IntroductionHepler and Strand published the seminal work on pharmaceutical care in 1990 (Am J Hosp Pharm, 1990;47:533-543). They proposed that the role of pharmacists in society should involve identifying, resolving, and preventing 8 types of medication-related problems:
? Drug use without indication?The patient is taking a medication for no medically valid indication.
? Untreated indication?The patient has a medical problem that requires drug therapy but is not receiving a drug for that indication.
? Improper drug selection?The patient has a drug indication but is taking the wrong drug, or is taking a drug that is not the most appropriate for the special needs of the patient.
? Subtherapeutic dosage?The patient has a medical problem that is being treated with too little of the correct medication.
? Overdosage?The patient has a medical problem that is being treated with too much of the correct medication.
? Adverse drug reaction?The patient has a medical problem that is the result of an adverse drug reaction or adverse effect.
? Drug interaction?The patient has a medical problem that is the result of a drug-drug, drug-food, or drug-laboratory test interaction.
? Failure to receive medication?The patient has a medical problem that is the result of not receiving a medication due to economic, psychological, sociologic, or pharmaceutical reasons.
What progress has been made toward the realization of this vision of pharmacy practice? Why has progress been so slow? The purpose of this article is to propose a vision for the future of the profession of pharmacy, based on the Hepler and Strand model, and to describe strategies for achieving this vision.
A Vision of Pharmacy in the FutureAlthough pharmacists still are responsible for oversight of medication dispensing and protection of the public from errors in prescribing and dispensing, the process is more efficient due to the increasing use of support personnel and technology. Pharmacists have evolved into a role as health care providers, assisting prescribers and consumers to ensure that medications are prescribed and monitored appropriately and consumers understand and adhere to medication regimens. Pharmacists are paid for these services through Medicare, Medicaid, managed care, insurance carriers, and consumers.
Physicians and other prescribers readily accept the assistance and services of pharmacists because drug therapy has become exceedingly complex. Prescribers in all settings routinely refer high-risk patients to consultant pharmacists for assistance in creating and modifying drug regimens to achieve the desired therapeutic objectives. Consumers readily accept the assistance of pharmacists with their medication regimens, and those at high risk for medication-related problems seek out help from pharmacists to review their drug regimens and provide assistance with managing the complex drug regimens.
All stakeholders (physicians, consumers, payers, pharmacists) understand the concept of medication-related problems and are familiar with the risk factors to identify persons who are at high risk for these problems. Pharmacists are valued by all for their expertise in identifying, preventing, and resolving these medication-related problems. As health care costs increase, and the number and cost of medications increases, pharmacists are also valued for their ability to prevent unneeded emergency room visits and hospitalizations and for their ability to tailor effective medication regimens with low cost or cost-effective medications.
Pharmacists who provide these medication management services work in a variety of settings. Some work from private offices. Others are based in offices within community pharmacies. Some may work from their homes and see patients at their home or in assisted living facilities, or see the clients of home health agencies.
Why Has the Vision Not Been Realized?The forces at work to hinder widespread adoption and implementation of this new vision for pharmacy practice come from 2 directions: internal to the pharmacy profession and external to the pharmacy profession.
Since Hepler and Strand published their work on pharmaceutical care in 1990, the leadership of the profession of pharmacy has embraced the concept of pharmaceutical care. Yet it has not reached the point of widespread adoption by the profession as a whole. Many pharmacists are frustrated that they are unable to obtain payment for what they perceive to be an important role in society. Other pharmacists are frustrated with the extreme demands associated with the dispensing process, which leaves little time for other functions related to pharmaceutical care. They would like to be more involved in patient care but lack the time and resources to conduct these activities.
On the other hand, many pharmacists are not yet ready to embrace a significant change in their role as pharmacists. Some pharmacists practicing today were trained in an era when it was considered unethical for pharmacists to talk with patients about their medications because it was considered an infringement on the physician-patient relationship. Other pharmacists are comfortable when focusing on the dispensing process and unwilling or unable to accept responsibility in assisting prescribers and patients with safe and appropriate medication use.
Consumers, legislators, policy makers, and payers do not understand the concept, cost, and clinical impact of medication-related problems. It is difficult to convince people to pay for something when they do not perceive that a problem even exists. Using an example with heart attacks may help illustrate this dilemma.
Suppose that you have been transported back in time with your present clinical knowledge. You know about the risk factors for heart attacks (smoking, obesity, lack of exercise, etc), and you know that aspirin can reduce cardiovascular morbidity and mortality. You know that you can help save lives and improve health by educating consumers with what you know. So when you find someone who needs your help, you offer your services and state your fee for providing the needed assistance. Before forking over their money for your services, however, this primitive consumer has some questions:
? What is a heart attack and why should I be concerned about it?
? How do I know I have an increased risk of having a heart attack?
? If I am worried about a heart attack, how do I know that you can really help me reduce my risk?
? Finally, the consumer will make a judgment about the value of your offered services in relation to the requested fee and make a decision about purchasing the services.
These are all legitimate questions that any consumer or payer would ask before spending money. Yet many pharmacists are frustrated about not being able to get consumers and others to pay for their services in preventing, identifying, and resolving medication-related problems. The issue of payment for these services is of keen interest to pharmacists, but most fail to understand the need to start at the beginning. The questions that need to be answered for pharmaceutical services consumers and payers are parallel to the questions in the prior example:
? What is a medication-related problem and why should I be concerned about it?
? How do I know I have an increased risk of having a medication-related problem?
? If I should be worried about having a medication-related problem, how do I know that pharmacists can really help me reduce my risk?
? Is the service of pharmacists in reducing my risk worth what it will cost?
How Can the Vision Be Achieved?
Achieving the vision for pharmacy practice will require developing and implementing strategies to influence 5 key stakeholder groups:
? Health policy makers
? Health payers
Before people can be sold on a solution to a problem, they must be convinced that a problem exists. Then they must be convinced that a proposed solution is effective. The discussion can then focus on the details of the proposal. What is feasible? What is cost-effective? Various possible solutions or strategies can be investigated and compared to determine the best course of action.
Pharmacists think we have all this figured out, but we are way ahead of everyone else. To achieve the vision, it will be necessary to move forward with a comprehensive plan that can be implemented step by step. In part 2 of this article, such a plan will be outlined.