. The cost of these adverse drug interactions is also in the billions. It’s even more difficult to measure the cost of human suffering and loss of life.

#29g:  Alerting patients about special pharmacy programs- 

Many pharmacies offer special clinical outreach programs and screenings including blood pressure checks, blood glucose screening, bone density testing and immunizations. These could be promoted via Twitter and other social media sites. Twitter could be used as a patient reporting tool for tracking health data.

#29h:  Drug recall notifications- 

Pharmacists and pharmacy technicians are often involved in drug product recalls, both prescription and over-the-counter medications. It’s important to pass this information on to patients and consumers alike.

#29i:  Pharmacist to Pharmacist interaction-

One of the greatest benefits I’ve discovered (and it took me awhile) on Twitter is the ability of pharmacists to connect with other pharmacists. Of course, many pharmacists on Twitter have ‘secret identities’ making it difficult to connect on a professional level, most of them hiding their identities because they use Twitter to vent or as a release from their daily tasks in the pharmacy. You know who you are! Over the past several years I’ve connected with a number of great Twitter pharmacists on a professional level and I look forward to meeting more of you ‘lurking’ out there.

#29j:  Twitter as an professional educational tool- 

Another benefit I’ve found on Twitter is the magnitude to which a pharmacist (or other medical professional) can learn. Professional education, much of it on par with any accredited continuing education or medical education programs can be found if you look in the right places.

#29k:  Building professional credibility- 

Using Twitter (and other social media) can do one of two things for pharmacists and healthcare professionals:  You can use it to build your credibility and establish yourself as an expert in your field OR you can use it to cripple your identity as a professional. Tweet responsibly.  Enough said.

#29l:  Using Twitter to build patient relationships- 

Probably one of the most important ways pharmacists (and other health care professionals) can utilize Twitter is in building relationships with patients and keeping those lines of communication always open. If you’re using social media properly it will have of some component or level of social interaction. And if you can interact with patients and let them get comfortable with who you are they’ll begin to respond by showing trust and confiding in you.

I’m sure if we put on our thinking caps and throw caution to the wind a bit, we could think of more ideas for pharmacists and other medical providers to improve health care by leveraging social media. More important is the charge to be a leader in utilizing this technology to improve health care and not lag behind other professions.

What do you think?

God heals, and the Doctor takes the Fees…
Benjamin Franklin: Poor Richard’s Almanack , 1736. 

Maybe old Ben Franklin even recognized the beginning of a trend in healthcare. It’s not the fault of the doctors per se but healthcare is not always focused on patient care, it’s business… big business. Non-profit hospitals used to be dedicated to giving appropriate healthcare to all, even those who could not pay. Now we see non-profit hospitals, formerly operated by faith based organizations, being turned into for profit corporate systems providing care to a community based on direction from share holders and management teams.

In Ben’s day the physician, more times than not, received payment in kind  from his patients.  A basket of eggs or sack of potatoes from the garden for minor services. Possibly the chicken itself; a goat, pig or cow for more major transactions. If the patient couldn’t pay, or pay in kind, they usually provided service later on to repay the ‘debt’ of receiving treatment and to express their gratitude. I’m sure that most patients were more than happy to repay for appropriate health care services in that day and age, especially when they survived and got better.

Life was probably much easier before health insurance:

Although the concept of being protected through health care insurance is a great idea it’s contributed to a big business mentality. Third party payers and corporate insurance companies are in it to cut costs and make money, or at least not lose money.

Yes, healthcare is big business. We don’t see the family doctor working out of his home doing house calls much any more. They’re usually affiliated with a hospital or group practice of multiple physicians. We don’t see many ‘mom and pop’ pharmacies anymore either. We now have the Walgreens, CVSs, Walmarts and mail order pharmacy. All of them along with pharmacy benefit management groups (PBMs) selling patient information to generate more revenue.  And with this type of change we’ve seen the transition from real patient care focused practices to enterprises designed to ‘drive’ healthcare services and generate profits to satisfy stockholders. Is this truly in the best interest of the patient?

Patient care seems to get lost in the healthcare world today. Even the patient centered medical home model (PCMH), while touting the focus on patient care, is really designed to manage healthcare costs. Accountable care organizations (ACOs) and continuity of care organizations (CCOs) basic premise is to control healthcare costs.  That doesn’t say much about patient care, does it. So when did we lose patient care and how do we get it back?

Having a mission statement does not mean fulfilling the right mission:

I don’t think that patient centered care is totally lost. But patient centered care must come from the individual providers. Now I’m not saying that this doesn’t happen. It just happens less often than it should. Those of us involved in healthcare, whether physicians, nurses, pharmacists or other auxiliary personal all need to be focusing what we do around the idea of what is best for the patient. Sometimes it means taking a stand for what is right for the patient, even if it’s not in the best economic interest of the healthcare machine.

Providers can be the stimulus that changes healthcare to patientcare. Focus on what is best for the patient in the long run. If the system is broken or fails to take care of people by following the usual and customary ground rules, changes need to take place. Decisions based on positive patient outcomes need to be made as opposed to decisions base merely on economic factors. Maybe if providers start doing this, with each patient, the system can be changed from within. One could only hope that by doing so we can change healthcare to patientcare.