Participants in the fifth and final plenary session on August 30 at the recent World Congress of Pharmacy in Vienna heard speakers from Britain, Finland, Malaysia, South Africa and the United States talk about how developments in information and communications technology had the power to change practice
 |
| Affordable internet access provides opportunities for consumers to disseminate their own health information |
Health care consumers are turning away from the doctor and pharmacist, having
less faith in authority. That was one of the conclusions of Mr Erkki Kostiainen
(chief editor of the Finnish Pharmacy Association Journal), when he considered
the attributes of the “informed and empowered consumer”. He asserted
that consumers would be more demanding because of their access to information,
more emotional than rational about health care, and more interested in personal
well-being than just treatment of disease.
Technology uptake in Finland had been extensive and rapid. Three out of four
Finns had mobile telephones, and one million people used the internet every
day. Finnish consumer developments in pioneering health information and communications
technology included the ability to book appointments with doctors online and
to use technology to monitor treatment for conditions such as diabetes. Recently,
it had become possible for consumers to locate the nearest pharmacy using their
mobile telephone.
E-commerce was growing, and companies which used customer data to provide tailored
services were most likely to be successful in the health care arena. Would pharmacists
in existing pharmacies be the providers of these services, or would new players
enter the arena? Would consumers be able to tell the difference?
Pharmacists had a key role in reducing inappropriate use of medicines, filling
gaps in customer knowledge, helping consumers to control the flood of information
and evaluating when they should be referred to their doctor. Social contact
would always be important, said Mr Kostiainen.
He went on to say that a recent consumer survey had revealed that people in
Finland were reluctant to buy medicines over the internet. For 10 years, pharmacies
had been able to print personalised patient information leaflets, and the ELIAS
customer information kiosks within pharmacies had proved to be popular. The
“tietotippa” project in Finland provided pharmacy staff with information
about prescription-only medicines that could help them to tailor consultations
effectively with consumers. It was being developed over the next four years
through listening carefully to users, and was supported by the Ministry of Health,
social security institutes and the National Agency for Medicines.
Internet opportunities
Dr Rahmat Awang (director, National Poisons Centre, Malaysia) highlighted the
opportunity that affordable internet access provided for consumers to create
and disseminate their own health information. There were possibilities to debate
freely, and it was open to anyone who could access it. There was real potential
to empower consumers and to promote individual responsibility, enabling them
to make health decisions in a knowledgeable way. It was estimated, however,
that there were more than 100,000 health websites from commercial, government
and academic sources: this could easily lead to “information overload”.
The quality of the information was problematic to determine, but it was suggested
that there were three main categories: “reliable, accurate and up-to-date”,
“well intentioned but misinformed”, and “misleading”. It
was becoming more difficult to determine which category was which. For example,
commercial sites were often attractive, fast, convenient to access, and allowed
efficient product ordering. But what about the quality of the information? There
were many risks for consumers who did not have access to reliable, accurate
and up-to-date information. They might have problems with interpretation, or
get the wrong advice. They might bypass necessary advice from their doctor or
pharmacist, and might purchase drugs that were inappropriate for them on the
grounds of either efficacy or safety.
Health professionals could help the consumer to recognise good quality information.
An interactive consumer internet tool to check information quality was being
developed, but simple advice, such as checking the identity of the author, could
be shared. Consumers could also be directed to sites that supported informed
health care debate, such as the British Medical Journal’s “rapid response”
web page. Site owners should also take responsibility by adopting a code of
ethics, including disclosure of authors, sponsors, etc. A system of “tagging”
sites with “metadata” would offer consumers and professionals an indicator
of accuracy and reliability. This “metadata tag” could be added to
a site by a third party who could be the arbiter of information quality.
Interface
Professor Bill Felkey (associate professor, Auburn university school of pharmacy,
United States) dismissed “smart cards” as the future method of patient-held
health information. Why should these be used, with risk of loss, when technology
was already available to map thumbprints for unique identification? This technology
was relatively cheap — it currently cost approximately $100 to set up such
a record, and the practice was already widespread in the finance industry.
Pharmacy had to decide where its internet presence would interface with other
information systems. Would pharmacy develop its own software, or would it commit
itself to a common medication record? Where would the patient be in the information
flow? Professor Felkey cited a poll that revealed that consumers wanted personalised
disease information sites. Disease and nutrition were their main interests,
and there was a desire to bring traditional and complementary medicine together
in health care. He described a unique example of consumer power, where they
could advertise surgery that they needed on a “reverse auction” site,
and physicians could bid for their business.
Because of security issues, consumers should be dissuaded from using standard
internet search engines for their health information queries. Professor Felkey
advocated the use of a “trusted site” from where consumers could be
linked to a range of good quality health information sites.
He concluded by encouraging pharmacists to prepare themselves for the future
by entering the word “pharmacy” and their home town into their own
internet search engine. If their pharmacy did not appear in the search results,
it was time to consider their web presence strategy: “If not you, who?
If not now, when?” he asked.
Decision support
The use of information and communications technology in disease management and
decision support in a South African managed care organisation was described
by Ms Geraldine Bartlett (managing director, Insight Management Medicine Pty
Ltd). She considered current practice as “islands of care” for patients,
where disease management was the “glue” that could bring them all
together. She believed that information and communications technology had a
transforming role in improving the quality of disease management, which went
beyond drug therapy. A system of “virtual private networks” was currently
being developed in her organisation for active operation later on in the year.
South Africa was fortunate in the development of online management packages
because remuneration systems for health care organisations demanded the collection
of detailed patient and intervention data. They had a unique patient identifier
for each individual, and standardised codes for drugs, diagnoses and procedures:
in short, they already knew “what is happening to whom exactly when and
exactly how”.
Information and communications technology was used to look at variability of
management for different diseases, and to identify those conditions that might
most benefit from interventions. Best practice guidelines were established and
used to educate physicians — a closed website was used to disseminate guidelines
and proposed patient care plans. Patients were identified for enrolment —
they were able to undertake their own risk assessment online, and determine
their baseline disease status. Claims data from diagnosed patients were also
analysed, and a screening questionnaire was available on the internet for undiagnosed
patients. Ongoing patient monitoring for deterioration or improvement was undertaken
from claims data, and from repeated questionnaires. Physicians and care providers
were similarly monitored for adherence to the guidelines.
The combination of the detailed data with an automated “inference engine”
that used algorithms to compare actual practice with agreed best practice enabled
the organisation to issue advice automatically about the management of specific
patients to physicians responsible for their care and to the patient themselves.
Interventions for the physician included the provision of continuing education
modules online. Pharmacists could be included in the derivation of the best
practice guidelines, and in the messaging about individual patients. The future
lay in “e-disease management”. She said: “You can choose to be
part of it or not, because the future is not what it used to be.”
Oral communication
Mr Lowell Anderson (treasurer, American Pharmaceutical Association, Minnesota,
US) received a spontaneous round of applause when he declared: “No matter
what information and communications technology you use, good patient care comes
down to oral communication.” The single mission for health care professionals
in communication networks was to get the patient better: “We must aggressively
pursue being care providers, not just providers of products.” Mr Anderson
asserted that the challenge for health care was to connect separate professional
links into a network; sufficient numbers of each discipline had to be involved.
When the use by different professions of current information and communications
technology was reviewed, it was clear that pharmacists were in the forefront
of technology uptake. One hundred per cent of claims transactions between pharmacists
and health maintenance organisations (HMOs) were executed online, and each transaction
included drug utilisation review. Over 94 per cent of pharmacists had access
to the internet either at work or at home.
In contrast, the American Medical Association had found that 60 per cent of
physicians did not use computers at all, and only one-third were accessing the
internet; they were the “weak link”. HMOs were offering incentives
for physicians to connect to the internet and co-payments for answering patients’
questions online.
Managed care organisations had invested in many interactive features on their
websites, and they would like others to be connected. “To get payers to
sign up they need providers, and vice versa,” said Mr Anderson. A new innovation
had been to issue handheld computers for electronic prescribing; with decision
support systems, the prescription could be “cleaned up” before the
patient left the physician. There was an inherent threat to community pharmacy
in these developments because there was bias towards mail-order pharmacies that
were connected to the internet. Network builders had to be convinced to include
pharmacy.
Mr Anderson felt that the patient would probably push the issue forward, and
increased competition between health professionals was good for patient care.
Research had shown that 73 per cent of internet users sought health information,
and some people bought medicines online — why were they not going to pharmacies?
Although the patient-provider relationship was a local one, “telemedicine”
could take services to more remote locations. Ultimately, virtual networks might
mean that location was irrelevant: competition would centre on competence and
the achievement of desired outcomes.
E-pharmacy infrastructure
Considering that pharmacy networks were used to inform pharmacists and patients
better, Mr Richard Jackson (vice-president — Europe, IMS Health) asked
why pharmacists should connect to them. Health care as it was today was becoming
unaffordable, and there was difficulty in demanding higher income without greater
efficiency and value: pharmacy networks could help to achieve this. The European
Commission’s “e-Europe 2002” initiative was intent upon building
an infrastructure to reduce waste, improve care and improve profitability.
Mr Jackson offered examples of where networks had brought innovation in patient
care and pharmacist performance. Aponet in Germany was a pharmacy network linked
to a consumer information portal, where the public could ask questions directly
of pharmacist specialists. Services to pharmacists themselves include online
banking. The Danish ErDA network offered an “experience exchange database”,
where pharmacists shared information about important or unusual cases. Pharmnet
in South Africa had a drug information service for pharmacists, including an
online “knowledge bank” of pharmaceutical resources for conditions
such as hypertension. These “banks” included patient information resources
and academic research papers. They also had a “buddy” programme for
pharmacists to check whether a particular patient posed a financial or medical
risk to their practice. In the United Kingdom, NPAnet offered National Pharmaceutical
Association members the facility to check the registration of a doctor, and
gave them online market statistics for the pharmaceutical sector. In the Gehe
Point system, the network press service gave pharmacists “a lead on what
their customers will read tomorrow”.
Mr Jackson stressed that these networks would only be successful if pharmacists
trusted and used them; high-profile banking security breaches had compromised
this trust. As these were intranets, however, there were high-security “firewalls”
between the network and the internet itself.
Mr Jackson concluded with a look ahead to innovations of the future: telepharmacy,
remote visual counselling and remote dispensing by automatic teller (cash) machines.