Pharmacy in the

st 21


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 .

patient satisfaction.Clinical Pharmacy in 2010 • Gaining acceptance throughout the world • Can improve health outcomes in hospitals and communities – Disease endpoints. 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 .

Safety. Access.Art and Science of Pharmacy . Efficacy .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.

ID. asthma. dyslipidemia • Specialist services – Oncology. hypertension. Smoking cessation. critical care. pediatrics • Wellness – Immunizations.Expanding Roles for Pharmacists • Chronic disease management – Diabetes. Education • Industry – Sales. research and development • Specialty compounding • Case consultant to insurers and payors . transplant. marketing.

000 100. government.000 (Assessment. etc) • Hospitals.000 165. PhD et al. • Distribution • Primary care services U.000 22. monitoring.000 • Non Patient Care 12.Professionally Determined Need for Pharmacy Services in 2020 David A. etc 18. counseling.S.300 (Industry. Data Number of pharmacists 2001 2020 136. Knapp. Inc. nursing homes.000 30. Pharmacy Manpower Project. academia. etc) .000 130.

Interactions with Health Care Provider Times per year 12-15 3-4 Pharmacist Physician .

43:173-84 . 2003. 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.Ashville Project Pharmacists offered community-based services for diabetics (education. monitoring. J Am Pharm Assoc.

when they could make medication adjustments without waiting for physician authorization. Shojania KC. JAMA 2006.296:427-440. et al.Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control. was the most effective strategy to lower HbA1c . • Meta analysis of 11 strategies to improve glycemic control (66 separate trials) • Nurse and pharmacist case management.

lipids. patient education – Administer medication • Approved in 46 US states • Immunization. – Initiate. modify. diabetes. asthma. monitor drug therapy – Order lab tests.Collaborative Drug Therapy Management • Formal agreement between physician and pharmacist that delegates authority to pharmacist. warfarin. 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 .

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 The prospect of using genetic information to treat disease or individualize drug therapy.

many others . – Drug selection and dosing • Expanding list of drugs where pharmacogenomics may be used: Warfarin.Pharmacogenomics • Personalized medicine • Maximize desired drug response and minimize adverse effects. cancer drugs. antidepressants.

etc. • 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.000 patients in US die each year from medical errors.000 to 98. 1999 • 44.Medication Safety “To Err is Human” Report from the Institute of Medicine. .

Med Safety Resources • Institute for Safe Medication Practices – – Preventing Medication Errors: Quality Chasm Series (2006) – Tools and resources • Institute of Medicine – www.

27:2149-53 . Nau DP.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. Diabetes Care. 2004.

Academic Detailing Academic detailing utilizes the effective communications strategies of the pharmaceutical industry. http://www.sccp. evidence-based clinical information about drug therapy and best-practices that will assist with making best prescription . Clinical consultants (pharmacists) meet with providers to offer them unbiased.

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 .

Bethel.Passive Active The Learning Pyramid National Training Laboratories. 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 (Bloom’s taxonomy) .

Bloom’s Taxonomy From

Audience Response Systems Percent of responses 50 40 30 20 10 0 A B C D E .

and M.D. Residency Certifications Board certification • Disease management certification • Continuing Professional Development .Pharm.Advancement of Pharmacy Education Degrees •Pharm.

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 .

Ambulatory care) Commission for Certification in Geriatric Pharmacy “Certified Geriatric Pharmacist” National Institute for Standards in Pharmacist Credentialing Diabetes.S. Anticoagulation Multidisciplinary Certification Certified Diabetes Educator . Nuclear. Asthma. Oncology.Certification Board of Pharmaceutical Specialties (U.) “Board Certification” (Pharmacotherapy. Nutrition. Psychiatry. Dyslipidemia.

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 .

pharmacogenomics • Greater reliance on credentials for privilege to practice . pediatrics. mental health.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. Infectious diseases.

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 .

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