Pharmacy Practice in Modern Times - Impact of Technology

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Uday Venkat Mateti, Asim Priyendu and Anantha Naik Nagappa

Manipal College of Pharmaceutical Sciences, Manipal University, Manipal-576104, India.

Practice of pharmacy is as ancient as medical and nursing profession. However pharmacy practice like other health care professions lagged behind to catch up as it was felt less important than supply of quality medicines for medical practice and nursing care. Industrialization also propagated the manufacture of quality drugs and related activities as the prime activity of pharmacy profession and the pharmaceutical care was slow to pick up like medical and nursing practice. The research and development in pharmacy emphasized to focus on drug discovery and development instead of professional practice to meet the increasing demand for drugs. In order to meet the challenges of epidemics of infectious diseases it seemed appropriate to manufacture the medicines for masses than an individualized patient care. That's how we have accepted the fixed dose combinations as a standard dose of drug administration. There were practices like compounding and dispensing extemporaneous formulations which slowly phased out of practice. One cap fits for all is the mantra of current medical practice which is inappropriate in many clinical conditions. Many times it is observed that the solid dosage form are broken as half or made into four pieces in order to meet the appropriate dose. This is unscientific and irrational way of drug administration.

It is interesting to learn that in Australia, Europe, USA, and Canada, there are compounding pharmacists who engage in making extemporaneous preparations for special prescriptions. The current medical practice has serious lapses in patient safety due to absence of clinical pharmacy inputs leading to avoidable morbidity and mortality in hospitals. Whereas in community practice where there is no pharmacist intervention, encouraging patients engaging in self medication instead of informed self medication, nephrotoxicity, damaged kidneys and other vital organs have been reported. To establish a system of health care with optimized outcomes clinical, humanistic and economic domains is very essential. The development and inclusion of pharmacy practice was very much felt necessary not only by pharmacists but also by regulators, policy makers and health advocates. The WHO is very much concerned about the long term effects of drugs on humans and live stocks in treatment of chronic diseases especially non communicable diseases.

Looking at the risks of long term exposure to drugs pharmacovigilance has become mandatory program for all the nations. Due to its impact on public health, the regulators started program demanding pharmacovigilance data as obligatory requirement for the sanction of marketing license from the manufacturers. This is also due to reporting of many drug accidents in mass media which are appearing quite often and has made regulators to demand for post marketing ADR report from each manufacturer as legal requirement. All these developments may have emerged due to paradigm shift from products centric approach to patient centric approach. In some parts of the world there are encouragements and incentive packages for individual pharmacists who volunteers to discuss with patients regarding drug, disease, and lifestyle changes. The first recorded protocol of pharmacy practice appearing in the literature was Hepler and Strand utilities USA.

In 2006, the WHO in collaboration with FIP took lead by releasing the guidelines of pharmacy practice as model practice for the world.1 In that, they have indicated the challenges, the bottle necks in implementing pharmacy practice in existing traditional clinical practice and streamlining the health care delivery. There was an over pouring evidence in favor of pharmacy practice across the developed and developing economies which has established the bench mark advantage over existing traditional practice. There is also unexpected shift in disease trends like emergence of non communicable diseases, as major cause for morbidity and mortality. Unheard viral epidemics like bird flu, dengue, Crime-Congo fever, are surprise that are difficult to treat and control. For e.g. In chicken guinea there are no specific drugs to combat and are mostly symptomatically treated. To meet the emergency conditions, there is an urgent action need to be taken where individual patient is given enough attention and support in care provision. However the existing model over depending on physicians assisted by nurses is grossly unable to control the problem. In order to meet the requirements new innovations like electronic prescriptions, telepharmacy, mobile healthcare, application of social media and healthcare and internet pharmacy were developed and pilot studies were conducted.

Advances in Concepts and practice of Pharma technologies

The innovations in basic health sciences have given jolt to the practice of healthcare in many fronts leading to revolutionary relief in patient care and safety. The issue of medication errors, increased costs of treatment, disease management, and demand for quality of life by patients has given a shot in the arm to develop and apply the new technologies. The paradigm shift from product centric to patient centric care has been instrumental in application of new technologies in healthcare.

Pharmacy Practice and Impact of Technology

The commercial and written prescriptions were having drawbacks like they have to be presented to the pharmacy as hard copies. They are many times not labeled properly and the patient is likely to know regarding professional communication between prescriber and pharmacist. There can be errors while dispensing due to ambiguity in the prescriptions. The advancement in secure internet communication between the prescriber and pharmacist has led to be an alternative for paper hand written hard copy prescription. The E-prescriptions supported by database can be fast, free of errors, economical and environmentally safe. The E-prescriptions are sent directly by the prescriber to pharmacist, the pharmacist can prepare the dispensing kit before the patient arriving for collecting medicines.2 The patient time is saved and the payment can be through electronic transfer. All these facilities are alternative and cost effective as compared to conventional paper based prescriptions. Implementation of this technology has happened in the USA wherein they have saved the money, time along with electronic documentation of dispensing. This technology is yet to take up in other parts world like developing countries like China and South Africa. The resistance to adapt this technology by the current practice is visible in developing economics as the prescriber are likely to document the details of treatment provided.

The access of right medicine at the right time in the right dose is daunting task for the pharmacist where the patients located in remote areas as villages where location on proper roads for transportation facilities and are water locked in island or deep inside the forest. These places have remained underdeveloped with least civic facilities and lacking infrastructure. They also suffer from poor economic and extremely difficult to serve health care. Other issues include refusal of qualified health care to stay in these locations. The people living over there have to travel all the way to the urban habit their facilities are abundant and are easily accessible. There is a new hope of improved services coming to the door steps of the remote areas by innovative technology. The buzz word called telepharmacy which include medication therapy management, patient counseling prior to attribution and refill authorization of prescription monitoring the formulary compliance with the teleconference or video conference, remote dispensing of automated packing and labeling systems.

New England Health Care Institute (NEHI) has listed 11 chronic disease technologies (Figure 1), categorized in four classes.3 It includes home telehealth, virtual visits, mobile diabetes management tools, mobile cardiovascular tools. In home telehealth, all the patients actively take and manage their chronic diseases by wirelessly transmitting physiological data from their homes to physicians. The virtual visits facilitate to real time interaction between patients and pharmacists. Their applications can be accessed from smart phone, personal computers and kiosks. They offer a potential of revolutionizing the challenge of excels and opportunity for the pharmacist to interview early before complications develops. For chronic disease management especially diabetic users, wireless devices to collect and lock the blood glucose readings which alerts the patients and healthcare providers. In case, the blood sugar shoots above normal further there are mobile applications to improve medication adherence and also to document presiding to any issues pertaining to compliance.4 On similar lines, mobile asthma management tool users global posting technology to look when and where, asthma attacks occur in an ambulatory patients and what appropriate precaution patient may take. If there is hostile where the changes precipitating the asthma attack mobile cardiovascular management tools enable the patient to monitor and share their vital signs with care givers and provide on wireless platform. It is usually observed that patients often not able to reorganizing usually ignore the symptoms which lead to expensive intervention sometimes leading to death. The clinical benefit of the mobile cardiovascular tool secure to lower the risk of stroke and heart attack like anti diabetic tool in bringing down the glycosylated hemoglobin (HbA1C).

Figure 1: Chronic Disease Technologies

Dispensing and administration of highly toxic drugs to cancer patients involves considerable occupational risk for the healthcare professionals and patients. As these drugs are highly potent need precise dose administration in order to maximize efficacy and safety for patients. Application of robots was found to be the remedy to resolve the issue of unnecessary exposure of drugs and to optimize the precise dosing. This concept came into practice by extending the application of robots in manufacturing of the drugs wherein the industrial hazard was noticed in workers. There are customized solutions such as automated dispensing technologies are available in the market which offers cost-effective solutions for dispensing and administration. The Smartphone solutions for patient education, medication adherence, patient alerts, hand-held devices for dose adjustments and electronic gadgets apps are profoundly influencing the healthcare management. One of the features of these game changers is empowering the providers and the patients' instant knowledge and solutions to make timely decisions which are affordable economically and environmentally acceptable. It has become very common practice by the health consumers, patients and even healthcare providers to look into Wikipedia, WebMD and Medscape and resolve the doubts. There are online patient counseling websites dedicated to particular conditions like cancer, diabetes, hypertension etc.

Interactive websites and social media offer opportunities for everybody to understand and share the experiences with fellow who are having similar conditions. For example- www.patientslikeme.com and websites and Apps related to disease management and healthcare management websites links were summarized in the Table 1.

Table 1: Patient education websites

The governments, regulatory agencies and several NGOs have established healthcare and consumer information databases which are freely accessible by anybody in the world.

Hospital information systems are playing a vital role in integrating the professional inputs by doctors, nurses and pharmacists to achieve the excellence in outcomes. It also aims at improving the time-efficiency and making the healthcare delivery easier. It has brought about a revolutionary change in the field of patient data management by bringing all medication data, lab-data and medication sales data together at one place.

The internet pharmacies came into existence due to demand by the patients who require the prescription medicines to be delivered at the doorsteps of patients and health consumers. The modus operandi involves internet order system in which the orders for the prescription medicine are placed to the pharmacy along with the proof of legitimacy and payment. After verification and cross checking, the medication basket is prepared and physically delivered to the authentic address.

The major limitations of this pharmacy are the absence of human pharmacists and mechanical instructions to patients in dispensing practices. However, this issue is addressed by video conferencing and face to face e-chatting. Further, these pharmacies are likely to be misused for ordering prescription medicines by fake prescriptions.

References

  1. The role of the pharmacist in the health care system. Preparing the future pharmacist: Curricular development. Report of a third WHO Consultative Group on the role of the pharmacist, Vancouver, Canada, 27-29 August 1997. Geneva: World Health Organization; 1997. WHO/PHARM/97/599. Available at: http://www.who.int/medicinedocs/
  2. Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals. J Am Med Inform Assoc. 2013;20(6):1159-67.
  3. Bartolini E, McNeill N. Getting to Value: Eleven Chronic Disease Technologies to Watch. Cambridge, MA: NEHI; June 2012. www.nehi.net/publications/72/getting_to_value_eleven_chronic_disease_tec.... Accessed March 13, 2013.
  4. NEHI. Thinking Outside the Pillbox: A System-Wide Approach to Improving Patient Medication Adherence for Chronic Disease. Cambridge, MA: NEHI; August 2009.

About the Author

Anantha Naik Nagappa's picture

I am professor, intrested in developing the community pharmacy services in India, We have an association called ASSOCIATION OF COMMUNITY PHARMACISITS OF iNDIA. CHECK AT www.acpi.in for further detials

Comments

Albert Ana-Maria's picture

Generations to come, are increasingly accommodated with technology. Generation Now, however, he learned a lot. How will we be in a few years? It will be like today's generation? Hard you try?

Anantha Naik Nagappa's picture

The time and tide waits none. The conventional practice shall be replaced by systematic approach. We can see the manual dispensing and physical labor is gradually being replaced by robots. The dispensing of anticancer drugs by robots and availability of drug information in finger tips are some of the indications. The changes shall happened out of necessity but not due to forced efforts. The team work of doctor, nurse and pharmacist can only deliver quality outcomes.

Prof Anantha Naik Nagappa

My Page : http://www.pharmainfo.net/ananthanaik

Ph. Bhagavan P S RPh's picture

Albert Ann Maria, your query is apt and pertinent.

Text book contents and Class room motes and sermons cannot be expected to become a reality unless the teachers who teach the field subjects are borne from the field and learners and the Health system mutually accommodate themselves and the system should familiarize the learners and the people on the need for delivering service with impactable technology.

There is an ocean of gap in knowledge level between clinicians and dispensing pharmacists, between Dispensing pharmacists and Clinical pharmacists and Clinical pharmacists and logistic managing pharmacists and people and patients are not aware of the profession called pharmacy and pharmacist. Pharmacist himself do not wish to project and identify himself as Pharmacist.

Further as said that Time and Tides wait for none, the gap widens further with the passage of time unless the reforms in course content and course system in the academic sector, identity and profession supporting measures in Regulatory and filed oriented mandatory continuous education to the professional pharmacists and empowerment for the pharmacists in health sector are not taken up on war footings, by salvaging all resources available and sacrificing useless components to optimize utility of learning and service.

Bottom line:

The real impact is:

'BACKLASH' on the Pharmacist and the profession with 'NO TAKERS' and those who have been taken and will be taken are serving as HELPERS.

Bhagavan P.S. B Pharm

Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India

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