Dipiro - Pharmacy in the 21st Century

Pharmacy in the 21st Century:Learning, Practice, and Education

Joseph T. DiPiro, Pharm.D.South Carolina College of Pharmacy, SC, USA

Does pharmacy adequately address the drug-related

problems faced by society?

Papyrus prescription: 1600-2000 years old (refers to lead monoxide)

Emphasis of the Pharmacy Profession

• Historic: Preparing medicines and source of knowledge about drugs

• Recent era: The dispenser of medicines

• Future: The provider of health care and promoter of wellness and healthy living

Art and Science of Pharmacy - Past -

Societal Concerns with Medicines

• Cost of medication• Access• Safety• Effectiveness

What is Causing Changes in Pharmacy Practice?

• Societal expectations• Prescription medicines becoming a

“comodity”• Government regulation• Policies of health care payors• Prevalence of chronic diseases• Decisions of the profession• Advances in biomedical science

Clinical Pharmacy in 2010

• Gaining acceptance throughout the world• Can improve health outcomes in hospitals

and communities– Disease endpoints, patient satisfaction,

quality of life • Can reduce health care costs

Societal Expectation of Pharmacists

• Assure the quality of prescription medicines

• Provide information and counseling (inconsistent)

• Manage chronic diseases (uncommon)• Provide health and wellness services

(inconsistent)

Factors Affecting Pharmacist Distribution Functions

• Automation and robotics• Mail order pharmacy• Internet pharmacies• Technicians

Pharmacy Automation

Art and Science of Pharmacy- Present and Future -Medication Therapy Management

Patient medication list• metformin (Glucophage) 1000 mg PO twice daily• simvastatin (Zocor) 40 mg PO QHS• aspirin 81 mg PO daily• lisinopril (Zestril) 10 mg PO daily• sertraline (Zoloft) 50 mg PO daily• omeprazole (Prilosec) 20 mg PO daily• loratidine (Claritin) 10 mg daily if needed

Art and Science of Pharmacy- Present and Future -Medication Therapy Management

Issues: Cost, Access, Safety, Efficacy

Patient medication list• metformin (Glucophage) 1000 mg PO twice daily• simvastatin (Zocor) 40 mg PO QHS• aspirin 81 mg PO daily• lisinopril (Zestril) 10 mg PO daily• sertraline (Zoloft) 50 mg PO daily• omeprazole (Prilosec) 20 mg PO daily• loratidine (Claritin) 10 mg daily if needed

Expanding Roles for Pharmacists

• Chronic disease management– Diabetes, asthma, hypertension, dyslipidemia

• Specialist services– Oncology, critical care, ID, transplant, pediatrics

• Wellness– Immunizations, Smoking cessation, Education

• Industry– Sales, marketing, research and development

• Specialty compounding• Case consultant to insurers and payors

Professionally Determined Need for Pharmacy Services in 2020

David A. Knapp, PhD et al, Pharmacy Manpower Project, Inc.

U.S. DataNumber of pharmacists2001 2020

• Distribution 136,000 100,000• Primary care services 30,000 165,000

(Assessment, counseling, monitoring, etc)

• Hospitals, nursing homes, etc 18,000 130,000

• Non Patient Care 12,300 22,000(Industry, academia, government, etc)

Interactions with Health Care Provider

Times per yearPharmacist 12-15 Physician 3-4

Ashville ProjectPharmacists offered community-based services for

diabetics (education, monitoring, drug management)• Paid for by corporate employer• Outcomes

– Improved diabetes control– Lower lipid levels– Decreased health care costs– Reduced sick time

• Cranor CW et al. J Am Pharm Assoc. 2003;43:173-84

Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control.

Shojania KC, et al. JAMA 2006;296:427-440.

• Meta analysis of 11 strategies to improve glycemic control (66 separate trials)

• Nurse and pharmacist case management, when they could make medication adjustments without waiting for physician authorization, was the most effective strategy to lower HbA1c

Collaborative Drug Therapy Management

• Formal agreement between physician and pharmacist that delegates authority to pharmacist.– Initiate, modify, monitor drug therapy– Order lab tests, patient education– Administer medication

• Approved in 46 US states• Immunization, asthma, diabetes,

warfarin, lipids, smoking cessation

Informatics

Availability of clinical patient information is a critical factor for pharmacist functions– Electronic medical record

• Internet-based or record on a chip– Electronic prescribing

Will allow greater pharmacist participation in health care

The “IT” Pharmacist

• Builds the clinical : computer interface• Supports transition of data to knowledge• Manages patient clinical data bases• Clinical decision support systems• Manages drug and technology

information

Antibiotic Stewardship Pharmacist

Roles• Advisor• Educator• Team member with physicians and

microbiology lab• Create and enforce antibiotic policy• Formulary management• Pharmacokinetic dosing

Pharmacogenomics

The prospect of using genetic information to treat disease or individualize drug therapy.

Example: Genetic polymorphism for Thiopurine-S –methyl transferase (metabolizes mercaptopurine)– 1 in 300 people are deficient in TPMT– Increased risk of bone marrow suppression with

mercaptopurine and azathioprine

Pharmacogenomics

• Personalized medicine• Maximize desired drug response and

minimize adverse effects.– Drug selection and dosing

• Expanding list of drugs where pharmacogenomics may be used: Warfarin, antidepressants, cancer drugs, many others

Medication Safety“To Err is Human”

Report from the Institute of Medicine, 1999• 44,000 to 98,000 patients in US die each year from

medical errors.

• Total cost is $17-29 billion

• Among the many recommendations:

“Have a pharmacist available on nursing units and on rounds”

“Implement physician computer order entry”

Use software to check for drug interactions, doses, etc.

Med Safety Resources

• Institute for Safe Medication Practices– www.ismp.org– Tools and resources

• Institute of Medicine– www.iom.edu– Preventing Medication Errors: Quality

Chasm Series (2006)

Adherence to Medication Therapy: An Unsolved Problem

02468

10121416

100 99 to 80 79 to 60 59 to 40 <40Adherence Rate (%)

Hospitalization Rate (%)

From: Lau DT, Nau DP. Diabetes Care. 2004;27:2149-53

Academic Detailing

Academic detailing utilizes the effective communications strategies of the pharmaceutical industry.

Clinical consultants (pharmacists) meet with providers to offer them unbiased, evidence-based clinical information about drug therapy and best-practices that will assist with making best prescription decisions.

http://www.sccp.sc.edu/centers/SCORxE

Future Vision of Pharmacy Practitioners

“Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes”

“Pharmacists will have the authority to manage medication therapy and will be accountable for patients’ therapeutic outcomes.”

Joint Commission of Pharmacy Practitioners

Biggest Challenges in Advancing the Profession of Pharmacy

• Lack of payment for clinical services• Laws and regulations that limit practice• Training and skills of pharmacists• Variation in models of practice

– Product versus patient centered

Is Pharmacy Education Keeping Up With the Pace of Change in

Health Care?

Recent Changes in Pharmacy Education

• Move to PharmD and clinical MPharm

• Increased time in practice experiences

• Expansion of the pharmacy education enterprise

• Greater emphasis on community pharmacy and primary care

• Professionalism and Interprofessional education

• Active learning

What is Most Important?

• Knowledge• Skills• Behavior / attitudes

Shift from Teaching to LearningTeacher centered Student centered

Transfer knowledge Student discovery

Passive learning Active learning

Competitive Cooperative

Focus on input Focus on outcomes

Set lecture time Variable time for learning

Answering questions Asking questions

Material covered Competency

Assumptions• Factual knowledge quickly looses its value and can

easily be updated with new media• Pharmacy and health care are rapidly changing,

requiring new knowledge and skills• Desirable attributes of pharmacy graduates include:

– Adaptability to changing healthcare environment– Motivation for life-long learning– Critical thinking and problem solving– Exhibit professional behaviors

• Traditional lecture approach does not instill the desirable attributes

The Learning Pyramid National Training Laboratories, Bethel, ME

Passive

Active

Active Learning

• Methods of instruction that focus more on the process of learning than on teaching.

• The responsibility for learning is shifted to the student from the teacher

• Develop critical thinking• Higher order cognition (Bloom’s taxonomy)

Bloom’s Taxonomy

From www.educationforum.co.uk/HA/bloom.htm

Audience Response Systems

0

10

20

30

40

50

A B C D E

Percent of responses

Advancement of Pharmacy Education

Degrees•Pharm.D. and M.Pharm. ResidencyCertifications• Board certification• Disease management certificationContinuing Professional Development

Internationalization

What Colleges are not Teaching Well

• How to work in a busy, complex environment

• How to effectively deal with people

• Making the best use of information technology

• Rapidly changing areas in biomedical sciences

• Complimentary and alternative medicine

CertificationBoard of Pharmaceutical Specialties (U.S.)

“Board Certification” (Pharmacotherapy, Nutrition, Nuclear, Oncology, Psychiatry, Ambulatory care)

Commission for Certification in Geriatric Pharmacy“Certified Geriatric Pharmacist”

National Institute for Standards in Pharmacist CredentialingDiabetes, Asthma, Dyslipidemia, Anticoagulation

Multidisciplinary CertificationCertified Diabetes Educator

Where Practitioners Can Have the Most Influences on Colleges

• Recruitment of students to pharmacy

• Mentoring of pharmacy students

• Providing high quality experiences

• Advisement and role modeling for working in current health care settings

Pharmacists in 2030• Less emphasis in preparing and dispensing

prescriptions• More direct patient care

– Emphasis on chronic disease management– More activity in population-based care

• Greater reliance on pharmacy technicians• More specialists in selected areas

– Oncology, pediatrics, Infectious diseases, mental health, pharmacogenomics

• Greater reliance on credentials for privilege to practice

Factors Likely to Influence Pharmacy Over the Next 20 Years

• Changing societal demand for services• Increased access to medicines through

global trade• Internationalization of education and

practice standards