Your pharmacist may know less than you think
Friday, May 23, 2014
Less about you, that is.
What I'm talking about is what I like to refer to as the "pharmacy information gap." That is my euphemistic way of saying that, in our current model for prescribing and dispensing, the retail pharmacist is often entirely blind to the diagnosis for which a medication is written.
We receive the prescription. We know the drug, the strength and the directions. We know who needs it, and we know who wrote it. But why has it been prescribed? Typically, all we can do is guess from the list of approved and not approved (off-label) FDA indications.
Decisions about appropriate dosing and who should receive the drug are often highly dependent upon the diagnosis. Take a drug as simple as lisinopril. Depending on whether the diagnosis is an acute MI, heart failure or hypertension we might expect to see rather different dosages being prescribed.
How about a proton pump inhibitor like omeprazole? Is it for GERD? Is it for a duodenal ulcer? Is it for Zollinger-Ellison syndrome? The diagnosis will change both the dosage and length of appropriate therapy.
How about most antibiotics? Take azithromycin, for example. Is it being used for sinusitis, prevention of traveler's diarrhea or off-label for acne? The "appropriate" dose changes with each diagnosis. But does the pharmacist know why it was prescribed? Usually not.
Of course, this isn't always the case. Some prescribers are helpfully adding diagnosis codes to their prescriptions these days. But more often than not, the prescription simply comes across with the bare minimum of information needed to fill it.
This problem is neither new nor unknown. In the January/February 2014 issue of the journal Research in Social and Administrative Pharmacy, a study was published entitled "Assessing the effect of providing a pharmacist with patient diagnosis on electronic prescription orders." The study was conducted by the University of Arizona College of Pharmacy.
While far from earth-shaking, the paper did conclude that "the addition of patient diagnosis to the e-prescription order can reduce confusion and uncertainty on the part of a DUR pharmacist, thereby decreasing the overall number of interventions and the subsequent number of contacts with prescribers."
Personally, I think the study understated the benefit, and more research would probably bear this out.
What does this mean?
The consequences of this current arrangement are significant.
First, pharmacists typically have to make broad assumptions about safe and effective dosing. Does the cefixime dose seem a bit low? Yeah, but maybe the person has compromised kidney function, so I'll let it go. Does the oxycodone dose seem a bit high? Yeah, but this patient may have terminal cancer, and this dose may actually just barely touch the pain.
But the ability to counsel and adequately prepare patients is also significantly compromised by this lack of diagnosis and medical history information. Even if the average retail pharmacist had the time to do more counseling, they have a significant amount of research to do just to get the most basic information needed to counsel appropriately.
Can this be fixed?
Yes, of course it can. We have the technology to easily transmit diagnosis information in the form of ICD-9 or ICD-10 codes right now. Some prescribers are doing that, and it is appreciated. Access to electronic health records would help, too.
But information alone isn't enough. Our whole retail prescription distribution system needs an overhaul. Today, many pharmacists hardly have time to just get the prescription filled — let alone time to analyze the dosage and diagnosis, and provide additional and sufficient counseling.
For example, we need to rethink the way we do filling. Better automation is needed for routine filling processes. Every time a pharmacist slides a pill across a counting tray we ought to ask ourselves, "Really? Does this make any sense at all?"
More time must be committed to patient education on medication utilization and patient follow-ups. Numerous studies confirm the benefit of pharmacist interventions. Armed with the right information — and time to use it — great things could happen.
Pharmacy software and dispensing systems need to get modernized and incorporate more sophisticated diagnosis and clinical notes fields for patient interactions. Again, some companies are getting progressive here, but others are lagging behind.
Benjamin Franklin once said that "an investment in knowledge pays the best interest." And in the interest of patients and the healthcare system in general, a little more knowledge on the pharmacy side would pay off quite well.
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