s Pharmacist prescribing - our best kept secret? | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

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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Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
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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
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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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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Pharmacist prescribing - our best kept secret?

Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

articles by this author...

Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care.

The opportunity for pharmacists to prescribe independently may be upon us sooner than we realise – like by the end of 2010.
Yes, that is this year.
I am very supportive of pharmacist prescribing, though personally would prefer collaborative prescribing because I doubt that pharmacists have, or wish to obtain, the extensive diagnostic skills required by a medical practitioner.

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But overall this has to be a way forward for pharmacy if we are not to be relegated to the role of professional shop-keepers, as nurses and others become more knowledgeable in medicines therapy, and also gain prescribing privileges.
Pharmacists must take the high ground and use their pharmacotherapy knowledge and understanding to become the experts in optimising the use of medicines – not just trying to get patients to comply with what another health care provider has prescribed.
Our practice nurses appear to be good at providing this adherence support role and working in nurse clinics that are now part of general practice, having time to spend with the patient.
Pharmacists must establish themselves as the health professionals with a high, and relatively unique, knowledge base and skill set relating to pharmacotherapy – our supposed area of expertise.
This is what differentiates us from other health care providers.

So, what thorny issues is pharmacist prescribing going to raise? (The following refers to prescribing in primary care rather than secondary care.)

Conflict of interest – access to third party payer funding

The first question is, can you prescribe and then benefit financially from the dispensing of the medicine?
There has always been a tacit agreement that ethically a medical practitioner cannot benefit financially from the dispensing of a medicine he / she has prescribed – from the perspective that if a third party (government) is paying, then the system is open to rorting and the over use of medicines.
I believe Japan had this problem when they allowed doctor dispensing.

This means that proprietors and their employees cannot prescribe and have the medicines funded through a third party.
Therefore, a prescribing pharmacist will need to be independent, preferably working closely with general practice.
We should be working towards having clinical pharmacists funded to work in general practices now, doing clinical medication reviews so that they become well placed to switch to prescribing pharmacists.

Qualifications

Nurses require a Master of Nursing degree, plus supervised experiential work to become a nurse practitioner (with prescribing privileges).
For pharmacists it is expected that a Postgraduate Diploma in Clinical Pharmacy, plus experiential learning will be the requirement.
One of the concepts that pharmacists will need to appreciate is that prescribing is for an individual, not a population.
While guidelines are useful for a general population, we need an in-depth knowledge of the medicines and the researched studies in order to individualise treatment … knowing when not to follow the guidelines.
If medicines therapy was simply following an algorithm, then an intelligent layperson could treat themselves (as indeed some try to do via the Internet).

Information sharing / collaboration

With concerns about the fragmentation of health care and current lack of coordination between health care providers, especially between primary and secondary care, then creation of yet another independent prescriber is potential hazardous.
Think of the patient under the care of a cardiologist, diabetologist, respiratory physician and rheumatologist, plus a general practitioner, nurse practitioner and a dentist, all prescribing independently and with the added possibility of these prescriptions being used in conjunction with OTC medicines and CAMs.
The risk of a drug therapy problem resulting in drug-related morbidity or mortality is great.
We don’t really need to add in another independent prescriber.

An electronic shared patient record is almost here, but the question still remains – who’s prescribing takes priority?
Therefore it is important that the pharmacist be prescribing within what is currently the most complete patient record – that of the general practice.

We will need to position ourselves within this collaborative environment, which is likely to be less threatening to medical practitioners than a competing independent prescriber located in the community pharmacy nearby. 

I also see the prescribing pharmacist working as part of the team with the practice nurse, who focuses on the lifestyle issues for people.

Prescribing situations

So, how could prescribing pharmacists be helpful to general practitioners and help resolve some of the workload issues for general practice?
I imagine that repeat prescribing will be an important role – with the pharmacist managing the prescribing for people with long term conditions for three of the four quarterly visits, and a medical practitioner reviewing the patient annually.
Currently all our eligible patients have a cardiovascular risk assessment.
We could target those with a risk greater than 15%, and initiate what is currently guideline-based treatment and then monitor and individualise therapy as necessary.
The practice nurse could concurrently be addressing the lifestyle issues.

Similarly, the District Health Board I work in is considered the “gout capital of the world”, so the prescribing pharmacist could audit and then manage people with gout to achieve the target of serum uric acid concentrations less than 0.36 mmol/l. And so on ….

Responsibility and accountability

The biggest change is the move from making recommendations to taking full and complete responsibility for prescribing, and being accountable in a court of law for your decisions.
However, for pharmacists who make recommendations on changing a patient’s drug therapy, they should already realise that they are accountable.
Some general practitioners I work with, believe that if they enact my recommendations from a medication review, it is because they see me as a ‘specialist’ filling a gap in their knowledge.
Therefore I am equally accountable if my recommendation causes harm.
Prescribing pharmacists would no longer be able to hide behind the, “I only gave the information (or recommendation).

The general practitioner did the prescribing, so he / she is ultimately responsible” 

Competencies

So what will be the competencies?
Having appropriate clinical knowledge and understanding, with the ability to apply it to an individual, is crucial.
To initiate pharmacist prescribing I believe we will need to use the skills of those who are the current experts in prescribing – the medical practitioners.
I have asked some general practitioners about what competencies are required for prescribing. It is not simple and is about living with uncertainty.
It is not simply knowing about the medicines.
We will need all the help we can get from the current experts in prescribing, who incidentally tell me that it takes a number of years to feel somewhat comfortable with the responsibility and uncertainty of prescribing.

I shudder to think that there is a move in the UK to have newly qualified pharmacists able to prescribe immediately.
Medical practitioners are not prescribing fully independently until they are 26 or 27 years old – and they have been entrenched in clinical patient health care in that time, not a dual role (supply and distribution).
Prescribing is not a useful ‘add-on’ service to fill in time between doing other things.
It needs to be the primary focus of the pharmacist and undertaken in an environment that is all about patient focused medical care.

We need to be establishing the environment for pharmacist prescribing now – in general practices.

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Submitted by Sean on Wed, 10/08/2011 - 12:40.

I agree with the above comment to a certain extent, however I do feel that there are some things that pharmacists may not be qualified for. Things like blood pressure, glucose, lipids, and antibiotics pharmacists should be able to manage just fine with the appropriate labs. However, there are also many things that require the expertise of the MD. I do not believe that pharmacists have the proper training to be able to look at a given part of the body and diagnose the abnormality for say something such as a skin rash, cancerous lesion, or even a hemerrhoid.

Submitted by titus on Thu, 10/02/2011 - 07:56.

this is a good piece,but i stand to differ on the inability of trained clinical pharmacists to undetake independent prescrbing.a well trained clinical pharmacist should be able to diagnose medical conditions and offer appropriate treatments

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