The role of pharmacists' continues to change
The role of pharmacists' continues to change
The practice of pharmacy has changed significantly in recent years, and continues to evolve today, according to MLC Solutions principals Charlotte Kenreigh, PharmD, and Linda Timm Wagner, PharmD. Writing for the Medscape Pharmacists Internet site, the two noted that in the middle of the 20th century, pharmacists' responsibilities centered around dispensing and compounding drugs, and they rarely communicated with patients about their medications or disease processes.
But with the introduction of "clinical pharmacy," pharmacists' attention began to shift from the medication itself to the interaction between the patient and the medication, and today pharmacists' role in many practice settings has expanded to include not only dispensing functions, but also direct contact with patients and other providers, Kenreigh and Wagner said.
In 1990, the term "pharmaceutical care" came into popularity, giving a new look to pharmacy practice, and in 2000 the American College of Clinical Pharmacy issued a white paper looking at pharmacists' future roles and responsibilities.
"Many pharmacists complain that this transformation is not happening quickly enough or going far enough," the two said. "On discussion boards and blogs, as well as in private conversations, pharmacists note practice realities that seem to contradict the change promoted by pharmacy leaders. As in many other professions, achieving true change has been a challenge, and many barriers still remain to be overcome."
Kenreigh and Wagner said pharmacists' ability to provide true pharmaceutical care depends on a redesign of the traditional pharmacy environment and services, according to the American Pharmacists Association (APhA). That group has called for what it says are revolutionary changes such as private consulting areas in pharmacies and pharmacist house calls. The association is looking for ways to add value to the pharmacist license through expanded patient services and encourages pharmacists to provide new and innovative services such as immunization clinics, emergency contraception, and collaborative practice provisions for optimal medication therapy management.
"There are increasing numbers of opportunities for pharmacists to assume greater roles in helping patients make better use of their medications and achieve optimal therapeutic outcomes in both the public and private sectors," said APhA Practice Development and Research group director Anne Burns. "The effective use of automatic and pharmacy technicians assists in freeing the pharmacist to have dedicated time for patient care delivery."
Practice change goals and objectives
Likewise, the American Society of Health-System Pharmacists (ASHP) has been working to improve pharmacy practice for hospital pharmacists, with its Health-System Pharmacy 2015 initiative that has six goals and 31 specific objectives to make medication use more effective, scientific, and safe. The overarching goal is said to be to raise the profile of the pharmacist from a quiet but valuable member of the health care team to a more visible and vital component of patient care.
"Despite these professional initiatives, recent studies suggest that the pharmacy practice revolution still has significant hurdles to overcome," the authors said. "For one thing, many patients and other health care professionals still have not fully embraced the concept of the pharmacist as a key member of the health care team."
A 2005 Harris Interactive survey conducted for the National Association of Chain Drug Stores found that many consumers believe it's important to have a comfortable, trusting relationship with their pharmacist and trusted their pharmacist as much as they trust other health care professionals, but only one-quarter of respondents felt it was easier to ask a pharmacist about a health issue than to ask a doctor.
And in a Medscape article on-line, doctors were asked to discuss how they can stay current on information about medications. While several potential solutions were offered, none of the doctors suggested turning to a pharmacist for assistance, an oversight quickly noticed and raised by pharmacists. As one pharmacist wrote in a discussion forum on the topic, "What happened to collaboration and using the health care team to...benefit the patient? This series just illustrates how far pharmacists must go to prove...they are needed on the team. A doctor can't survive without a nurse. Maybe someday they will realize the same for pharmacists."
In addition to struggling for broader acceptance among patients and physicians, the authors said, pharmacists also face barriers in the workplace that may prevent them from realizing their patient care role. Thus, while in some settings pharmacists have been able to reassign the more technical aspects of pharmacy practice to technician counterparts, thus creating time and opportunity to perform value-added services, this is not a universal truth.
More technology doesn't mean more patient contact
In the hospital setting, some pharmacists have reported seeing increases in the use of technology without a corresponding increase in direct patient contact.
In the survey conducted by Kenreigh and Wagner, a pharmacy director at a Minnesota hospital said the facility is implementing a robot and medication carousel for the distribution system, along with fax imaging. But four technicians were removed from the budget, once a year starting the year after implementation. Any pharmacist savings were identified as needing to be moved to medication reconciliation. "Personally, I don't think that will be a large savings in personnel costs," the director said.
And a pharmacy director in Ohio said the struggle was to get FTEs to accommodate new clinical services. "I truly believe pharmacists can have an impact on clinical care and outcomes from an inpatient and outpatient perspective," the director was quoted as saying. "Physicians are very busy with the volume of patients they must see and are often relying on hospitalists to manage their inpatients."
Reimbursement is also a concern since no means currently exist for being reimbursed separately for inpatient clinical services by a pharmacist. Quantifying the return on investment for hospital pharmacy clinical services is difficult, the Ohio pharmacy director said, since it usually represents an avoidance of expense. Once inventory and contracts are being managed, the bottom line is drug utilization, which is the most difficult to manage.
Kenreigh and Wagner say there are several reasons why the transition to a value-added role has not been more complete since the move for change is more than a decade old. Finances are an important factor, they say, and investing in technology that can free pharmacists from many distributive functions is costly. "Given the focus on cost containment in the current health care environment, getting approval for new technologies can be difficult," they wrote.
Also, an increased role in patient care has created a need for greater clinical skills. Schools of pharmacy have reworked their programs to address the issue, but the change cannot come overnight. And an expanded role for pharmacists has met with some resistance within the health care community, even leading to some turf battles.
Staffing models changing
"Anecdotal evidence suggests that more and more hospitals are shifting positions from predominantly distributive, with maybe just a few clinical positions, to a model that has most positions serving in an integrated clinical/distributive role, plus a number of clinical specialists," said ASHP director of Pharmacy Practice Sections Doug Scheckelhoff, MS, RPh. "This is occurring because it is the best way to provide comprehensive clinical pharmacy services for the greatest number of patients, rather than those few on a covered service. It is also occurring because of the clinical expertise of new graduates and their expectation of a clinical role when they are seeking employment."
He said the growing number of residency programs and corresponding graduates is also contributing to the change. "Technology is being adopted for many dispensing tasks, and technician roles continue to evolve," Scheckelhoff said. "In reality, recruitment and retention in a primarily distributive environment will become insurmountable in the very near future."
"Meanwhile, the body of literature about the value of pharmacists continues to grow," the authors concluded. "Studies continue to demonstrate that adding a pharmacist to the patient care team produces better outcomes, both clinical and economic. Even though challenges remain for the profession, pharmacy organizations are committed to expanding the clinical focus of pharmacy."
[Editor's note: Reach Drs. Kenreigh and Wagner at (740) 965-6258.]The practice of pharmacy has changed significantly in recent years, and continues to evolve today, according to MLC Solutions principals Charlotte Kenreigh, PharmD, and Linda Timm Wagner, PharmD.
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