Pharmacy education — toward a more clinical care model
Six years. That’s how long it usually takes for any candidate to earn the Doctor of Pharmacy degree, or PharmD, now required to practice as a licensed pharmacist. In addition, PharmD graduates also must pass state licensure examinations required by state boards of pharmacy in all 50 states.
That puts pharmacists on par with nurse practitioners and physician assistants in terms of the level of advanced classroom and residency requirements needed to achieve professional status as a health provider. And particularly since 2004, when the six-year PharmD degree was fully implemented as the minimum level of education required, pharmacists have broadened their scope of practice to include a wide array of clinical skills in such areas as preventive health care, disease management, medication therapy management, immunization therapy and wellness counseling.
“The education of student pharmacists is shifting to meet the envisioned and evolving role of the pharmacy profession,” the American Pharmacists Association reported. “As practicing pharmacists have assumed greater roles in patient care, … introductory and advanced pharmacy practice experiences are now critical elements of future pharmacists’ education and training.”
Ronald Jordan, dean of the Chapman University School of Pharmacy, describes the demanding level of preparation required to reach professional status. “The Doctor of Pharmacy degree involves approximately eight semesters of rigorous training with approximately 140 graduate school-level required course credit hours of work,” he explained. One-third of these hours are experiential in nature via prescribed types of clinical practice mentoring.
“This professional program is usually following a minimum of at least four semesters … of required undergraduate college-level work in the sciences (chemistry, biology and psychology), math and [such humanities courses as] ethics, communications and economics,” Jordan said.
This “minimum of six years of professional education … reflects an evolutionary change for pharmacy education that mirrors the evolution in pharmacy practice to a more patient-centered focus,” the National Association of Chain Drug Stores reported. “It is the goal of all pharmacy schools to prepare pharmacists who can assume expanded responsibilities in the care of patients and assure the provision of rational drug therapy.”
Indeed, said Eric Wright, associate professor of pharmacy practice at Wilkes University, “schools of pharmacy in the United States have been training pharmacists to be active members of a patient care team since before the institution of the entry-level Doctor of Pharmacy degree over a decade ago.”
“Our education is patient care-focused with the goal of producing competent pharmacists ready to work with the rest of the healthcare team in maximizing the benefits from the use of medications,” Wright said. “In addition to more classroom coursework, the education of pharmacists is increasingly experiential in nature, with about one-third of the curriculum being learned at practice sites like community pharmacies, hospitals, outpatient clinics and long-term care facilities.”
What’s more, said Javad Tafreshi, professor and chair of the department of pharmacy practice at Loma Linda University School of Pharmacy, “Recent trends in the pharmacy profession have seen more demands for pharmacists with additional training and experience over and above the PharmD degree.”
“The profession has changed substantially in the last decade or so,” Tafreshi said. “Years ago, the PharmD was recommended, but not required; now it is a basic requirement. Today, we are seeing more and more positions where both general and specialty residencies are required, along with the PharmD degree.”
The nation’s 133 schools of pharmacy — every state except Alaska and Delaware are home to at least one of them, according to the Accreditation Council for Pharmacy Education — have stepped up their degree requirements in direct response to the acute and growing demands by the U.S. health system for a more cost-effective, accessible and responsive level of patient-centered care.
“While we continue to prepare pharmacy students to provide medication-related expertise, we also prepare them to accept responsibility and accountability for the overall care of the patient,” said Scott Stolte, dean of the College of Pharmacy at Roseman University of Health Sciences. “Pharmacy students learn aspects of public health, disease prevention, patient history-taking and interviewing, physical assessment and many other topics that prepare them to accept a role in affecting the health-and-wellness of the patients we serve.”
Increasingly, effective patient care is driven by a team-based approach, with pharmacists working with and sharing privacy-protected patient information with physicians, hospitals and other team members on behalf of the patient. Pharmacy education reflects that approach, Stolte said.
“In classroom and practice settings, pharmacy students now work alongside students of other health professions, including medicine,” he noted.
The new health paradigm puts patients at the center of this hub-and-spoke model of integrated care. “Modern doctor of pharmacy curriculums are designed to provide knowledge, skills and behaviors that put the patient and the public at the center of healthcare delivery,” said Jeff Goad, professor and chair of the department of pharmacy practice at Chapman University School of Pharmacy. “The pharmacy school graduate today is both a self-sufficient independent provider and a valuable member of the healthcare team who expertly provides disease prevention and the pharmacotherapy of disease management.”
“Pharmacists also are lifelong learners who actively impact people’s lives in measurable consistent ways, from birth to death, and in every setting where pharmaceuticals are used,” Goad added. Recognition of pharmacists as fully qualified and highly trained members of the modern patient-care team will continue to grow as the nation’s health system continues to evolve, said Don Klepser, PhD, associate professor in the department of pharmacy practice at the University of Nebraska Medical Center College of Pharmacy. “Given their education and accessibility, pharmacists are an underutilized resource, but you can … see that changing as those trained in modern pharmacy curricula begin to push for an expanded role in today’s patient-centered care teams,” he said. “A lot of the credit for that goes to pharmacy educators who not only train students, but also lead the research that shows how pharmacists can positively affect patient care when given the opportunity practice at the top of their license.”
Even before they’ve completed their PharmD requirements, said Michael Malloy, dean of the School of Pharmacy at MCPHS University, “our students are nationally certified while in school in the areas of immunization and medication therapeutic management.” That certification, Malloy said, “enables them to provide direct health care in conjunction with other healthcare professionals. If one combines this education and certification with the accessibility to patients via the community pharmacy system throughout the United States, we have created a professional who can meet the needs of our current and future healthcare system.”
Electronic prescribing yields a trove of benefits
Connecting all the dots in health care. That’s the ultimate goal in the health industry’s migration to an electronic platform, where doctors and other prescribers write prescriptions digitally and send them — directly and immediately — to a patient’s pharmacy for dispensing.
Key to that effort is the ongoing shift from paper prescriptions to electronic prescribing, by which prescribing doctors and other clinicians generate and transmit a new prescription electronically, direct to a patient’s pharmacy of choice. At the pharmacy, the digital prescription is automatically queued up for dispensing by the pharmacy’s computer system, simultaneously creating a record stored in that patient’s electronic medical record (EMR).
The U.S. Centers for Medicare and Medicaid Services (CMS) defines electronic prescribing as “the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network.” That network “includes, but it is not limited to, two-way transmissions between the point of care and the dispenser.”
Led by Delaware, Minnesota, Vermont, Wisconsin and Massachusetts — where nearly all physicians now prescribe electronically — all 50 states now embrace e-prescribing. In all, roughly three out of every four office-based physicians now prescribe electronically, generating more than 600 billion transactions a year, and 95% of pharmacies are equipped to receive and process those e-scripts.
That marks a dramatic gain from 2004, when just 4% of office-based doctors had converted to paperless prescribing, according to Surescripts, the largest health information network for connecting pharmacies with other health providers, benefit managers and health information exchanges.
Driving that rapid adoption of paperless prescriptions is a confluence of forces impacting all facets of healthcare delivery in the United States. Among the most pressing: the health system’s unsustainable rise in costs, the clear need for collaborative-care and accountable-care models integrating all members of the health delivery team, and the urgent drive to connect all of a patient’s health history with a comprehensive medical record that’s privacy protected but accessible to both the patient and to his or her health providers.
The goal for e-prescribing, said Sure-scripts CEO Tom Skelton, is “a more connected and collaborative healthcare system with a technology-neutral platform that exchanges vast amounts of data across a disparate range of health technology systems in use today.
“There is no question that health care is going digital,” said Skelton. “Providers across the country are sharing critical information to coordinate patient care. Just as we’ve witnessed continued growth in e-prescribing, so too have we seen the complexity of the healthcare system multiply, while patients and providers demand easier access to health information.”
Indeed, e-prescribing brings benefits to all participants in the care continuum — from patients and health plan payers to doctors, pharmacists, health administrators and care coordinators. By holding down prescription processing and dispensing costs and eliminating potential errors of handwritten prescriptions, it also benefits taxpayers who foot the bill for the nation’s federal and state health programs.
For patients, the e-prescription software linking their individual medication use records can catch potential problems like drug-to-drug adverse interactions, while helping patients and their healthcare team keep track of all their medications within a comprehensive, individualized medical record.
Shifting from paperless to digitized prescriptions also yields another big benefit: giving pharmacists and prescribers a powerful tool to track and improve medication adherence rates. Said Kristi Rudkin, senior director of product development and adherence for Walgreens Boots Alliance, “E-prescribing has given us more insight into the problem of primary nonadherence, where the patient doesn’t pick up that prescription.
“When scripts are handwritten, the pharmacy staff isn’t aware of scripts that never make it to the pharmacy,” said Rudkin. “But with e-prescribing, if the prescription is coming right from the prescriber to the pharmacy, the pharmacy is at least aware that the patient should be getting this medicine, and can intervene.”
Also add a safer pipeline of abuse-prone prescription drugs to the list of benefits. Electronic prescribing of controlled substances is now allowed in nearly every state and the District of Columbia, reducing fraud and diversion.
The National Association of Chain Drug Stores strongly endorses the concept. “E-prescribing holds great promise to generate a robust database of real-time information that could be used by DEA, state enforcement officers, pharmacies, insurers, wholesalers, and other partners to assist with the proactive identification of prescription drug abuse,” NACDS noted.
Among the federal agencies promoting e-prescribing and the integration of patient-centered care is the financially stressed Medicare program. “CMS promotes this patient-centered approach to care and recognizes the downstream effects of having or not having certain critical pieces of information communicated across providers and settings,” the agency has stated.
Embracing the benefits of e-prescribing, Congress in 2008 passed the Medicare Improvements for Patients and Providers Act (MIPPA), instructing CMS to promote adoption of the technology among physicians treating patients on Medicare.
“Going green with a paperless program can benefit patients [and] improve provider workflow,” the agency asserts. “Gaps and duplication in patient care delivery can be reduced or eliminated through proven technologies, such as interoperable electronic health records, e-prescribing and telemedicine.”
To encourage physicians to ditch the prescription pad and switch to prescribing electronically, the agency provided a diminishing series of payment incentives to participating prescribers, beginning in 2009 and ending last year. At the same time, CMS imposed a gradually escalating series of financial penalties, beginning in 2012, for those who refused to budge: a reduction in Medicare payments that reached 2% of a billable fee for beneficiaries receiving treatment in 2014.
“CMS encourages care coordination across the healthcare continuum and supports providers to care for patients with chronic diseases so they get seamless and effective care,” the agency explained in a memorandum to caregivers.
“We know that people and organizations working together, across silos, will make healthcare more efficient, more effective and easier to navigate,” Surescripts asserts. “We believe that healthcare is inextricably linked to technology, and if technology improves, healthcare will improve with it.”
Pharmacy-based adherence efforts: The value of face-to-face interventions
“Drugs don’t work in patients who don’t take them.”
That obvious but overlooked truism, uttered by the late former U.S. surgeon general C. Everett Koop, sums up the nagging and very expensive problem of medication nonadherence. The failure of many patients to take their medicines as prescribed, abandoning prescription therapy in the course of treatment or failing altogether to even fill a written prescription, is one of health care’s most challenging choke points. It compromises successful health outcomes and costs an estimated $300 billion a year in unnecessary hospitalizations, physician interventions and other costs.
Three-in-4 Americans admit in surveys that they don’t always take their medications as directed, according to the National Consumers League, and as many as one-third do not fill all their prescriptions. “The result is a high rate of both medication errors and readmissions to hospitals for patients whose illnesses could have been managed at home,” the University of California-San Francisco reported.
“Medication nonadherence is one of the greatest and most costly barriers in treating illness today,” said Kristi Rudkin, senior director of product development and adherence for Walgreens Boots Alliance. “By developing programs and services that can help reduce these barriers, and examining ways to drive cost savings and improved health outcomes through better adherence, we can help more people get, stay and live well.”
Doug Long, VP industry relations at research giant IMS Health, says adherence breakdowns and medication errors lead to 4 million hospital admissions and 1.4 million outpatient visits per year. “Almost 10% of the 3.6 billion retail prescriptions written by physicians [were] not dispensed to patients” in 2013, he said.
Indeed, some 25% of patients prescribed medications for a new illness fail to fill their initial prescription, and “half of patients taking maintenance medications for a chronic disease stop taking their medications within a year of starting therapy,” CVS noted in a report.
Pharmacists a ‘go-to source’
Faced with those daunting statistics, health plan payers and health advocacy groups have turned to the nation’s 65,000 community pharmacies for help. “A patient with a chronic heart condition who does not take their medications as directed can clearly endanger their health,” said Sue Nelson, VP of federal advocacy for the American Heart Association. “Pharmacists are a key go-to source for these patients. They can arm them with the critical information they need to successfully manage their medications.
“Additional research, education and awareness on adherence also can increase our understanding of best practices and interventions that ensure patients take control of their health,” Nelson said.
Pharmacy chains and independents have responded with an all-fronts campaign to track and improve Americans’ medication adherence rates, achieving significant results by leveraging a core competency of community pharmacy — the trust patients already have in their local pharmacist.
Building on the relationships already established between patients and practitioners — and on powerful, computer-driven analytical systems that can identify patterns of nonadherence within patients’ privacy-protected prescription records — the pharmacy industry has emerged as the health system’s primary resource for improving adherence.
“Our research has shown that pharmacists are among the most effective health providers in encouraging medication adherence among patients,” said William Shrank, M.D., SVP and chief medical officer for provider innovation at CVS Health. “Many patients see their pharmacist more often than their doctor, and that face-to-face interaction and counseling can provide important insights as to why a patient isn’t adherent and how to address their issues.”
Extensive research proves the effectiveness of face-to-face interactions between pharmacists and patients in keeping people on track with their prescription therapy. One study in 2010 by a team of researchers from Harvard University, Brigham and Women’s Hospital and CVS found that “pharmacists at a retail store are the most influential health care ‘voice’ in getting patients to take medicine as prescribed.”
“Pharmacist contact with patients and their doctors increases patient medication adherence rates and physician initiation of prescriptions. The greatest improvements can be seen in patients counseled face-to-face at retail pharmacies,” CVS reported.
The 2010 research, based on a review of more than 40 years of studies published in medical journals, showed that nurses talking with patients as they are discharged from a hospital are the second most influential voice encouraging patients to stay on their medicines. “Both in-store pharmacists and hospital-based nurses are more effective than pharmacists communicating to a patient via the telephone or doctors instructing patients regarding prescriptions,” researchers reported.
Reducing expensive hospitalizations
“We know that pharmacists and nurses are among the most trusted healthcare professionals. Trust translates into effective patient communications,” said Troyen Brennan, M.D., EVP and chief medical officer at CVS.
Walgreens’ Rudkin agrees, “We feel that part of understanding why a patient doesn’t take their medication — and part of the willingness of the patient to share that information — is based on that relationship with the pharmacist. That’s not to say call centers aren’t appropriate, but there’s a lot of pharmacists who know their patients really well. And if we really want to solve the problem, we have to get to the heart of what the problem is, … and identify gaps in care.
“We do other things, like automated refill reminder calls, email and text reminders that do help patients without that personal touch,” Rudkin added. “But it’s really about deciding who we feel is at most risk, and what level of interaction that patient needs. Driving adherence is more about personalizing that interaction with the patient so that it’s relevant to them, and then providing the pharmacist with that relevant information to have a good conversation with the patient.”
Smaller regional pharmacy chains are no less determined to contribute to the adherence effort. Thrifty White Drug, the Plymouth, Minn.-based chain of 87 drug stores, has enrolled thousands of its patients to its synchronized monthly prescription refill system, which simplifies the refill process by letting patients pick up all their prescriptions in just one pharmacy visit per month. By doing so, the chain is shifting those patients to an appointment-based pharmacy care model, where patients come into the store for periodic, face-to-face counseling sessions with the pharmacist that not only improve adherence but patients’ overall health, according to company president and CEO Bob Narveson.
Hy-Vee, the West Des Moines, Iowa-based supermarket and pharmacy chain, assigns each patient in its specialty pharmacy unit a Hy-Vee Pharmacy Solutions Pharmacist who provides personalized care and counseling, including providing refill reminders to “promote greater adherence to prescribed therapy, improved health and faster recovery.”
The results of all these efforts can be dramatic. One study from CVS Health and Brigham and Women’s Hospital found that patients with coronary artery disease who take their medications correctly save the health system up to $868 per patient per year. “Third-party studies indicate that $1 spent on adherence produces anywhere from $5 to $10 in medical cost savings,” CVS reported.
A survey from IMS Institute of HealthCare Informatics found that improving medication adherence rates was the most formidable “lever” available to the health system for reducing avoidable costs, with potential annual savings of more than $105 billion [see accompanying chart].
Another study from the University of Arizona and Avella Specialty Pharmacy bears out those projections. The survey found that renal transplant patients who participated in an intervention program by pharmacists had a statistically significant improvement in adherence rates over patients in a control group who did not have a contract or receive support to ensure adherence to their monthly medication therapy. The study also found that patients who complied with their medication regimens had fewer in-patient and outpatient visits, and were 78% more likely not to be hospitalized, according to a report in Drug Store News.