Rethinking the Pharmacy and Expanding Services
Why the Pharmacy Needs Changing
So let's jump into it. The modern pharmacy is a enigma of technological developments. We have finally reached the point where we can process prescriptions sent electronically, but still rely on a fax machine (it's fascinating that the pharmacists graduating today are having to learn about a piece of technology their parents used, but they have never seen before), where the pharmacy is cut off from the major technological developments occurring int he health sector, such as integrated EHR platforms, digital health solutions, and telemedicine.
Pharmacy Practice has changed significantly in the past, we stopped compounding 90% of the medications we had to in the past in favor of mass-produced pharmaceuticals, we are earning provider status nationally, and are expanding our capabilities. The modern pharmacy does not demonstrate many of the clinical abilities of the modern pharmacist. That being the case, I have to question if the modern pharmacy is capable of keeping up with the times?
Envisioning a Future Pharmacy Environment
I wanted to take into consideration some major changes the health field and pharmacy practice are going through when I thought of how the pharmacy store could be updated. This included the following, and were the starting points for my imagination.
Improving Pharmacy Dispensing Process and Inventory Management - So there are a few things here I think that can be improved. Namely the whole process of receiving a prescription, filling it, and verifying it by the pharmacist. Obviously, this is not all the considerations that need to be taken into account. Often, patients and other health practitioners forget that the pharmacy is more than a place to 'count, lick, stick, and pour,' but is a veritable operation in itself from drug acquisition, management of inventory (no one wants to get expired medications), billing for prescriptions, and data management. Pharmacy has alot of laws, and they vary from state to state. That being the case, some areas may be addressed from some recent advancements. For instance, filling of medications off-site has shown some success, and I would say Wegman's has done a good job of filling their medications at outside facilities and then delivering to the pharmacy for patient pickup, which really reduces the workload of the pharmacy staff to concentrate on immediate fills. Other advances I have seen includes the success we are seeing from PillPack who have brought an 'oldy by goody' pharmacy automation technology to the mass market by using multi-drug dispensing systems for mail order. Automation is a big solution, and I think it is slowly getting better. However, application of it always seems to be a barrier. Sometimes, I think pharmacy could learn alot from other industries that have to deal with mass inventory management, and I would say Amazon has always impressed me. I think that pharmacy needs to turn an eye to others for possible new disruptive technologies to change up the way it delivers medications to its patients.
Expanding Pharmacists Roles and Duties - Sometimes I think the modern pharmacist is the most overeducated individual for their position. We have been fighting for years to expand our clinical skills and services to patients and be reimbursed for such services. Provider status is slowly coming to the profession and I think that it will take time, but we will eventually get there. That being the case, the space to function is drastically compacted in the pharmacy to engage in such roles. Look at vaccinations, we are doing it in the aisles behind a screen. I would fully support the development of suitable space for pharmacists to engage their patients. This space would be a better environment to provide patient counseling, point-of-care testing, various other services. I feel that if pharmacists want to be seen as providers, the environment should suit such roles.
Patient Engagement and Expanded Services - I look at the 15 or more minutes the patient waits at the pharmacy as wasted time for patient care and engagement. Yes they can shop, and I think that should be encouraged for business purposes, but often times a patient playing on their smartphone could be engaged better. I propose a redevelopment of the 'waiting room' for patients. One where we give them something to do that could impact their personal health. Lastly, I think there are alot of opportunities to leverage the role digital health has been playing in our patient lives by directly supplying and using such devices in the pharmacy.
Envisioning the Digital Pharmacy
The following is a mass amount of different thoughts on how the pharmacy could integrate things I have seen or thoughts on potential developments. That being the case, some of it is farfetched, but in an age where we are experimenting driverless cars I figure why not think of the possibilities. Maybe someone would make it.
- Augmented Reality Pharmacy - I like the idea of Google Glass and Microsoft's Hololens and Facebook's Oculus Rift. I think the concept of augmenting how we perceive the world is interesting, and I can see some applications in the pharmacy, after the initial quirks are worked out. For instance, I think it would be interesting on the production side of things to be able to see when I start to fill the prescription, the information is presented in front of me, along with a beacon or alert of some sort telling me where the drug is in stock (along with how much and if there is not enough), a picture of what the drug should look like, and where the patients medication is when ready for pickup. There are some possibilities here, and I heard others envision facial recognition as a tool to identify patients instead of just asking for their Name/DOB/Address as a means of ensuring the right medication for the right patient. Other applications will be interesting I think for pharmacists, whether it could be teleconference with other specialists (e.g. dermatology) or even helping to show how to do a compounding procedure they never done before, or just even IT support.
- Wearable or Associated Technological Support - Bouncing off the previous idea of AR, I think the sheer amount of digital tools available could be better leveraged for pharmacist and staff support. I know many pharmacists that use their smartphones to look up drug information or access other literature when answering patient questions (often because they can't access the web browser on their own workstation, yeah). Apples recent live event showed how the Apple Watch has a HIPAA compliant app coming out that shows patient's data (e.g. lab values, EKG) in real time, and allows them to communicate with others. I mean, I think thats a great thing that we are leveraging these mobile tools as potential solutions to daily workflow, and I see no difference for pharmacists. Some wearables could be used to update the staff on alerts or questions or other items that come up.
- Patient Use of Mobile - Here I think we can make huge inroads. I recently read a paper asking how iPads could be used in the hospital while a patient is being monitored, and it explored the possibility of using it a teaching tool. I see no difference with those that wait in pharmacy. I think if patients used their own devices, or one supplied by the pharmacy, they could be engaged in their care. First, this could include having the patient update their personal information, and insurance (e.g. image capture with the camera), along with say forms that need to be filled (e.g. vaccination). This data could be then transmitted to the pharmacy database, instead of having a tech enter it in manually later on. Other considerations include giving the patient digital prints of their drug information (instead of physical copies that get lost/thrown away), along with videos or articles around their disease states and treatment to encourage any counseling points, patient questions, and adherence. To help reaffirm such methods, quizzes or assessments could be given via the device that the patient can partake in, and be awarded (e.g. pharmacy points, coupons, discounts).
- Patient use of Digital Health Tools - So here is a big changeup for me. I think pharmacies should be selling digital health tools (e.g. fitness trackers, associated health wearables), and show patients how to use them. I think the doctor office is limited, and Best Buy and the Apple Store are limited options with a lack of health advice associated with it. I would say set something up similar in the pharmacy to what Apple or the others do, so that when the day insurance companies start reimbursing these things we are ready. In addition, I would say have devices loaded up with health apps for patients to play with that are sponsored by the pharmacy to learn about and potentially use in their own care. Along with this, is that wearables and apps offer a good opportunity to collect data for chronic diseases that pharmacists can leverage in the treatment of patients and use for pharmacist provided service (see below). I mean we sell glucose and blood pressure monitors afterall and teach patients on them.
- Pharmacy Clinical Activities - As a mentioned, a space should be set apart for a pharmacist to perform clinical activities, such as vaccination, POC, counseling, etc. I think that if patients are approached (such as above through mobile) we could even have patients schedule time to meet a pharmacist for services, such as Medication Therapy Management. I think this is all piggybacking off of current pharmacy functions, but expanding time and effort along with possible reimbursement. Other items I think include using data collected from pharmacists using digital health tools. What are you eating? Hey, here are some options for a healthy diet and store coupons. Hows your blood pressure? Let's call and go over current therapy, adherence issues, and if necessary adjust therapy with a collaborative agreement or let your doctor know. Testing? There's Theranos to handle it, and we can get some lab values for that. Got Digoxin? When was your last levels? Here we go. I se alot that can be accomplished and that pharmacists can do with all the recent advancements going on.
Where do we go from here?
Nowhere, anywhere, it's hard to say. I think the biggest limitation to updating the pharmacy environment will be pharmacists and corporate. One, pharmacists don't like change, and our training is all over the place. Sometimes I worry about a pharmacy schism of sort happening between clinical pharmacists and the majority of the profession. Let me be clear, I see the changes coming to all pharmacists, and not a select group. I think with the training we have we can do the above and be fine. Hell, I think most pharmacists want to expand their services and have more patient face time and offer clinical services.
Nonetheless, the other component that will limit is cost and corporate. Do they see value in this and a financial benefit? Maybe in time, CVS and Walgreens are on my radar due to their pursuit of minute clinics and on-site testing. They are embracing digital. I think they recognize with changes in insurance for the country, they have a market they can grab. Whether they see including pharmacists and staff as part of it will be the conundrum.