Leaders Envision Pharmacy In the New Millennium
Leaders Envision Pharmacy In the New Millennium
We live in a world where it is hard to predict the change that might occur in the next year -- much less imagine what the next century or millennium will bring. But, in keeping with the phenomenon known best as Y2K, the staff of Pharmacy Today set out to do just that: try to express where pharmacy is now and envision where it might be going.
In this first issue of 2000, we provide you with articles about:
To put these snapshots in a broader perspective, we first provide a "virtual roundtable" with a few thought leaders in pharmacy. We use the term "virtual" to indicate that none of the participants talked directly with one another. Rather, in keeping with the communication possibilities of the times, the participants expressed their thoughts independently through face-to-face interviews, e-mail messages, telephone interviews, and live continuing education presentations. As we worked to pull their thoughts into a cohesive piece, it seemed in places as though they were responding to one another, so we chose to present the information to you in that format.
Participants in this virtual roundtable included the following leaders:
Pharmacy Today (PT): While change seems to be a given in our world, is your view of the future of pharmacy one of growth, stagnation, or decline?
Alvarez: I believe that a period of growth will follow the stagnation that is occurring today. The profession continues to grapple with implementing and being paid for cost-effective, outcomes-based drug therapy. Those practitioners at the forefront of practice and research continue to fuel the journey, yet it does not seem as though the mass of pharmacists has been able to successfully make this transition.
Lee: As the new decade begins, pharmacy will need to grow by addressing the safety, efficacy, and accountability of how we manage the medication use process. Throughout the inpatient and outpatient settings, the skilled-nursing facility, the patient's home...it's really the same system, even if the processes are a little different. Technology allows us to bring the information from these settings together in a seamless way, and we will need to use that technology to solve many of these medication use problems.
Vogenberg: On that point, many policy makers understand the data from hospitals that demonstrate the extent and seriousness of medication-related problems, and they recognize the role pharmacists can play in solving these problems in health systems. They also surmise that similar problems exist in the community, but they don't know what pharmacists in the community have to offer to help improve the situation. Yet all the pharmacists who have gone out on a limb and instituted pharmaceutical care are swamped. Pharmacists are finding out that they can offer innovative services, be very successful -- and, yes, get paid for it.
Zellmer: As more pharmacists get involved in pharmaceutical care, the public stereotype of the pharmacist will change. However, it will take longer than most pharmacists realize. There will be a continuing need to work assertively in bringing the public up-to-date on the knowledge, skills, and abilities of pharmacists. Serious consideration will have to be given to periodic state board reexamination of pharmacists as a qualification for continued licensure. This will allow mid- and late career practitioners to prove that they know as much as recent graduates and will induce the public -- including payers -- to accept patient care roles for pharmacists.
Prevost: I agree. In three focus groups we recently conducted in Celebration, Fla., residents were asked what they expected in terms of pharmacy services when they originally decided to move to this Disney-planned community. Invariably, the answer was, "We expected a drugstore in the middle of town with a soda fountain." But that's not what we offered -- the only pharmacy is in a medical complex on the edge of town. The notion of disease state management by pharmacists was a stretch for the general public.
Penna: The main issue pharmacy must address today is who will manage the medication use process in the future. Biotechnology, genomics, combinatorial chemistry, and high-throughput screenings are changing the way drugs are developed and the types of agents that reach the market. Customized, complicated medications may be the norm in just a few years. Are we pharmacists going to give up a role in this process and let someone else do it for us?
Stergachis: Pharmacy will change only incrementally in the next 5 years or so as the Internet, electronic prescribing, greater use of technicians, and central filling programs continue to take hold. Pharmacy regulations will become permissive for new technologies in a manner that protects and even enhances patient safety.
PT: What factors do you think will drive the profession in the coming years, and why?
Prevost: At Celebration Health, we're pretty high-tech, high-touch, and that's what I would like to see pharmacy be in the future. We're really trying to use the best technology. But you have to remember that everyone is a separate individual with different wants and needs. What we're hearing that patients in our technology-savvy community want are these things: convenience in both pharmacy hours and delivery of medications and the ability to transact and obtain information using a computer.
Alvarez: Social desire to experience human interaction, compassion, and empathy will affect pharmacy the most. Once the technologic "fads" of the Internet, e-commerce, and e-mail plateau, I think individuals will gravitate to health care professionals who "care" for them. I believe people will want to return to the feeling of the corner drugstore as an anchor of support in communities. Right now, numerous distractions prevent these relationships from growing. In fact, in community pharmacy, third party challenges derail the focus of the practitioner away from the patient.
Zellmer: The self-care movement and direct-to-consumer advertising will alter the pharmacy landscape. Pharmacists will need to act as buffers between patients and Madison Avenue, and pharmaceutical manufacturers and marketers will respond by redoubling their attempts to persuade patients to use their products. Unless practicing pharmacists can find a way to assertively help patients put those powerful messages in perspective, there is great risk of patient harm and wasted drug expenditures. Practicing pharmacists will also face immense ethical challenges as they balance their obligations to patients with the cost-control imperatives of the health systems in which they work.
Lee: We have a population that is aging. People are taking lots of maintenance medications. Why can't we move these medications closer to them? For instance, in a recreation center in a senior community, why can't we bring the medication to the patient at the time it is needed? Suppose an automated dispensing kiosk were located there. Patients would be able to put in their own cards and obtain the medicines due at that time. This may sound like heresy to some, but it's a natural extension of the existing technology if we focus on our responsibility to the patient. Think of the profiles we could develop -- and the counseling and education we could offer, for example, when a patient hasn't had the medication refilled in 6 months.
PT: What do you think a "pharmacy" will be like in 5, 10, 50, or 100 years, and what will pharmacists be doing?
Zellmer: The drug product handling function in all health care settings will increasingly be carried out by technicians and highly automated dispensing systems. Much of this function in health systems will be "outsourced" to companies that are developing a high level of expertise in "pharmacologistics" -- moving the drug product from the manufacturer to the patient.
Alvarez: Pharmacists will work less directly with drug products across many different practice settings. They will spend their days collaborating with others to design the medication portion of patients' care plans and assisting in monitoring and collecting information on their patients. I am not sure that pharmacies will look much different than they do now, at least in the near future. Although telemedicine will continue to affect brick-and-mortar pharmacies, I think that there will continue to be a need to have the local, physical environments that exist today.
Vogenberg: For community (chain and independent) pharmaceutical services, the Veterans Affairs (VA) model is pretty insightful. That system has regional processing centers for long-term medications, on-site pharmacies for short-term medication needs, and pharmacists providing pharmaceutical care. The open question is whether two kinds of pharmacists will emerge: some who dispense, and others who practice clinically. That is happening in the VA, but the chains right now are testing models where pharmacists provide both functions. Institutions may more often have pharmacist-specialists, while community pharmacy may be less specialized but still have support staff.
Lee: Because of communications and technology, I envision an international practice of pharmacy. It's not a pharmacy in the United States and a pharmacy in Canada and a pharmacy in Spain -- it's just pharmacy practice. The underlying principles of pharmacy are the same no matter where you are in the world -- only the processes differ.
Penna: Pharmacists will be freed up by automation, but most will not be able to capitalize on it. I hope I'm wrong, but I'm skeptical about this. A few pharmacists will become "therapy masters." Eventually, some profession will emerge and take charge of the drug dilemmas we face. I hope that will be pharmacy, but I'm concerned that we may bypass the opportunity and give it to someone else.
Stergachis: In 50 years, the majority of customers will leave physicians' offices with their new prescriptions in hand or get their prescriptions via a kiosk, get their refills home delivered, and fulfill their information needs via future versions of the Internet. I envision pharmacists as having limited but very focused face-to-face contact with their customers. There will continue to be a need for community, brick-and-mortar pharmacies.
Consumers will continue to select their pharmacy and pharmacists on the basis of convenience, cost, trust, and services. However, these factors will carry different meanings in the future. Consumers will increasingly value saving time and money and learning how to make better decisions to stay healthy. But convenience, for example, will mean tailoring the provision of medicines, other pharmacy services, and information to customers' schedules, lifestyles, needs, and technologies.
In the future, customers will be better informed and will expect more from pharmacists. Pharmacists of the future will need to be proficient with the use of technologies -- many of which haven't been deployed yet in pharmacy. The prescription process of the future will be safer, more efficient, and convenient, and will give customers a wealth of information and tools they can use to be better empowered in making their health care decisions.
We live in a world where it is hard to predict the change that might occur in the next year -- much less imagine what the next century or millennium will bring. But, in keeping with the phenomenon known best as Y2K, the staff of Pharmacy Today set out to do just that: try to express where pharmacy is now and envision where it might be going.
In this first issue of 2000, we provide you with articles about:
George F. Archambault, described by some as the "Pharmacist of the 20th Century."
Michelle Childs, who may represent the prototypical "Pharmacist of the 21st Century."
Washington State, where a 20-year history of licensed technicians and collaborative practice agreements for pharmacists are producing change that other states hope to replicate.
An analysis of where the profession stands on collaborative practice agreements.
To put these snapshots in a broader perspective, we first provide a "virtual roundtable" with a few thought leaders in pharmacy. We use the term "virtual" to indicate that none of the participants talked directly with one another. Rather, in keeping with the communication possibilities of the times, the participants expressed their thoughts independently through face-to-face interviews, e-mail messages, telephone interviews, and live continuing education presentations. As we worked to pull their thoughts into a cohesive piece, it seemed in places as though they were responding to one another, so we chose to present the information to you in that format.
Participants in this virtual roundtable included the following leaders:
Nancy Alvarez, vice president of professional development at excelleRx, Philadelphia.
M. Patricia Lee, practitioner-in-residence, American Society of Health-System Pharmacists, Bethesda, Md. -- and formerly with Pyxis Corporation, the University of California, San Diego Hospitals, and the University of California, San Francisco School of Pharmacy.
Pete Penna, P. M. Penna Consulting, Farmington, Conn., and formerly with the Group Health Cooperative of Puget Sound, Seattle.
Rebecca R. Prevost, director of pharmacy, Celebration Health, Celebration, Fla.
Andy Stergachis, director of pharmacy services, drugstore.com, Bellevue, Wash.
F. Randy Vogenberg, director and national practice leader, ASA Health System Education and Pharmaceutical Consulting, Wellesley, Mass., and chair of APhA's Strategic and Tactical Analysis Team (STAT) on Pharmacist Payment and Empowerment.
William A. Zellmer, deputy executive vice president, American Society of Health-System Pharmacists, Bethesda, Md.
Pharmacy Today (PT): While change seems to be a given in our world, is your view of the future of pharmacy one of growth, stagnation, or decline?
Alvarez: I believe that a period of growth will follow the stagnation that is occurring today. The profession continues to grapple with implementing and being paid for cost-effective, outcomes-based drug therapy. Those practitioners at the forefront of practice and research continue to fuel the journey, yet it does not seem as though the mass of pharmacists has been able to successfully make this transition.
Lee: As the new decade begins, pharmacy will need to grow by addressing the safety, efficacy, and accountability of how we manage the medication use process. Throughout the inpatient and outpatient settings, the skilled-nursing facility, the patient's home...it's really the same system, even if the processes are a little different. Technology allows us to bring the information from these settings together in a seamless way, and we will need to use that technology to solve many of these medication use problems.
Vogenberg: On that point, many policy makers understand the data from hospitals that demonstrate the extent and seriousness of medication-related problems, and they recognize the role pharmacists can play in solving these problems in health systems. They also surmise that similar problems exist in the community, but they don't know what pharmacists in the community have to offer to help improve the situation. Yet all the pharmacists who have gone out on a limb and instituted pharmaceutical care are swamped. Pharmacists are finding out that they can offer innovative services, be very successful -- and, yes, get paid for it.
Zellmer: As more pharmacists get involved in pharmaceutical care, the public stereotype of the pharmacist will change. However, it will take longer than most pharmacists realize. There will be a continuing need to work assertively in bringing the public up-to-date on the knowledge, skills, and abilities of pharmacists. Serious consideration will have to be given to periodic state board reexamination of pharmacists as a qualification for continued licensure. This will allow mid- and late career practitioners to prove that they know as much as recent graduates and will induce the public -- including payers -- to accept patient care roles for pharmacists.
Prevost: I agree. In three focus groups we recently conducted in Celebration, Fla., residents were asked what they expected in terms of pharmacy services when they originally decided to move to this Disney-planned community. Invariably, the answer was, "We expected a drugstore in the middle of town with a soda fountain." But that's not what we offered -- the only pharmacy is in a medical complex on the edge of town. The notion of disease state management by pharmacists was a stretch for the general public.
Penna: The main issue pharmacy must address today is who will manage the medication use process in the future. Biotechnology, genomics, combinatorial chemistry, and high-throughput screenings are changing the way drugs are developed and the types of agents that reach the market. Customized, complicated medications may be the norm in just a few years. Are we pharmacists going to give up a role in this process and let someone else do it for us?
Stergachis: Pharmacy will change only incrementally in the next 5 years or so as the Internet, electronic prescribing, greater use of technicians, and central filling programs continue to take hold. Pharmacy regulations will become permissive for new technologies in a manner that protects and even enhances patient safety.
PT: What factors do you think will drive the profession in the coming years, and why?
Prevost: At Celebration Health, we're pretty high-tech, high-touch, and that's what I would like to see pharmacy be in the future. We're really trying to use the best technology. But you have to remember that everyone is a separate individual with different wants and needs. What we're hearing that patients in our technology-savvy community want are these things: convenience in both pharmacy hours and delivery of medications and the ability to transact and obtain information using a computer.
Alvarez: Social desire to experience human interaction, compassion, and empathy will affect pharmacy the most. Once the technologic "fads" of the Internet, e-commerce, and e-mail plateau, I think individuals will gravitate to health care professionals who "care" for them. I believe people will want to return to the feeling of the corner drugstore as an anchor of support in communities. Right now, numerous distractions prevent these relationships from growing. In fact, in community pharmacy, third party challenges derail the focus of the practitioner away from the patient.
Zellmer: The self-care movement and direct-to-consumer advertising will alter the pharmacy landscape. Pharmacists will need to act as buffers between patients and Madison Avenue, and pharmaceutical manufacturers and marketers will respond by redoubling their attempts to persuade patients to use their products. Unless practicing pharmacists can find a way to assertively help patients put those powerful messages in perspective, there is great risk of patient harm and wasted drug expenditures. Practicing pharmacists will also face immense ethical challenges as they balance their obligations to patients with the cost-control imperatives of the health systems in which they work.
Lee: We have a population that is aging. People are taking lots of maintenance medications. Why can't we move these medications closer to them? For instance, in a recreation center in a senior community, why can't we bring the medication to the patient at the time it is needed? Suppose an automated dispensing kiosk were located there. Patients would be able to put in their own cards and obtain the medicines due at that time. This may sound like heresy to some, but it's a natural extension of the existing technology if we focus on our responsibility to the patient. Think of the profiles we could develop -- and the counseling and education we could offer, for example, when a patient hasn't had the medication refilled in 6 months.
PT: What do you think a "pharmacy" will be like in 5, 10, 50, or 100 years, and what will pharmacists be doing?
Zellmer: The drug product handling function in all health care settings will increasingly be carried out by technicians and highly automated dispensing systems. Much of this function in health systems will be "outsourced" to companies that are developing a high level of expertise in "pharmacologistics" -- moving the drug product from the manufacturer to the patient.
Alvarez: Pharmacists will work less directly with drug products across many different practice settings. They will spend their days collaborating with others to design the medication portion of patients' care plans and assisting in monitoring and collecting information on their patients. I am not sure that pharmacies will look much different than they do now, at least in the near future. Although telemedicine will continue to affect brick-and-mortar pharmacies, I think that there will continue to be a need to have the local, physical environments that exist today.
Vogenberg: For community (chain and independent) pharmaceutical services, the Veterans Affairs (VA) model is pretty insightful. That system has regional processing centers for long-term medications, on-site pharmacies for short-term medication needs, and pharmacists providing pharmaceutical care. The open question is whether two kinds of pharmacists will emerge: some who dispense, and others who practice clinically. That is happening in the VA, but the chains right now are testing models where pharmacists provide both functions. Institutions may more often have pharmacist-specialists, while community pharmacy may be less specialized but still have support staff.
Lee: Because of communications and technology, I envision an international practice of pharmacy. It's not a pharmacy in the United States and a pharmacy in Canada and a pharmacy in Spain -- it's just pharmacy practice. The underlying principles of pharmacy are the same no matter where you are in the world -- only the processes differ.
Penna: Pharmacists will be freed up by automation, but most will not be able to capitalize on it. I hope I'm wrong, but I'm skeptical about this. A few pharmacists will become "therapy masters." Eventually, some profession will emerge and take charge of the drug dilemmas we face. I hope that will be pharmacy, but I'm concerned that we may bypass the opportunity and give it to someone else.
Stergachis: In 50 years, the majority of customers will leave physicians' offices with their new prescriptions in hand or get their prescriptions via a kiosk, get their refills home delivered, and fulfill their information needs via future versions of the Internet. I envision pharmacists as having limited but very focused face-to-face contact with their customers. There will continue to be a need for community, brick-and-mortar pharmacies.
Consumers will continue to select their pharmacy and pharmacists on the basis of convenience, cost, trust, and services. However, these factors will carry different meanings in the future. Consumers will increasingly value saving time and money and learning how to make better decisions to stay healthy. But convenience, for example, will mean tailoring the provision of medicines, other pharmacy services, and information to customers' schedules, lifestyles, needs, and technologies.
In the future, customers will be better informed and will expect more from pharmacists. Pharmacists of the future will need to be proficient with the use of technologies -- many of which haven't been deployed yet in pharmacy. The prescription process of the future will be safer, more efficient, and convenient, and will give customers a wealth of information and tools they can use to be better empowered in making their health care decisions.
