Tele-pharmacy
For they un-initiated, tele pharmacy is a relatively new concept. With pharmacies being unable to sustain a practice in areas without sufficient population density, many rural communities are left without access to a pharmacy. Tele-pharmacy is a potential way to bring a pharmacy back to an under-served population by decreasing the cost of running a pharmacy.
The math, however, appears to be suspect. Running any pharmacy includes significant overhead: technician salaries, rent, drug product, and pharmacy specific computer systems. Tele-pharmacy adds additional costs in the form of software and network requirements, while reducing only one expense: the pharmacists salary. Implementing a tele-pharmacy would only be able to lower the cost of running a pharmacy by some fraction of a full time pharmacist’s salary. Keep in mind a pharmacist still needs to be accessible to check prescriptions and counsel patients. The concept of tele-pharmacy simply allows one pharmacist to manage more than one site.
The physical lack of a pharmacist at a pharmacy is a scary proposition, both personally and professionally. The number of hours our pharmacists spend face-to-face with patients each day is significant. This type of accessibility is what enables our pharmacists to optimize each of our patients care. Tele-pharmacy limits that access significantly. If tele-pharmacy is limited to locations not served by a traditional pharmacy, I understand the compromise. But this technology is being pushed as a method to combat the ever decreasing reimbursement pharmacies are seeing. Give the questionable savings this technology provides, tele-pharmacy is troubling.
New Practice Model
In states like Iowa, the Board of Pharmacy is piloting the use of technicians checking the work of other technicians. This is strictly limited to refills; pharmacists still must perform final verification on new prescriptions and counsel the patient. The goal of the program is to free the pharmacist from the final verification process so they can focus on patient care. This model makes a lot of sense, and when used in this way actually can increase overall accuracy and significantly enhance patient care in the pharmacy.
The concept, however, is could be significantly abused if decreasing business expenses in the form of salary savings were allowed to supplant the current goal of freeing the pharmacist to perform patient care. Like tele-pharmacy, this technology could ultimately be used to significantly decrease patient access to pharmacists. The development of this trend deserves continued scruitny.
Mail Order Pharmacy
Mail order pharmacies leverage automation to create an extremely efficient work-flow. They are highly tuned dispensing centers, and the pharmacists working here perform final verification on mind-boggling numbers of prescriptions each day. Patient communication is limited to patient initiated phone calls to a pharmacist-staffed call center.
Mail order prescriptions has a place in the pharmacy world. It offers a limited service with certain advantages appealing to some patients. On the other hand, mail order pharmacy cannot provide acute care. This creates a significant fragmentation of care, as the local pharmacist has little knowledge of the patient and their conditions when presented with a new medication.
Mail order pharmacy presents a unique set of challenges for pharmacists out in the community. The increased risk for significant drug mis-adventures mail-order creates is scary.
Prescription ATMs
For lack of a better description, technology has been able to create a robotic pharmacy in a box. These units are being sold to physician offices and clinics. The machine contains a limited formulary of medications and is designed to provide the patient with their initial supply of both acute or maintenance medications.
The potential for problems is significant with this type of technology. While medical professionals are certainly in proximity of the units, there is no pharmacist involved to screen for drug therapy problems the prescriber may have missed. Counseling is limited to whatever the prescriber managed to fit into their encounter.
While the restricted formulary and the limitation to the first fill limit the damage such technology might cause, certainly there are going to be cases where a pharmacist’s knowledge would be beneficial. Unsupervised dispensing is both frightening and potentially dangerous.
Central Fill
Central fill is becoming increasingly popular with smaller chain pharmacies. It leverages the efficiencies of a mail-order pharmacy with a local pharmacist as long as the patient does not need the medication until the next day. A central fill pharmacy typically will heavily leverage automation, requiring few technicians and pharmacists. Central fill could also be leveraged with a medication synchronization program to further enhance efficiencies.
Besides the advantage of efficiency, central fill has the potential to free the local pharmacist to spend more time working with patients at the time they pick up their order. In fact, using a model like this could ultimately create an almost office-like pharmacy practice. If a high percent of patients were synchronized and picking up all of their medications at the same time, the pharmacist could sit down with every patient to perform continuous medication monitoring.
While the potential for central fill to advance the profession of pharmacy exists and is exciting, it also has a dark side. Central fill could also be used to create a mail-order like workflow, removing access of the patient to the pharmacist. Pharmacists need to be aware of this potential and address it before occurs.
Diminishing the Value of the Pharmacist
While some of the trends above are already embedded in our healthcare system, others are just appearing. Every one of these, however shares a common trait: they either do not value, or have the potential to diminish the value, of pharmacists.
If this is the value the public puts in the profession of pharmacy, maybe I am in the wrong profession. Fortunately, I hear the exact opposite repeated time after time, day after day. When given the option of access to a pharmacist, most patients jump at the opportunity. Why, then, does the public and our elected officials regularly look to take the pharmacist out of pharmacy?
Without pharmacists, medications become terrifying. Without a pharmacist, you just have medication. The pharmacist is the care component of medications. Don’t let anyone take the pharmacist out of your pharmacy.
