Statistical Sources for Pharmacists

for Community Pharmacy Practice

By Homer Boutwell, Dewey D. Garner and Mickey C. Smith

" We must knock at a gate to know whether it be shut"

Montaigne he term "futurible" as used in the title of this article was taken from the Futuribles Project which was originally commissioned in France to conduct serious investigations into the future.! The term, which combines "future" and "possible," seems an ideal one to describe the practice model which we will propose, for while we are engaging in speculation, we believe it to be not idle, but possibility-oriented. We have been brought to this speculation by, among other things, the current emphasis on clinical pharmacy which to us takes the easy way out by giving little study to community pharmacists. We asked ourselves whether the model of clinical pharmacy now in force in a few major hospitals (clinical pharmacist on the wards, at the bedside, central dispensing source) could be brought to community practice.

T

Rationale It is not unusual to find direction for the future by studying the past. Central to the model which we propose must be acceptance of pharmacy as a medical specialty. The historic base and the logic for this requirement may be found in the 14th century when King Fredrick the Great for the first time furnished a clear demarcation line between physicians and apothecaries. The result of this separation was the establishment of

the first specialty in medicine-pharmacy.

The apparent birth of any specialty comes about when (1) an awareness of the need for the specialty becomes apparent, (2) a body of information surrounding this need becomes significant because of the development in technology and (3) a group of practitioners start to spend time in this area. We believe there were more reasons for the designation of pharmacy as a separate entity of medicine-perhaps economic and perhaps to place a safety check on the physician. Nevertheless this separation set the stage for the 18th and 19th-century development of pharmacy. With the industrial revolution it became evident that man could mass-produce medication with machinery at less cost. So we see the beginning of the drug industry as we know it today. It did not take long for the industry to conclude that the operation of a machine did not require the skill of a pharmacist and that the employment of less skilled employees would not only save in salaries but would in effect remove the industry from the regulatory requirements covering pharmacists and then we had the development of the industry as a subspecialty of pharmacy with the development of large numbers of pharmacy technicians. Fischelis3 recently called attention to the 1803 treatise on medical ethics

which anticipated the value of the true pharmacist-consultant. This amicable intercourse and cooperation of the physician and apothecary, if connected with the decorum and attention to etiquette, which should always be steadily observed by professional men, will add to the authority of the one, to the respectability ofthe other, and to the usefulness of both. The patient will find himself the object of watchful and unremitting' care, and will experience that he is connected with his physician, not only personally, but by a sedulous representative and coadjutor. The apothecary will regard the free communication of the physician as a privilege and means of improvement; he will have a deeper interest in the success of the curative plans pursued; and his honour and reputation will be directly involved in the purity and excellence of the medicines dispensed, and in the skill and care with which they are compounded.

The APhA House of Delegates, at their 1972 annual meeting in Houston, considered the following definition of pharmacy practicePharmacy practice is defined as that personal health service that assures safety and efficacy in the procuring, storing, prescribing, compounding, dispensing, delivering, administering and use of drugs and related articles. The aspect of pharmacy'practice that can be considered 'clinical'.is the assurance of safety and' efficacy in the prescribing, administering and use ofdrugs and related articles. 2

We maintain that pharmacy has abVol. NS14, No.1, January 1974

31

dicated the control necessary to maintain these assurances. We propose as have others that pharmacy participate in the medical care process in the truest sense of the term consultant (i.e., in the sense that the radiologist is a consultant, or the anesthesiologist is a consultant, deciding the best course of therapy and the type and amount necessary to do the job). This is not a new idea! H.owever, upon implementation the pharmacist would then be a "legitimate" colleague of the physician providing valuable expertise in the selection of appropriate treatment.

Homer Boutwell is presently chief pharmacist at the Methodist Hospital, Hattiesburg, Mississippi. He also does pharmacy consulting work, serves as an instructor to several small hospitals and convalescent homes and lectures at the University of Mississippi school of pharmacy. He holds a BS in pharmacy from the University of Mississippi and has done graduate work there and at Tulane University. His employment experience has been predominately in hospital and community pharmacy. Boutwell's memberships include APhA, ASHP, Mississippi State Pharmaceutical Association, Mississippi Society of Hospital Pharmacists and Hattiesburg Pharmacist Association.

Dewey D. Garner is associate professor of health care administration at the University of Mississippi school of pharmacy. He received his BS and PhD degrees from the University of Mississippi. He has served for three years as a community pharmacist. Garner's research interests include delivery and financing of pharmaceutical services and community pharmacy practice management. His association memberships include APhA, AACP, NARD (Associate), AMA (affiliate), American Public Health Association, Rho Chi and Kappa Psi.

Previous Work of Others

Some of what we propose may be considered as a kind of variation on or type of group practice. Among others, Donald Dee has previously pointed out many advantages which can accrue through group practice. 4 Included among these were enconomies of fixed and variable costs, better utilization of the pharmacist and better working hours for him, increased opportunities for professional growth and better services for the patient. Hennessey5 has been in the vanguard of those demonstrating the feasibility of nontraditional methods of compensation, and the National Pharmacy Insurance Council combined the elements of group practice into a model for those wishing to pursue such an arrangement. 6 This latter document is an extremely important development and is completely compatible with the model which follows, as is the theoretical model developed by Kidder and Isack, which listed components of a pharmacy service delivery system within the framework of HMO organizations. 7 We also acknowledge the excellence of the recent report on group practice published by the American Society of Hospital Pharmacists. 8 Since our proposal includes some aspects of group practice we recommend the ASHP report as one of the most balanced and comprehensive to date. Our model however, includes more than just practice relationships. The Community Practice Model

What follows are the characteristics of a type of practice which we believe is workable, desirable and possible. Some are essential, denoted by * and others are at least desirable, denoted by **. Necessary-

* Equal roles for pharmacist and physi*

32

cian in drug selection following diagnosis Free choice of pharmacist (We believe that this is a necessary further step beyond free choice of pharmacy.)

Mickey C. Smith is chairman of and professor in the d'?partment of health care administration and assistant director of the bureau of pharmaceutical services at the University of Mississippi, where he earned his PhD. He earned his BS in pharmacy and MS ill pharmacy administration at St. LOllis College of Pharmacy. Author of over 80 professional publicatiolls including three textbooks, Smith is currently preparing two additional books. A member of APhA and the Academy of Pharmaceutical Sciences, Smith is a fellow of the American School Health Association, associate member of ASHP, member of the American Sociological Association and the American Association of Comprehensive Health Planning.

* Pharmacist control of all drug therapy for his' patient-outpatient or inpatient, prescription or non-prescription * Payment mechanism completely separate from number and size of drug purchases (probably capitation) * Complete patient drug records synchronized with medical records * Patient education * Pharmacist education * Physici~n education **All drugs purchased through the pharmacist from a pharmacist-supervised dispensary **Community formulary **Education of paramedical personnel

Figures 1 and 2 provide some ideas of the type of physical arrangements which could serve such a model. Figure 1 (page 33) shows a free-standing pharmacy with facilities for four practicing pharmacists with an additional pharmacist in charge of a central dispensary. All drugs would be dispensed from the dispensary only to pharmacists or physicians. This includes non-prescription drugs. A rather down-to-earth analogy would be to compare the dispensary to the parts department in an auto repair department. The cost of the drug plus a small percentage markup to be charged to the professional, would be charged ultimately to the patient or third party preferably via capitation methods.

Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

Our model requires close pharmacistphysician communication and preferably contiguous location. Figure 2 (page 33) shows how pharmacists' and physicians' facilities might be combined in a single structure. The use of the modular approach would allow easy expansion. We feel that such a facility is compatible with private practice, the HMO concept or hospital-based practice. Figure 3 (page 33) shows how the medical and pharmaceutical affairs of a new patient would be handled. The pharmacist would be responsible for his hospitalized patients as well. The analogy of the central dispensary holds here as well, with the pharmacist ordering drugs for his patients from the hospital pharmacy and assuming responsibility for drug interactions, chart maintenance, etc. The lessened burdens for the hospital pharmacy should be obvious as the patient's pharmacist makes daily rounds and assumes many of the responsibilities for drug use control. We feel that the model as proposed is feasible for a population of approximately 10,000. Advantages To the Patient

The most important advantage which the patient should experience is higher quality service. This should result from improvements in continuity of

care, better records and utilization review. We believe the overall patient payment for drugs and drug-related services could be reduced.

FIGURE 1

To the Physician A

= Central

Dispensary

=Private Pharmacist Offices C =Common Reception, Waiting and D = Drug Information Center B

Records

and Conference Room E

=Option Area

- Patient Education,

Fitting Room etc.

F = Private Entrance or Connection with Physician' Ol/ices

FIGURE 2

G

=Physicians' Offices

Someone could now share the burden of responsibility for drug therapy and remove much of the burden of drug information retrieval for the physician. Someone else could now monitor drug response as well as share liability. To the Pharmacist

The model should do many of the things which group practice does-reduce initial capital investment, reduce fixed and variable costs, and rationalize working hours. The fear, sometimes expressed, of physician "reprisals" for questioning drug therapy should be largely removed. The model allows for the personal and professional growth of the pharmacist as an individual. No longer would his image be largely that of the pharmacy in which he practices. His compensation would truly reflect his professional reputation and the temptation removed to recommend or renew unnecessarily due to financial rewards. He would find it possible to follow his patient into the hospital because of flexibility of working hours which he would set. Discussion

FIGURE 3 New Patient Patient

1

I I

Physician Takes medical history, tests, etc.

Pharmacist Takes drug history

~ Diagnosis

~

Consultation on therapy

Medical instructions to patient Updates medical record

Pharmaceutical decisions Orders medication from dispensary

~ Provides medication and pharmaceutical instructions to patient Updates medication record

~ As appropriate-follows up on action of medication informs physician

In a 1972 study of pharmacy practice in group medical clinics, Knoben concluded that-"The clinic pharmacist practices at a level reflecting an emphasis on the dispensing role, often to the exclusion of professional interaction and influence the pharmacist has with patients and clinic physicians."g The switch to the greater involvement proposed in this paper would require that the pharmacist live up to the function of "drug use control," with all that the phrase means. How are the physician and pharmacist to arrange the communication necessary to make this work? We can only say that such communication takes place routinely between other medical specialties and that if both parties are committed to the concept they will find the means to achieve it. Would the patient be willing to accept a new method of payment such as capitation? We do not know for sure. We do know that similar payment systems have been acceptable in such health plans as those at Harvard, Johns Hopkins and Kaiser. We also know that such a payment mechanism is acceptable under many proposals for third-party programs including those (continued on page 40) Vol. NS14, No.1, January 1974

33

American Social Health Association Fights VD u. S. taxpayers paid approximately $50 million in 1971 to care for the syphilitic blind and insane according to the former chairman of the National Committee on Venereal Disease. Bruce Webster, MD, now national program chairman of the American Social Health Association, noted in' a press conference October 30 that gonorrhea, with 2.5 million cases is the most common infectious disease in the United States today. Syphilis is fourth with an estimated 85,000 new cases last year.

"There is an attitude," Dr. Webster said, "that both gonorrhea and syphilis are harmless; 'no worse than a bad cold.' Nothing could be further from the truth. The manifestations of untreated syphilis are crippling to the individual and expensive to the taxpayer. If syphilis is untreated in the acute infectious stage, heart disease, blindness, paralysis and insanity can result. As for gonorrhea, a few of the complications are arthritis, invasion of the bloodstream, heart disease and abdominal infection often requiring surgery. Sterility is an all too

A Futurible Model

The "synthetic" rather than the "analytic" method has been used in presenting the model for consideration-i.e., we have chosen to view the model as a piece of whole cloth rather than to present the details. We also want to emphasize that any further models must share commonality with past and present. They must allow for a continuity during the transition which is not disturbing to the patient. •

(continued from page 33)

sponsored by the federal government. The basic question will always bedo pharmacists want such developments badly enough to make them work? Conclusion We have presented here some ideas for a model which we believe has real possibilities for the future. All of the answers were not given but we believe enough were provided to stimulate further investigation.

NEW-FOR PHARMACISTS If you use a standard label device on your

~ typewriter, you do one (or more) of these:

• Spend time (& caution) to avoid typing on METAL. • Concentrate wear at a SMALL AREA of rubber platen. • Need BOTH handsto affix label. • Move (or remove) device for OTHER typing. • Type labels DIRECTLY against platen. You ca n STOP a ny of a bove with

Labelholde~ A durable plastic film that rolls into any typewriter like a sheet of paper and CURLS itself around the platen. Labelholde~ has a "formed" seam to grip label (top OR bottom) ... • No I\.I!ETAL to chip type-quick label insertion. • Provides its OWN typing surface-to a bsorb type impact. • Permits back-feed (normal) OR front-feed (faster). • Type envelopes, cards RIGHT OVER Labelholde~.

• DISPOSE of Labelholde~ (and wear) after thousands of labels. SAVE TIME-SAVE TYPEWRITER WEARLOW COST-NO INSTALLATION For Pkg of three (3) send NAME/ADDRESScheck ($1.30) to

Labelholdeij P. O. Box 98 Glen Echo, Maryland 20768 available ONLY via prepaid mail order-3 or any multiple of 3 Labelholde~. Shipped (with instructions) FIRST CLASS MAIL in flat envelope.

40

References 1. de JouvenaI, B., Futuribles: Studies in Conjecture (I), Geneva,Droz (1963) 2. APhANewsletter, 11,3 (Feb. 26, 1972) 3. Quoted in Robert Fischelis, "Things We Can or

Statistical Sources (continued from page 30) eral categories of vitamins, antibiotics, vege· table alkaloids, hormones, glycosides, com· bination preparations, and medicinal and pharo maceutical products donated for rei ief or charity. Information given is the country of origin, net quantity and dollar value.

PUBLIC HEALTH The pharmacist because of his accessibility is often called upon to advise his patients in their personal health problems and inform the public of larger health issues confronting the local and national population. The pharmacist can seek government statistics to provide him with the most recent and accurate quantitative data available on the status of specific health and medical conditions, and this form of information ranks among the valuable public services performed by the pharmacist. Important sources includeMonthly Vital Statistics Report, U.S. Public Health Service, National Center for Health Statistics. Distributed by the issuing agency, W
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

frequent outcome in both the male and female." He concluded his remarks by saying that, "The main hope for the control of these diseases lies in the individual himself or herself. Prompt detection and treatment prevent the spread." A campaign against venereal disease is being conducted by the Advertising Council sponsored by the American Social Health Association. The advertising was prepared on a volunteer basis by N. W. Ayer and Son, Inc. Cannot Change," Drug Intel!. and Clin. Pharm., 5, 387 (Dec. 1971) 4. Dee, D. A., "Group Practice in Pharmacy," JAPhA, NS8, No.6 (June 1968) 5. Hennessy, W.B., "A Fee-Per-Patient-Per-Day Basis for Delivering Pharmaceutical Services to an Institution," JAPhA, NS9, No. 11 (Nov. 1969) 6. National Pharmacy Insurance Council, Guidelines for the Formation of a Prototype Pharmacy Group Practice, Including a Model Operational Review System (MORS), Washington, nd. 7. Kidder, S.W. and Isack, A.G., "Health Maintenance Organizations and Pharmaceutical Services," JAPhA NS12, No.1 (Jan. 1972) 8. A Report on Group Practice of Pharmacy, American Society of Hospital Pharmacistl, Washington D.C. (Sept. 30, 1971 ) 9. Knoben, 1.E., "Pharmacy Practice in Group Medical Clinics," HSRD Briefs, National Center for Health Services Research and Development, No.5 (Aug. 1972)

Atlanta, GA 30333. Dept. HEW Item No. (HSM) 73·8017. Weekly with annual supple· ment. No charge. This publication features news notes on communicable diseases and outbreaks af· fecting areas of the U.S. Regular statistical tables show incidences of each disease by region and individual state. The annual supplement gives cumulated tables, graphs and distribution maps of reported incidences of notifiable diseases for the past year. Mortality, Vol. II-Part A. Vital Statistics of the United States, 1968 (1972) U.S. Public Health Service, National Center for Health Statistics. Available through the Superin· tendent of Documents, Government Printing Office, Washington, DC 20402. Item No. 0-470· 419. Annually. $6 Part A presents general, infant, fetal and accident mortality statistics with demographic and cause·of·death detail. It includes an annual life table and a technical appendix. Unfortunately, there is a four·year lag during which the data is compiled and published, therefore, the 1972 issue contains 1968 data. Mortality, Vol. II-Part B. Vital Statistics of the United States, 1968 (1972) U.S. Public Health Service, National Center for Health Statistics. Available through the Superin' tendent of Documents, Government Printing Office, Washington, DC 20402. Item No. 0-452· 524. Annually. $7 Part B shows the total number of deaths, deaths from selected causes, infant deaths, neonatal deaths, fetal deaths and selected rates and ratios. Tabulations are shown for each state and county, specified urban places, metropolitan and non metropolitan counties, population-size groups and standard metro· politan statistical areas. As with part A, there is a four·year lag during which the data is compiled and published. For additional statistics dealing with public health see Health Services Reports, U.S. Public Health Service, Health Services and Mental Health Administration. Available through the Superintendent of Documents, Government Printing Office, Washington, DC 20402. Dept. HEW Item No. (HSM) 73-1. Monthly. $15.50 a year.