Inside Tomorrow's Pharmacist (2001)

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The way we see IT: threat or opportunity?

The way we see IT: threat or opportunity? by Bill G Felkey and Brent I Fox

It is obvious that the internet and the world wide web are transforming much of the way we think, work, act and play. Already an important communications medium for health care matters, the internet is something that all pharmacists will need to know how to use in their day to day practice. However, we have the crazy situation at the moment where thousands of pharmacists world-wide can produce a label on a computer for a prescription, but may be unable to navigate the world wide web. Yet patients approaching pharmacists with sheafs of paper downloaded from the internet are no longer rarities, and real computer literacy is a basic skill that all pharmacists need to fulfil patient care.

Information

More than 800m web pages are now available on the internet. Whether you are looking for information on drugs, a lesson in history or a flight to Singapore, it is all there. The chairman of Microsoft, Bill Gates, predicted that by the end of 1999, more information would exist on the internet than in the entire history of print for mankind, and it is here where the first opportunity and threat lies.

A huge amount of information is available for browsing, and pharmacists may be tempted to think that patients will have access to so much information that they will no longer need the pharmacist's advice. But this assumption may well be wrong. Accessing the information is one thing, but how does the information apply to the individual? Patients need to know this and when they have become overwhelmed by a mass of information, they need a trusted health professional to sort it out and interpret it. But this means that pharmacists too have to find a way of managing this information glut.

Most of the health care information on the web is not peer reviewed. Studies focusing on the quality of drug information on the internet have found that around half of it is incorrect, biased or otherwise untrustworthy, and in the absence of good science the most preposterous garbage gets promulgated. Fortunately, however, the most respected pharmaceutical and medical reference sources are increasingly available to us online. In addition, access to the primary literature for research has improved so much to the point where we can now go into databases like PubMed and search over 11m journals. Even more information can be accessed in full text by tapping into the thousands of journals that are now available directly, free of charge, from our desktops.

We can even keep up with the exciting developments in our areas of interest through "push technology" resources that send us daily e-mails about news and issues occurring within our chosen topic areas. Furthermore, one service offers to send the table of contents on up to 50 professional journals to the end user via e-mails on a monthly basis. The user can then request the individual articles of interest electronically and receive the full text via e-mail. Increasingly, we are able on our palm computers, sub-notebooks, notebook, and desktop computers to access online, offline, and wirelessly the information we seek when we need it and where we need it.

Patient care

No pharmacy organisation is backing away from the position that pharmaceutical care is the mission of pharmacy, ie, not counting tablets, but addressing patients' pharmaceutical needs. However, facilitating the environment for delivering such care is another matter. According to John Gans, the executive vice president of the American Pharmaceutical Association, there are now 1.2 jobs for every pharmacist in the United States. Simultaneously, we have 4bn prescriptions that will need a pharmacist's professional scrutiny over the next few years. Bonuses of $20,000 and rumours of a free BMW in return for a two-year commitment to a retail pharmacy chain abound. At least one pharmacy chain is testing a scheme where a single pharmacist could be responsible for as many as six community pharmacies. With all this pressure from prescription volume and patient safety issues, will pharmacists be able to get the point where they can truly focus on having a responsibility for patients' drug therapy?

The sheer volume of prescriptions is actually creating a better financial climate to support the move to pharmaceutical care in the US. In addition, the software to help pharmacists provide pharmaceutical care is getting better, although pharmacy as a profession needs to specify what it wants from the companies that provide it. The schools of pharmacy are turning out professionals better trained to provide pharmaceutical care, but the profession still needs to market this service. How can patients ask for it of they don't know it exists?

One possible way to resolve the shortage of pharmacists, the growing number of prescriptions and the associated challenge of time to deliver truly patient focused care is through central processing of prescriptions making use of the infrastructure of the internet. In the US the reported costs for preparing a prescription by heavily automated mail order companies range from $1.82 to $1.94, excluding the cost of the drug, but including the cost of mailing the prescription. Contrast this with the $3.50 to $7.50 reported by many community pharmacies as their cost to fill a prescription. Pharmacies could participate in a centralised filling operation, which could deliver ready to dispense medications bearing the pharmacy's label. One automation company has estimated it could fulfil orders of 5,000 prescriptions a night at a cost of about $0.77 a prescription.

The ability to outsource dispensing and other routine tasks is increasing as a result of something called application service provider (ASP) capability. ASP is a web-based platform that uses a web browser interface to the pharmacy applications and the users either rent the applications or pay on a fee for transaction basis. Digital subscriber lines, with their higher bandwidth, will be required to gain the desired throughput.

Investing in a second computer and having a clinical workstation is another step to providing good patient care. A clinical workstation would employ core software products to bring the power of information to the point of patient care, where pharmacists and patients can interact. This workstation would be connected both to the pharmacy dispensing system and the internet. Finding information from evidence-based sources is essential to bring clarity to our decisions when we are addressing a patient's problem.

E-business

The good news is that people still seem to like to do business with people they trust, but that does not necessarily mean always doing business face to face, and an increasing proportion of retail sales are occurring via the internet. New research is showing that many people browse in a local store and then buy on the company's web site. Alternatively some browse on the company's web site but buy in the shop. It is not an either/or model but a both/and. So the Amazon.coms thrive, but the "bricks and mortar" business like Barnes & Noble exist too, because it would seem, some of us still relish the atmosphere of a book store.

This model of doing business is now moving into health care too, and pharmacists not prepared to have the internet channel open to their customers will lose business. If customers want a preparation for haemorrhoids, they will probably not want to wait for the van to deliver it to their door, but it may be a different story for customers wanting to buy a year's supply of vitamins.

It is obvious that the range of products you can show on a web site is enormous. Imagine the advantages if your pharmacy is small. Being able to offer 32 different models of wheel chair while stocking none is a huge benefit — in other words, a small pharmacy connected to a huge virtual warehouse.

A web presence

Pharmacists should definitely develop their own web sites, and in the US, this can cost as little as $70 for a domain name and as little as $9 a month for a hosting service. You can either develop the site yourself or pay someone to do it for you. Information on the pharmacy itself — location, contact details and services — should be included, but the site can also be used to provide quality customised health care information for patients. The way most people search for information on the internet is by typing a key word into a randomly chosen search engine, which can provide a mass of untrustworthy information. Pharmacists could change this way of accessing health care information by getting their patients to start at a known location with a validity filter offered by their pharmacist. Patients should be reassured that this is a less risky method than using a non-specific search engine.

In addition, patients could use the web site to obtain information on the management of their conditions and expected therapeutic outcomes, and the internet could become a global pharmaceutical care database. Eventually, patients could be in touch not only with their pharmacist, but also with other patients — building a virtual community bigger than the geographical locality.

Education

Distance education has brought learning opportunities to practising pharmacists instead of the pharmacist having to go to an educational institution or conference. There are now web sites offering continuing education for pharmacists, postgraduate degrees and even graduate education. Some disciplines like medicine are offering just-in-time delivery models. These can take two main forms. In the first, the practitioner achieves continuing education credit by keeping up with professional information delivered via the internet. In the second, the practitioner accesses online information of direct application to a patient's care. This type of approach will continue to grow as pharmacists realise the benefits of being able to access information in a variety of different formats at times to suit themselves.

Conclusion

Future pharmacists who ignore the challenges the internet is bringing to health care delivery do so at their peril. Pharmacists are the professionals with the training and expertise which makes them capable of identifying, preventing and solving problems related to drug therapy. But increasingly, care needs to be delivered to the patient rather than the patient coming to get it. And to do this effectively means integrating the internet into everyday practice. There is, at this point in time, a narrow window of opportunity for pharmacies to shift from a "bricks and mortar" to a "clicks and mortar" way of doing things.

Professor Felkey is associate professor and Dr Fox is an informatics research associate, Auburn University, United States