Pharmacy in the

st 21

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 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

Issues: Cost, Access, Safety, Efficacy

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.

Distribution Primary care services

U.S. Data Number of pharmacists 2001 2020 136,000 100,000 30,000 165,000 130,000 22,000

(Assessment, counseling, monitoring, etc)

Hospitals, nursing homes, etc 18,000 Non Patient Care 12,300

(Industry, academia, government, etc)

Interactions with Health Care Provider

Times per year 12-15 3-4

Pharmacist Physician

Ashville Project
Pharmacists 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

Hospitalization Rate (% ) 16 14 12 10 8 6 4 2 0 100 99 to 80 79 to 60 59 to 40 <40 Adherence 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 Learning

Teacher centered Transfer knowledge Passive learning Competitive Focus on input Set lecture time Answering questions Material covered Student centered Student discovery Active learning Cooperative Focus on outcomes Variable time for learning Asking questions 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

Passive Active

The Learning Pyramid National Training Laboratories, Bethel, ME

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 (Blooms taxonomy)

Blooms Taxonomy

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

Audience Response Systems

Percent of responses 50 40 30 20 10 0 A B C D E

Advancement of Pharmacy Education

Degrees
Pharm.D. and M.Pharm.

Residency

Certifications
Board certification Disease management certification

Continuing 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

Certification
Board 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 Credentialing

Diabetes, Asthma, Dyslipidemia, Anticoagulation

Multidisciplinary Certification
Certified 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