Pharmacy goals, a reality check and insanity – what the heck are we doing?

I’ve been conversing with several pharmacists about the future of pharmacy practice, specifically about the PPMI developed earlier this year by ASHP. This is a sharp group of people, but what I continually hear is the same thing I’ve heard for a number of years. While I’m not as experienced as many of my esteemed colleagues due to a late start to my career, I have worked in several acute care facilities. I’m not sure who said it, but Einstein gets credit for defining insanity as doing the same thing over and over again and expecting different results.

The literature presented in support of a new practice model is, in reality, based on current practice. It’s all looking at how best to apply the pharmacist’s current knowledge and resources to the current practice model. Economic outcomes improved by a pharmacist; great, but not new. Improved patient outcomes with a pharmacist in a team approach; awesome, but not new. Use a pharmacist as a prescriber; cool idea, but not new. These models are easily ten years old and we’re still talking about them as if they were new ideas. See a trend here? I think this is exactly what Einstein had in mind when he defined insanity.

I believe a reality check is in order. Here are some things I think need to be addressed:

1. Pharmacists can save healthcare systems money – This alone isn’t enough to drive any healthcare organization to employee additional pharmacy resources or change their model. This is especially true for small to mid-sized hospitals where financial and labor resources are scarce.
2. Pharmacists can positively impact patient care – No one can logically argue otherwise, the literature supports it. But again, this alone will not drive healthcare organizations to employee additional pharmacy resources.
3. It’s easier to drive a clinical model in the academic setting – Unfortunately this doesn’t translate well to real world situations. My introduction to the workforce was completely different than the picture painted of pharmacy practice while in pharmacy school. UCSF School of Pharmacy painted an image of the perfect clinical world where pharmacists were an accepted and valued member of healthcare team; the roses and butterflies approach. In reality I’ve worked in hospitals where the pharmacist was despised; in some where we were tolerated; and finally in a couple where the pharmacist was embraced, but not in the role defined by my pharmacy education. I believe that pharmacy schools need to continue driving the idea of clinical pharmacy models and a collaborative approach to healthcare, but ultimately the pharmacy profession must find a way to change the practice model from the grassroots level. As the famous Geddy Lee once sang “And the men who hold high places must be the ones who start. To mold a new reality.” It will ultimately be hospital leadership, along with pharmacy directors that drive a change in the pharmacy practice model at the acute care hospital level.
4. Retail pharmacy is a shadow of what it could be – Throughout my career I’ve dabbled in the retail setting just to gauge what’s going on. As a whole it’s an embarrassment to what pharmacists are trying to accomplish and will eventually do nothing more than hurt the profession. This presents an opportunity as a key area of focus for the future state. These pharmacists interact with patients far more consistently than the average acute care pharmacist. Technology and increased pharmacy technician involvement should be considered here as the retail setting is an ideal place for such a model.
5. The pharmacist’s role in healthcare is built on a foundation of sand – If pharmacists were not required by law to check medications would the healthcare system continue to function if they were to disappear tomorrow? This is a tough question to answer and it requires complete and brutal honesty. While the answer may be complex, the simple reality is that the answer is no. Would patient care suffer? Perhaps in some facilities, but not in all; it would depend on the model deployed. If physicians vanished tomorrow would healthcare be in trouble? Based on the current model we would be in big trouble. If nurses vanished tomorrow would healthcare suffer? Absolutely. The healthcare system would simply shut down as nurses are the front line resources in the acute care setting. As a pharmacist can you imagine trying to do your job without nurses on the floor taking care of the patients? I can’t. We’re playing with fire as long as our role in healthcare depends on shackles in place by legal necessity. We need to define a role desirable to both the patient and other healthcare professionals. Note: a colleague challenged the question of whether or not the absence of physicians would hurt healthcare. He referenced an interesting article in BMJ (http://www.bmj.com/content/320/7249/1561.1.full). The article infers that mortality dropped following a physician strike to protest against a proposed wage contract. I read the article and I’m not convinced that the information is worthwhile. With that said, I believe pharmacists could easily function in a primary care role, but would most certainly struggle in others. I can’t remember the last time I performed a heart transplant. And the reason I can’t remember the last time is because I’ve never done one. I’m sure I could eventually figure it out, but would you want to be one of my first customers/patients? Thought not.
6. Technology is creating a new healthcare landscape – Let’s face it, pharmacists currently act as an advanced clinical decision support system for physicians, nurses and patients. As technology gets better pharmacists will slowly be removed from this role. While there will always be complex patients that require multiple medications where a pharmacist might provide value, the numbers don’t support an entire army of pharmacy professionals. With that said, where will the pharmacist fit in this model? We’ve always been relegated to handling complex medication issues along with handling complex dosing such as what’s seen with vancomycin and the aminoglycosides. Simply put, that’s because it takes the physician longer to deal with the issue than he/she would like. That’s changing. Don’t cubbyhole pharmacists into management of single drug entities as our usefulness will eventually disappear along with the drug. Remember doing kinetics on procainamide and lidocaine? I do, but I haven’t had to do any in many years because the drugs have become clinically irrelevant for the most part. See my point?
7. Automation is capable of, and probably will replace dispensing pharmacists at some point. – I’m not saying this will happen next week or even a decade from now, but make no bones about it, our profession is in trouble if we continue to tie ourselves to the art of dispensing. With that said, there are some pharmacists that don’t like being “clinical”. I think that’s strange as everything we do could be considered clinical in one form or another, but I digress. I’ve met pharmacists that like the operational role they play and have skill making things run smoothly in a central fill model. In addition I’ve me pharmacists that specialize in IV preparation and solution stability; they’ve found a niche. Not all pharmacists want to be in a direct patient care roll. Some will remain in the physical pharmacy, but their role will be completely different than what we see now.

I think there are two basic questions that need to be answered as simply and completely as possible before attempting to redefine pharmacy:

• What will pharmacists do in the new model?
  • Medication consulting at the bedside?
  • Prescribing?
  • Routine general care?
  • Chronic disease state management?
  • Specializing in regulatory compliance?
  • Specializing in medication safety?
  • Prospective chart review?
  • Preventative care?
  • Medication reconciliation beginning in the ED?
  • PBM claims adjustment?
  • Workflow managers?
  • Leaders or followers?
• What infrastructure do we need to build the new model defined in question #1?
  • Fully automated?
  • Zero automation?
  • Hybrid technology model?
  • Centralized?
  • Decentralized?
  • Point-of-care?
  • Hybrid?
  • Tied to dispensing?
  • Completely free of the physical pharmacy and physical drug?
  • Pharmacy technician driven focus?
  • Pharmacy as its own department?
  • Pharmacy as part of the nursing department?
  • Pharmacy as part of the department of medicine?

I’m just sayin’.