Physician dispensing is a hot topic for several reasons. And while I’m notÂ opposedÂ to the use of medication kiosks to dispense medications to patients, I believe that their use must be carefully defined andÂ continuouslyÂ monitored. As I said in a post in September 2010 “Under the right set of circumstances, and with thoughtful implementation, kiosks could free up pharmacists to spend more time with patients in emergency departments and urgent care clinics across the country. After all, donâ€™t pharmacists argue for more clinical face time with patients and less association with the physical medication dispensing process? Thatâ€™s what Iâ€™ve been hearing from pharmacists for years.”Â The key part of that quote is “under the right set of circumstances”. You cannot remove the pharmacist form the medication use process. It would be a mistake to do so, and I believe ultimately would lead to increased patient risk. I’ve worked in retail, long-term care, home infusion and acute care pharmacy, and let’s face it, physicians struggle at times to get things right. That’s why God made pharmacists. While I’m not naive enough to think that a pharmacist has to speak to each and every patient about every medication they use each time they receive it, I do think there should be some oversight of the process; regardless of the method of distribution.
ISMP does a good job of describing the issue in their March 8, 2012 Medication Safety Alert Newsletter. According to ISMP “proponents of physician dispensing cite improved patient access to medications, patient convenience, greater use of lower-cost generic medications and therapeutic substitutions due to the physicianâ€™s enhanced awareness of medication costs, and improved patient adherence with medication regimens. Opponents of physician dispensing cite serious medication safety concerns, particularly the loss of a crucial second check by a pharmacist and use of software to detect prescribing errors, and lack of regulatory oversight, which may lead to lax procedures for medication labeling, record-keeping, storage, and supervision of the dispenser. Thereâ€™s also a sense of unease regarding a potential conflict of interest when the physician prescribing the medication is also the person dispensing the medication and, perhaps, making a profit from the sale.” That’s a fair assessment of the situation.
My opinion on the subject has changed slightly over the past couple of years. I still believe “remote” dispensing with kiosks can help pharmacist by improving distribution efficiency, but I no longer think it can be done without carefully scrutinizing the motives behind each implementation and how it will best serve the patient.
I think ISMP sums it up best: “ISMP fully supports the removal of any barriers to patients’ access to medications, cost containment that can be achieved by use of lower-cost but effective medications, and steps that improve patient adherence to prescribed medication therapy. However, we cannot support unbridled physician dispensing due to the increased risk of medication errors, particularly with high-alert medications such as chemotherapy. While physician dispensing is permitted in most states, it is often carefully regulated and restricted to samples or conditions of immediate need. Some states require dispensing physicians to be licensed by or registered with the Board of Pharmacy, or they must obtain a special permit. The American Medical Association Code of Ethics notes that “Physicians may dispense drugs within their office practices provided such dispensing primarily benefits the patients.” However, we worry about the unintended consequences of physician dispensing, as described in more detail below.”
I believe in the technology, but I think the circumstances under which we choose to use that technology should be carefully evaluated. Sounds like an opportunity for a good study to me.