s The CareTrack Project: An Application for doctors and pharmacists | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists


From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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The CareTrack Project: An Application for doctors and pharmacists

Steve Jenkin

articles by this author...

Steve Jenkin has spent 40 years in ICT in a wide variety of roles and systems.
He developed an interest in Quality and Turnarounds, "Working Smarter" and reducing wasted effort.
From working in Telecommunications, he was imbued with the notion of "Client First" and owing a "Fiduciary Duty" towards clients, as underlies Medicine. His current interests include the intersection of Quality, Safety and I.T. in Medicine and Healthcare.

July saw a landmark report published on the state of Primary Care by GP's in Australia: Caretrack [1][2][3].
The Caretrack project site notes: The editor of the MJA, Dr Annette Katelaris, has described it as the most important study published in the MJA in the last 10 years.
The reasons for the study were twofold: an earlier American study suggested only 50-60% of GP's followed known Best Practice and with the explosion in Medical technology, drugs, treatment and published research, and GP's are finding it increasingly hard to stay abreast of all current research.

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The essential steps of the study were: Identify the most important conditions to follow: 22 selected with 522 indicators.

Create Best Practice Treatment Guidelines for each condition from the published evidence.
Data Collection and Analysis from selected GP's and patients.
Which reminded me of a highly refined Treatment Guideline for Community-Acquired Pneumonia (CAP) developed in Utah for Primary Care clinics of Intermountain Healthcare (IMHC). [4][5][6][7].

This simple 2 page document arose from a Quality Improvement (QI) project for Brent James' ATP course and they've calculated lives saved and reduced treatment costs.
It was refined over time through use, it also served as a Data Collection tool and met the prime requirement for QI projects: Can you prove you've improved things, not just changed them?

Donald Berwick asserted in 1996: Not all change is improvement, but all improvement is change.[8] The reasons for the success of the IMHC CAP Treatment Guidelines are linked to Caretrack: A central, specialist organisation researched Best Practices then refined them into a practical, usable document.

The CAP Care Instrument a) included Data Collection b) invited feedback and c) allowed physicians to deviate for individual treatment plans and document their deviations.
The Guidelines were refined and extended over time through the feedback and analysis of the deviations.

The integrated Data Collection allowed whole region care and outcomes to be centrally monitored and reported.
Just as in a Hospital, the primary care physicians had the backing and support of experts in many fields.
A similar example in hospitals is the use of Checklists for surgical and other procedures, as written about by Atul Gawande.[9]
Routinely following exactly known, effective protocols not only saves lives and avoids injuries, it would seem to be commonsense.

Gawande's checklist for inserting lines has led to ICU's with 0% rates of infection from them. Unfortunately, more US hospitals don't use the checklist than do.
Given the litigious nature of the USA, I'd be expecting an uptick in malpractice suits, even without injury, for hospitals and practitioners not using proven Checklists for standard procedures where they exist.

Since this CAP Treatment Guideline is over 10 years old, I think we have to ask: Why aren't expert-prepared Treatment Guidelines for GP's the norm?
The essential strengths of well designed Treatment Guidelines are: Continuity and correctness (no steps skipped/duplicated) of care, regardless of changes in physician.
Delegation of appropriate duties: nursing and other staff can deliver routine care according to the prescribed protocol.
Physicians are freed for more demanding and important tasks.
Automatic exception reporting to the physician responsible for a patient allows better treatment and earlier detection of complications and other conditions.

In an Multi-Disciplinary Co-ordinated-Care system with standardised Treatment Guidelines (TGs), the Caretrack study is simple, continuous and avoids ethical issues.
The team could request a Central Service Provider for de-identified data for all patients matching certain criteria.
Best Practice compliance by all GP's using the TGs is simply demonstrated.
Other GP's could be classified as non-compliant if they couldn't demonstrate written TGs and provide evidence of their consistent use.

I agree with a comment from Dr Brent James that no GP can now stay current and have time to practice. Reading all research and reducing it to procedural guidelines and protocols is now a separate, specialist activity.
This is a systemic problem that will only worsen, at a gathering pace. Healthcare is far more than Medical Treatment and Surgery.
This approach of Standardised Treatment with Data Acquisition, Monitoring and Reporting is as valid for drug use in Hospitals, Primary Care Clinics and Healthcare-in-the-Home as the ICU.

Good friends of mine suffered a medical misadventure 20 years ago when an ear specialist, not a GP, prescribed multiple courses of gentamicin, without any blood tests, to treat an ear infection without result.
A subsequent specialist found it was a fungal infection acquired from garden compost and cleared it with topical treatments.
The patient now has moderate to severe hearing loss as a side-effect of the gentamicin.
They would've been spared this outcome from a dangerous drug with known side-effects if their community pharmacist had been issued with a standard Treatment and Reporting form.

In a private communication, I've had described to me a Pharmaceuticals Treatment and Reporting system that was instituted and used in a public hospital for around 5 years.
While the project was running, the medical and nursing staff were extremely happy with it and the Clinical Pharmacist staff, at only 50% strength, were able to easily handle the work load whilst producing better results, more consistently.

[1] UNSW, Australian Institute of Health Innovation, Caretrack Project http://www.aihi.unsw.edu.au/project/caretrack-australia

[2] MJA: CareTrack: assessing the appropriateness of health care delivery in Australia https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia

[3] ABC Radio National, Health Report: Caretrack Study - The standard of health care in Australia http://www.abc.net.au/radionational/programs/healthreport/care-track-study/4133230
The researchers took 22 medical and surgical conditions and lined them up with the best evidence informed care.
They screened 35,000 people and ended up with just over 1,000 with one or more of these conditions and then examined the notes. Jeffrey Braithwaite again. ... had to go through 225 Ethics Committees in order to be able to do this study?
We found that 57% of care against our 22 conditions and 522 indicators was in line with best practice. What we're calling appropriate care, evidence based

[4] Brent James of Intermountain Healthcare. [PDF] Last 5 pages of this presentation are the clinical forms for Community-Acquired Pneumonia (CAP). http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/clinical-safety-and-effectiveness-educational-program/selected-lectures/csetraining-modeling-processes.pdf

[5] Intermountain Healthcare ATP (Advanced Training Program): http://intermountainhealthcare.org/qualityandresearch/institute/students/Pages/atp.aspx

[6] ATP Quality Improvement projects: http://intermountainhealthcare.org/qualityandresearch/institute/alumniresources/Pages/home.aspx

[7] CAP project presentation [PDF's] http://intermountainhealthcare.org/qualityandresearch/institute/alumniresources/Documents/2005-002.pdf 

[8] BMJ: A primer on leading the improvement of systems, Donald M Berwick http://www.bmj.com/content/312/7031/619

[9] "The Checklist Manifesto", Atul Gawande http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000/


Further Reading

Prof. Chirs Del Mar comments on Caretrack. Unread, behind a paywall. https://www.mja.com.au/journal/2012/197/2/dog-walking-its-hind-legs-implications-caretrack-study

Despite its limitations, this important study highlights a genuine need for systematised performance monitoring.

An unrelated, though major, study soon after Caretrack.

Supports more competence testing and training.
MJA: The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments. 06-Aug-2012. https://www.mja.com.au/journal/2012/197/3/effect-clinical-history-accuracy-electrocardiograph-interpretation-among-doctors


Related projects at Uni of NSW, Australian Institute of Health Innovation (AIHI):

Building quality,governance, performance and sustainability in Primary Health Care through the Clinical Microsystem Approach http://www.aihi.unsw.edu.au/project/building-qualitygovernance-performance-and-sustainability-primary-health-care-through

Uni QLD: Clinical microsystems http://aphcricremicrosystems.org.au/research

Patient Safety: enabling and supporting change for a safer and more effective health system http://www.aihi.unsw.edu.au/project/patient-safety-enabling-and-supporting-change-safer-and-more-effective-health-system-0


IHI citations on Community-Acquired Pneumonia. Not read. Source an IHI paper:

Dean N.C., et al.: Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia. Am J Med 110:451–457, Apr. 15, 2001.

Dean N.C., et al.: Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest 130:794–799, Sep. 2006.


Patient Safety and Aviation arguing "it's not the same"...
A standard excuse for not pursuing Quality Improvement.
Patient safety is harder than aviation safety, And five practices to borrow from aviation. http://nextlevel.gehealthcare.com/quality-safety/medical-errors/patient-safety-is-harder-than-aviation-safety.php

Patient safety: What can medicine learn from aviation?

The article lists under "Aviation's methods, medicine's applications"

* Checklists [standard Operating procedures]
* Teamwork Training
* Briefings, Debriefings and timeouts
* Incident reporting
* Simulator training
* Standardisation [equipment and controls]


Doesn't argue for a Medical version of the NTSB and FAA.

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