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Answering questions using the system
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Can you imagine a community pharmacy being supervised by a pharmacist
who is not physically present? Instead, the pharmacist supervises the
sales of medicines and dispensing of prescriptions from a remote site
using a combination of the latest technology. Nothing can take place
until the pharmacist has given the go-ahead: there is no over-ride button
for the pharmacy staff.
This is exactly what has happened at a trial of a remote supervision
system at Pharmacy Plus in Bristol. Whatever your opinion on the concept
of remote supervision, it is hard not to be impressed with the standards
of the system that Pharmacy Plus has designed.
Tariq Muhammad, managing director of Pharmacy Plus, says that his interest
in remote supervision was borne out of frustration and sparked by internet
pharmacies. “It is an enabling tool,” he comments.
Mr Muhammad explains that he set up Pharmacy Plus — a chain of
nine pharmacies — with the aim of pharmacists being focused on
providing a clinical service. “We found that the tools to enable
us to get out of the pharmacy were lacking. This, along with poor remuneration
and problems with recruitment and retention, meant that we were not achieving
our aims,” he says. The year was 2000 and internet pharmacy was
getting going in the UK. “I thought it was an interesting model.
There was no face-to-face interaction between the pharmacist and patient,
the patient did not automatically talk to the pharmacist and yet somehow
it was legal. I wondered what the difference was between that and the
patient entering a pharmacy and asking questions of a remote pharmacist.”
This was the starting point and it has taken nearly four years for the
system to be designed, debated, trialled and perfected.
The legalities of supervision
The reason why remote supervision is not done, and the reason why Mr
Muhammad is not actually using the system despite its successful trial,
comes down to the Medicines Act 1968. The Medicines Act requires that
pharmacy or prescription-only medicines can only be sold or supplied
under the supervision of a pharmacist. Mr Muhammad points out that
the Medicines Act does not specify that the pharmacist has to be physically
present in the pharmacy to do this. “It is only the test cases
that have led to this conclusion. My argument is that if I can prevent
a sale from happening then I have got complete control of the transaction,
regardless of whether I am in the pharmacy or not.” He adds,
moreover, that the test cases all pre-date new technology.
The relevant test case was in 1943 after the sale of a Part I poison
to a Pharmaceutical Society inspector by a pharmacy operated by Littlewoods
Mail Order Stores Ltd. The store contended that the sale was supervised
by a pharmacist who was in an upstairs stockroom and unaware of the transaction
at the time. Barnsley magistrates agreed. The Society appealed and the
High Court ruled that a pharmacist had to be physically in a position
to supervise or superintend the activities of individual staff members
making individual sales (PJ, 30 January 1943, p30).
However, there is a second issue. The Medicines Act requires that a pharmacy
is under the personal control of a pharmacist when it comes to the sales
of medicines. The Royal Pharmaceutical Society’s “Medicines,
ethics and practice” guide states that a pharmacy that continues
to operate during the temporary absence of a pharmacist, for example,
during a three-quarters-of-an-hour lunch break, is still under the personal
control of the pharmacist. The same is not the case for a pharmacist
who leaves the pharmacy all afternoon. This requirement for personal
control is completely separate from that for supervision of the sale
and supply of medicines other than general sale list medicines.
Mr Muhammad has taken legal advice and been told that his system does
comply with the requirements of the Medicines Act. However, he is awaiting
the opinion of the Department of Health and the Society.
Jim Smith, chief pharmaceutical officer at the Department of Health,
says: “The system developed by Pharmacy Plus is an innovative and
interesting approach to supervising the supply of medicines, using modern
information technology. I visited Bristol to see it in operation and
used the video link myself and it appears to be technically feasible.
However, it is unclear whether, under current NHS and Medicines Act requirements,
this form of supervision is lawful. We are therefore taking legal advice
on this point.
“Given the current workforce constraints and the continuing growth
in the scope of pharmacy services, it is important that we consider carefully
all options for making better use of pharmacy staff,” Dr Smith
says. “We will be issuing a consultation paper shortly on the wider
issues of skill mix in pharmacy and we will take account of this development,
in the light of legal advice.”
David Pruce, director of practice and quality improvement at the Royal
Pharmaceutical Society, gives the system a cautious welcome. “Pharmacy
Plus has come up with an interesting experiment that might be acceptable
if the rules on personal control are changed,” he explains. “We
are waiting for an announcement about this from the Department of Health
but, at the moment, the system is not strictly speaking legal to use.
Under the current definition of personal control, prolonged absence of
the pharmacist is unacceptable.”
Mr Pruce says that he has two major concerns. “First. a pharmacist
might be looking after more than one pharmacy. Second, I would be really
concerned if the system led to a pharmacist not being in a pharmacy for
a significant period.”
He adds: “Personally, I was impressed with Pharmacy Plus’s
thinking behind the system but I still have reservations. For remote
supervision to work we would need to build in lots of safeguards, which
the Pharmacy Plus system has.” It is important to note that despite
these positive words, the Society has not given Pharmacy Plus approval
to proceed any further with rolling out the system. How the system works
A pharmacist consults a patient via the webcam |
The computer system that Pharmacy Plus has developed
has many components. Altogether, the system is called CAPA (consolidated
application for pharmacy
administration) (see www.fusionhealth.co.uk).
The technology it uses is a computer, a telephone, a webcam, broadband
internet connection and
the appropriate computer software. Point of sale At the point of sale, the computer can operate on one
of three levels. At the first setting, it works just like a till. The
next level is to alert the assistant selling a pharmacy medicine to what
they should be asking the customer. “This is particularly useful
if we are training a new counter assistant,” points out Mr Muhammad.
The highest setting is for remote supervision.
At the remote supervision level, the questions are compulsory. By scanning
a product, the assistant is prompted to ask a range of questions, including
whether the medicine is for the person in front of them or someone else,
specific questions about the presenting condition or request for medicine,
and questions about allergies and other medicines being taken. The answers
are then instantly transmitted to the pharmacist who is remotely supervising
the sale. The system does not allow the sale to proceed until a response
has come back from the pharmacist. The assistant can also send questions
or additional information to the pharmacist at the same time. If for
instance, the patient wants particular advice, this request can be sent
to the pharmacist via a chat function, which is similar to text messaging
and appears instantly in an area of the computer screen.
A patient in the video booth |
The supervising pharmacist can ask the patient to go to a consultation
booth where communication is possible either by video (using webcams)
or by telephone. Indeed, patients do not need to go to the medicines
counter first at all: they can go directly to the video booth and request
advice from a pharmacist.
Once the supervising pharmacist is happy that the sale is acceptable — either
through the questions the assistant asked or following the consultation
with the patient — a message is sent to the sales computer and
the sale can proceed. The system also has the capability to record all
sales against patients’ records.
Hooman Ghalamkari, director of Morph Consultancy, a consultancy agency
advising Mr Muhammad, comments: “This works as a decision support
tool for assistants as well. In light of the Which? report [see PJ, 7
February, p143], this system ensures that all the safety questions are
gone through every single time.”
Supervising prescriptions For remote supervision in the dispensary,
prescriptions are scanned into the computer system and sent to the supervising
pharmacist along with the name of the patient. The pharmacist makes a
clinical check of the prescription, examines the patient’s records
and then types the details of what is to be dispensed into the computer
for the label to be produced. This then appears on the dispenser’s
screen. The dispenser cannot make any changes to what the pharmacist
has entered except for giving less than the full quantity if the pharmacy
does not have sufficient stock.
Once the product has been dispensed, an accuracy check is carried out
by a qualified checking technician. However, the system has one more
safety feature. During the dispensing process, the barcode of the product
selected for dispensing has to be scanned. It has to match what has been
labelled for the process to be completed. This also means that the exact
product dispensed is recorded in the patient’s record.
At the head office, the pharmacist supervising the pharmacy has a screen
on which supervision requests appear. Mr Ghalamkari comments: “The
supervising pharmacist has access to all the information needed: the
patient’s medical record, a list of previous sales if the patient
is registered and access to reference sources here.”
Every aspect of the system has a standard operating procedure that sets
out exactly who is responsible for what and how everything works. Mr
Muhammad is keen to ensure that the system provides a good audit trail
so to carry out any transaction, the pharmacist or assistant has to enter
their own individual code and a record of this is kept on the computer
system.
Remote supervision of both the sale and dispensing of medicines are part
of the same system. All parts are networked, linked by a virtual private
network to the head office system. It takes one millisecond for data
to be transmitted between the head office and pharmacy.
Benefits, but guidance needed
It is clear that the system offers real benefits. “It allows a
pharmacist to carry out other roles without compromising patients’ access
to a pharmacist,” says Mr Ghalamkari. “Pharmacists need protected
time in order to spend an hour doing medication reviews in a consultation
area without being constantly interrupted and this system allows this
to happen.”
The system could also be used in rural areas where there is no pharmacy
cover and in out-of-hours situations where one pharmacist could cover
several pharmacies.
Another point is that it could be used to cut costs. The need to cover
locum costs is one of the reasons why sessional work in primary care
by community pharmacists is considered expensive. This system could allow
a pharmacy to get just one hour of remote supervision rather than a half-day
locum cost.
To implement remote supervision, practice guidance on how it will be
used will be needed. It will have to answer questions like, in what circumstances
should remote supervision be used, how long a duration can a pharmacy
be remotely supervised, how many pharmacies can be supervised at once
and how remote supervision should operate. The answers to these questions
are a long way down the line. Even if you do not agree with the concept
of remote supervision, Tariq Muhammad has been able to create a system
that provide a solution to the problems the sceptics have.
Positive pilot results to be presented next week
A pilot of the system has been carried out under
controlled conditions. The system was operated as envisaged but
there was a pharmacist in
the pharmacy who could intervene if necessary. In October last year,
two pharmacies were remotely supervised: 300 pharmacy medicines were
sold, 600 prescriptions were dispensed and 70 video consultations
carried out. The evaluation is in two parts, examining patients’ perceptions
of the system and also its safety and appropriateness. The first
part of this is to be presented next week at the Health Services
Research and Pharmacy Practice conference in London.
Paul Bissell, lecturer in social pharmacy at Nottingham school of
pharmacy, is leading the evaluation of the system. “Patient
response to the CAPA system has been positive,” he says. “The
top line message is that patients thought it was great in terms of
increasing access to pharmacy services.” In particular, they
highlighted the fact that the system meant that access to a pharmacist
became possible where no service was currently offered, such as in
rural areas and on Saturday mornings.
However, there were some concerns. “Patients’ main concern
was that the technology could be used to cut the number of pharmacists
in a particular area thereby reducing the availability of pharmacy
services. They also expressed some concern about the impact it could
have on the patient-pharmacist relationship,” Dr Bissell explains. |
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The
Pharmaceutical Journal