Written by Terry McInnis, M.D., MPH
Editor’s Note: Dr. Terry McInnis is President of Blue Thorn, Inc., a health care management consulting company. She is a board-certified physician in preventive and occupational medicine and has an extensive background in health policy and program administration, including her most recent position as Medical Director for Health Policy and Advocacy for GlaxoSmithKline US. Dr. McInnis co-chairs the Center for Public Payer Implementation for the Patient Centered Primary Care Collaborative (www.pcpcc.net) and co-leads the PCPCC Medication Management task-force together with Linda Strand, Pharm.D., Ph.D., and ACCP Associate Executive Director C. Edwin Webb. Her email address is firstname.lastname@example.org.
I am a physician. Although arguably the practice of medicine is an art, by no means is it a “free-hand” art practiced at the whim of the artist on the canvas of a complacent patient. The diversity of our patients’ experiences, expectations, and beliefs paired with the wonderful complexity of the human body in various degrees of health and disease all demand a level of systemization in our approach to practice. If we as practitioners are to meaningfully engage our patients in optimizing their health, we must have an orderly and evidence-based process to apply our “art.”
Even with all of the knowledge of various diseases, symptoms, and signs, without an effective and efficient approach to reveal the various degrees of health and disease in a particular patient the knowledge is worthless. Thinking back over 25 years to my medical school days the familiar approach remains in place today—chief complaint, history of present illness, review of systems, past medical history, etc., including the SOAP format (Subjective, Objective, Assessment, Plan) for our documentation system. Clinical decision support tools, reminders, and electronic medical records (EMRs) have helped to embed this rigor. This was and is a systematic approach, used to try to ensure that important details and clues are not missed and are then adequately addressed and communicated with the patient and other providers.
The practice of “pharmaceutical care” demands the same rigor and systemization to truly take its rightful place as a provider-based discipline in a whole-patient approach. What I mean by this is that it is easy to answer a specific question, such as, are there any drug-drug interactions occurring with this patient? A pharmacist can compile a medication list for medication reconciliation or review the INR level and suggest dosage changes of warfarin. Even the familiar question people hear from their car windows at the drive through or across the dispensing counter at the cash register as they are handed a bag of medicines and asked “do you have any questions about your medications that you want to discuss with the pharmacist?,” is easily and readily answered. All of these questions are important and at times are the questions to be answered. But this is not the practice of pharmaceutical care1 whereby all of the medications being taken are systematically reviewed with the patient in the context of the disease state for which the medications are being used. Comprehensive medication management2 involves optimizing the medications in an attempt to achieve the clinical goals of therapy for each disease state in a patient-centric approach. This practice must be orderly and fully understood by the profession and is essential to the successful discovery and resolution of drug therapy problems that are preventing patients from reaching these goals. The practice must be documented, communicated, evidence-based, and reiterative—in short, the practice requires a systematic approach.
Dr. Linda Strand, Distinguished Professor Emeritus of the University of Minnesota. School of Pharmacy, recently commented after her keynote in Reykjavik, Iceland for the Nordic Social Pharmacy Conference to an international audience3: “Pharmacists are coming together, however, for the very first time for the purpose of defining a common professional practice. It is becoming apparent to everyone, perhaps those outside of the profession sooner than for those inside the profession, that unless a common, scientifically-based and professional patient care practice is understood, implemented and practiced by all pharmacists around the world, there will be no place for this service in future health care systems. This is still a revelation to many pharmacists, and yet, is the starting point for marking real progress in establishing a valuable contribution to the ethical care of patients.”
Closer to home, in a recent article in Pharmacy Times addressing the role of pharmacists in coordinated care models, Professor Fred Eckel4 stated: “As these newer models (accountable care organizations/patient-centered medical homes) become more common, will the pharmacist become a member or will others provide the patients’ drug therapy needs? The answer to this question will impact pharmacy’s future significantly. I am concerned that too many pharmacists are spending too much energy holding onto the current dispensing practice model instead of investing time and money to establish this new practice. What advice would I give to those working on the incorporation of pharmacists into the PCMH and the ACO? It would be to make sure you position pharmacists to take care of the patient.”
I believe that these two elements—a professional, standardized practice and the evolution of the pharmacist as a practitioner “taking care of patients” as part of the patient-centered medical home or ACO team—are equally critical. This systematic approach embodied in a common professional practice of pharmacy will unleash the full power of the appropriate use of the phenomenal medications that we have to improve health for patients and simultaneously lower our total healthcare costs in collaboration with physicians and other team members! Then we as a society will realize the true value that pharmacists can play by applying the full-force of their pharmacology knowledge in this clinical role.
My keynote address at the National Leadership Roundtable held earlier this year at the University of Maryland School of Pharmacy, which was co-sponsored by ACCP, included my conviction (it was actually the title of the keynote!) that “pharmacists can be the most transformative force in improving health for patients and reducing costs—but will they?” You cannot practice this level of care while you are behind the counter dispensing medications. The skill set to effectively interview and interact with patients as a trusted clinical pharmacist in making drug therapy recommendations, while having the confidence and respect of the physicians and prescribers with whom you are collaborating, will demand a systematic and evidence-based approach to identifying and resolving drug therapy problems that undeniably adds value to the outcomes of the patient’s care. Simply suggesting therapeutic or generic switches (which do not change clinical status), pointing out a drug-drug interaction, or compiling a list of the medications a patient is taking, can be done by other caregivers—and often times, easily available computer software.
Will you take your knowledge of pharmacology to the level of applying it to practice by making the more difficult recommendations such as suggesting based on the evidence, an additional drug be added, a change of dosage, or a different drug prescribed which resolves a drug therapy problem that you have systematically found and documented, based on the evidence and your professional knowledge, to actually improve patient outcomes and safety? Are you prepared to consistently practice at the absolute top level of your license and scope of practice?
For pharmacists, I believe that you have come to one of the rare crossroads that will define the future of your profession. You will either take your place as providers of care, or your numbers will dwindle as most dispensing activities are replaced by robotics and pharmacy technicians. I am a physician, and I say our profession and the patients that we serve need you “on the team” as clinical pharmacist practitioners. But, will you truly join us?
1 Pharmaceutical care practice is fully described in the following textbook: Cipolle R, Strand L, Morley P. Pharmaceutical Care Practice—The Clinician’s Guide, 2nd ed. New York: McGraw-Hill, 2004. (The third edition is pending publication.)
2 Comprehensive medication management is defined and described in the Patient-Centered Primary Care Collaborative Resource Guide: The Patient-Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Available at www.pcpcc.net/files/medmanagement.pdf. Accessed October 10, 2011.
3 Linda Strand, Pharm.D., Ph.D., is Vice President of Professional Services at Medication Management Systems (www.medsmanagement.com), and the comments can be found on her July 8 blog (http://blog.medsmanagement.com/linda-strand-keynotes-international-conferenc).
4 Fred Eckel, R.Ph., M.S., is a professor at the UNC Eshelman School of Pharmacy and formerly an executive director of the NC Pharmacists Association. The article appeared in Pharmacy Times (http://www.pharmacytimes.com/publications/issue/2011/May2011/The-Patient-Centered-Medical-Home-and-ACOsu2026-What-Should-Be-the-Pharmacistu2019s-Role).