Personalized Medicine and The Pharmacist

Personalized medicine is the utilization of a particular patient’s genetic information yielding a more individualized approach to providing health care. This is interlinked with the field of pharmacogenetics, which focuses on how genetic information impacts a patient’s response to a drug. Using this individual genetic information, we would be able to customize drug therapies for each patient in terms of choosing the most effective and safest class of drugs and dosing information. This can be accomplished by assessing a particular patient’s metabolic profile with respect to a particular class of drugs. For instance, we would look into the isotypes of enzymes expressed in an individual patient that may be responsible for metabolizing this drug. Furthermore, we may look into the extent a particular enzyme or receptor (to which the drug may bind to) is expressed to account for not only the effectiveness of the drug but also potential adverse effects (i.e. receptor prevalence in non-target tissues). Ultimately, using an individual’s genetic information to tailor their drug therapy would optimize their health care.
Pharmacists would be an excellent breach into this world in terms of easily accessible health care. With proper training, and an increase in knowledge base, a new age of personalized medicine can be just beyond the horizon and the scope of pharmacy practice will be able to expand. Pharmacists could have access to their patients’ genetic identity and be able to identify potential problems in drug therapy. For example, if a patient lacks a certain enzyme in order to properly degrade and metabolize the drug while in the body, the levels of drug in the body may build and toxic levels may be reached. With prior knowledge that this enzyme is not coded in certain patients, a pharmacist would be able to circumvent the entire toxicity profile testing and simply change drug therapy. In many cases this would eliminate the trial and error period of therapies, where patients take different doses of drugs and their response is gauged. On a less dark note, pharmacists would be able to work more closely with physicians and maximize the gain from their patient’s drug therapy which would create a more individualistic, patient centered type of care.
As drug experts, we are really adept at understanding how drugs work and how the body handles the drug. This fits really well with personalized medicine. We can take our knowledge base and apply it to each individual. Pharmacists are able to interpret lab tests and turn that into clinical decisions. Pharmacists in different locations, such as in hospitals, have access to lab values of a patient. This makes personalized medicine very accessible. In addition, patients may also want to understand what these lab tests mean for their health. Patients, potentially, can meet with pharmacists to discuss their lab tests and best ways to manage their medicine. This can be one component of patient centered care. Pharmacists are more accessible than doctors and can provide patients with an understanding of their disease and treatment. This builds upon the pharmacist’s relationship with patient and adds another aspect to it. In addition to medication management and counseling, we can also counsel the patient on their personalized treatment. This includes how their genetics and their diseases interact and what they need to know in order to optimize their drug therapies.

An example of where genetics and personalized medicine is used is in the screening for abacavir hypersensitivity reaction for HIV patients. We can screen patients’ HLA-B*5701 to see if a patient is allergic to abacavir. This is beneficial as it increases safety for patients. Patients are able to avoid abacavir if the screening showed that they would be hypersensitive.(1)

Personalized medicine and pharmacogenomis offer an amazing opportunity for pharmacists to fully utilize their unique knowledge of drug therapy and expand their role in the health care system. Patients could be screened to determine the most effective drug therapy for particular disease states, and which drugs could lead to significant adverse effects. As one of our group members so eloquently put:
We are a collective.
We are the cogs in the machine that make the world run.
For the most part we are faceless. You walk past someone on the street and you never see them again. This is why, sometimes, it is hard to remember that all these cogs are individual.
Diverse.
Unique.
Distinct.
It is because of our differences that personalized medicine is relevant and required in the world today.
Personalized medicine is a way of looking at an individual and giving a treatment option that is tailored to their particular needs. Not everyone finds Tylenol effective for their headaches, or gets a rash when they take penicillin. Simple applications of this idea are being applied already, such as taking a patient’s medical history, family history, social situation into account when choosing the right therapy but the possibilities are endless as our ability to work more specifications, such as a person’s genetic code, into how we proceed with therapy.
Rather than treating a disease, we are now looking to treat a person.

Pharmacists should most definitely be involved in this process. If we are the medication professionals, then we should be taking charge and making sure that the medication will be the right one for this patient. If the time comes that we can be applying a person’s genetic code to how we are deciding what drug to give a person, then it is our expertise that will be needed to look at that code and interpret how we can best solve that patient’s issue with the most benefit, and least harm possible with the medication that is not only right for their condition but right for them.
If we are involved with this process we can be putting patients on fewer drugs, with fewer side effects, for a much affordable cost. It will raise adherence and a patient’s over-all quality of life.
Personalized medicine is one of the greatest possibilities in the future of all medical fields, and the $67.5 million dollars that Canada has just invested in the health care model is the first step on the path to a bright future.

::Group 17:: Thomas Bateman, Sunny Johal, Daisy Ji, Alexander Li, Clay Palmer, Nick Fleming::

(1)Genetic Screening to Prevent Abacavir Hypersensitivity Reaction: Are We There Yet? [Internet]. 2011 [cited 2012 Feb 1]. Available from: http://cid.oxfordjournals.org/content/43/1/103.full

Personalized medicine is definitely a good way for pharmacy to be heading right now. Pharmacists are under-utilized in a pharmacy with the current “dispensing model.”  With the advancements in personalized medicine, it seems that a change is definitely coming this way along, especially with the establishment of the Blueprint for Pharmacy.

Recently, CTV.ca posted a link on a story about personalized medicine and how the government is investing $6.5 million in certain groups doing research on the area. The information on the article was good, but as it is just an article on the web, there was no external links to read for more information. The comments on the article itself were very biased. There were many comments that talked about how there are not enough physicians in certain areas and how there are too many specialists rather than general practitioners. But the most striking thing to me was that there was absolutely no mention of pharmacists being involved.

It seems that the public believes that personalized medicine would be an area of expertise for certain physicians, rather than a way of treating patients, in a general sense. The article made no mention of pharmacists and their roles in personalized medicine. I agree that physicians would have a role in personalized medicine, but there is so much a pharmacist can do as well considering the personalized medicine is aimed towards tailoring drug therapy to a unique individual. Drug therapy is a pharmacist’s field of expertise.

The image of a pharmacist has not changed in years and this is possibly a reason why the public only views personalized medicine as an area for physicians. Pharmacist’ need to be more pro-active in marketing our profession and showing the public and the government that we are more than just people who dispense drugs. There should be more emphasis on how our profession is changing and what the public can expect from pharmacists in terms of health care services.

By: Karmen Shum, Willy Lu, Kevin Seok, Joy Qiao, Nazneen Dhaliwal, and Shane Tamana

Pharmacists have no place in a dispensary. Period.

History of the Profession:

In the past, pharmacists were masters of their domain, they would prepare compounds from scratch, double check their own work, and frequently owned their own businesses.  Like many other industries however, in recent decades the profession has changed.  As new diseases are discovered,  old diseases are better understood, the number of drugs available to treat these have steadily increased.  With this increased understanding, and increased availability of drugs, the number of individuals with regular or recurring prescription drugs has drastically increased.  This has demanded increases in efficiency and scale of dispensaries in communities.  This is not uncommon, the streamlining of professions like pharmacy is akin to the implementation of machines in factories to increase productivity.  It only stands to reason then, that as the sheer volume of prescriptions that are written increases, the community pharmacy industry will find ways to improve efficiencies.

What Pharmacists do (Currently):

As it currently stands, community pharmacists have 3 main roles in pharmacy. The first is assessing the appropriateness of therapy for an individual, this cognitive work is unique to our profession, and because of our specialization in training, we are, bar none, the most proficient profession at doing this. Secondly, is counselling the patient on the medication, this is also a unique skill that only pharmacists can perform, as we receive more training and education on doing this than any other profession. Thirdly, is we physically check prescriptions, ensuring that from point of entry, to point of sale, the drug that was prescribed is in the correct bottle, and goes to the correct patient.  This portion of our job can be done by anyone who can read a doctor’s writing, and who has enough visual acuity to compare tablets in a stock bottle to those in the dispensed bottle.  Pharmacists are no better trained to do this than any technician.  Depending on the pharmacy, the third role of pharmacists can easily take up the majority of the pharmacists time, with the time dedicated to assessing therapy and counselling being severely limited.  Consider the following: the vast majority of community pharmacies are owned by large corporations, with the minority being privately owned stores.  The current business model for community pharmacies is based on the volume of prescriptions dispensed, and not the quality of care.  Additionally, most of these large companies are publicly traded companies, which forces huge emphasis on them to cut costs and maximize profits wherever possible.

The problem:

Community pharmacy in general is trending towards a business model wherein they can accomplish selling the most number of prescriptions, at the least cost to themselves.  As I already stated, the third role of the pharmacist (technical role) occupies the majority of the pharmacists time in most community pharmacies; and this role is easily replaceable.  What we have already begun to see is the training of technicians who will perform the coveted task of “final check” on prescriptions.  Simply put, this job is to ensure that correct product is in the correct bottle for the correct patient.  Herein lays the problem.  Large corporations have the right idea.  There is no reason that pharmacists should be performing this role; we are no more proficient checking prescriptions than a technician, and yet we hold monopoly on it, and expect 2x-5x the salary for it.  Who can blame these large companies for lobbying to have this power relinquished by pharmacists? From a business standpoint, they can eliminate more than 50% of the pharmacist’s workload in the community pharmacy, by replacing them by equally capable, and much cheaper, technicians.

The flaw of current practice model:

So what does this mean for pharmacists?  It means that the fundamental model of community practice is going to change.  The problem is that pharmacists exist in a bizarre loophole of how they are financially renumerated.  The vast majority of pharmacists in community are in one of two situations. They either work for a pharmacy (private or corporate) or own their own pharmacy.  Either situation is faced with the same dilemma.  On one hand, the pharmacy in which a pharmacist may work is reimbursed by the volume of prescriptions sold, which are paid for by the government via pharmacare.  On the other hand, the pharmacists themselves are paid salary by the pharmacy they work for.  Therefore, for pharmacists to protest against the implementation of registered technicians, they are going against their employers best interests.

What this results in is two bodies lobbying the college of pharmacists for conflicting changes to the territory of physically checking prescriptions.  The pharmacists want to protect their monopoly in this area, and the companies who own the pharmacies want to employ skilled technicians to do it for cheaper. The result is a profession which is at war with itself.  When pharmacists are involved in selling prescriptions, they are inescapably stuck in a tug-of-war between good business vs good healthcare.

What is the solution?

Get pharmacists out of the dispensary.

As I already stated, the majority of the pharmacists work currently is performing the “final check” on prescriptions.  Pharmacist should not be doing this for 3 main reasons:

1) Technicians can do the exact same job for cheaper (like it or not).

2) Being responsible for the “final check” ties pharmacists inexorably to the current business model which requires high volume of prescription sales. This generates the conflict of interest between pharmacists and the employers.

3) This is not what they are trained for, and is an inefficient use of pharmacists as a resource.  In current practice the two roles we are actually trained for: Therapy assessment and Counselling, are SECONDARY to checking prescriptions.  Pharmacists are the experts at counselling, and therapy assessment, NOT physically checking prescriptions.  Perhaps more importantly however, is the fact that because of current business models, these important skills  of pharmacists are woefully underutilized.  Were pharmacists able to provide adequate therapy assessment and counselling to every patient, the adherence to medications, quality of life, and savings to healthcare system would be extraordinary.

How do we accomplish this?

It is a simple as passing legislation which mandates that “before any prescription can be filled, it must be signed by both a physician (prescriber) AND pharmacist (assessed proper therapy)”.  One such model of this would place the pharmacist in the medical clinic, right across the hall from the physician.  For instance:  A patient comes in, sees the physician, gets diagnosed with a strep throat, the doctor writes a prescription for antibiotics, and the patient leaves, walks across the hall to the pharmacist. The pharmacists takes the prescription, assesses the appropriateness of it, evaluates the patients other medications, and then counsels the patient on the antibiotics right then and there.  After counselling, the pharmacist signs off on the prescription, which the patient can take to any dispensary, and have filled. At this point the prescription has been assessed for appropriateness and the patient has been counselled.  The patient goes to a pharmacy, and the technicians which work there count the correct number of tablets from the correct bottle, perform a final check, and dispense it to the correct patient.

With this model, pharmacists are now able to perform the job they are trained to do, and because they are situated in the same geographic location as the prescribing physician, they are much more apt to communicate as a team, resulting in better healthcare.

There are many different possible models of payment for pharmacists with this model.

• The first options is that pharmacists could have a billing account like physicians do, and be renumerated different amounts depending on task which they performed.  Assessing new therapy can be billed at X, whereas doing an entire medication review could be billed at Y… etc..
• Alternatively, the pharmacist could be paid a salary, much like nurses and other staff in a medical clinic are.  For instance, the physician has a billing number which he bills for all patients that he sees.  Out of the money he is renumerated, he pays the wages of any associated staff at the clinic.  Pharmacists could be paid in the same manner that nurses at the clinic would be; hourly or monthly etc.  This may require adjustments to the amounts that physicians can bill for, but these are small details in the grand scheme of things.

The net result is that the government will be paying pharmacist’s wages instead of community pharmacies.  This removes any conflict of interest between pharmacists providing thorough care to patients, and the rush to sell as many prescriptions as possible.
How would we finance this?

Easy. 

Change the dispensing fee on prescriptions from $10 per prescription, to $1.  Dispensaries are no longer providing the cognitive services that used to be fulfilled by pharmacists, so this professional fee no longer applies.  This makes dispensaries much more like any business which sells goods, where the profit is due to mark-up on the drug costs.

This means that all the money that the government would have paid for dispensing fees, is now available to fund pharmacists.  The same amount of money that the government had set aside for cognitive service before will now be available to pay pharmacists! The only difference is that now, without the burden of the technical work they previously were buried under…. pharmacists will be able to provide much more time, and much better care to each and every patient.

A functional model of practice for pharmacists:

What would happen:

1. Pharmacists move out of dispensaries.
2. Legislation passed requiring prescriptions to be signed off by both a Physician and Pharmacist before getting filled at a dispensary.
3. Pharmacies (dispensaries) no longer need pharmacists, and only employ technicians.
4. The professional fee on each dispensed prescription is drastically reduced, and the money is reallocated to paying pharmacists directly (in their medical clinic setting).

Who this is good for:

1. The patient.  Pharmacists will have SUBSTANTIALLY more time to counsel patients, develop a therapeutic relationship, and assess their current therapy completely, on a much more regular basis. Results in better medication adherence, decreased risk of complications from diseases, and improved quality of life.
2. The taxpayers/government.  The amount of money available to pay pharmacists after cutting the amount of professional fee currently reimbursed will pay for pharmacists salaries, so the net cost is the same.  In addition, by providing much better care, the pharmacists will be able to reduce the number of hospital admissions every year, and prevent many medication related complications with any patient’s health, resulting in substantial savings.
3. The community pharmacies.  These businesses will no longer have to employ pharmacists.  They can save substantial amounts of money by employing completely capable technicians to do the entire technical role of dispensing a prescription.  Whether or not these savings are balanced with the loss of revenue due to not receiving dispensing fees however, remains to be seen.

In summary:

As a pharmacy student, I am in an impossible situation.  I am less than halfway through training for a profession which is in very dire straights.  If it doesn’t extricate itself from its current entanglement with business, it will die.  This will be a huge loss to the healthcare system, patients, and the pharmacists.  Currently, many practicing pharmacists are either too complacent, or too busy trying to stay afloat with the onslaught of prescription volume they see at work, to address this overarching problem.  As a student, I hardly have the time to think of solutions for our profession’s problem.  However, the frightening reality is; that unless we make these changes, and soon, the profession might very well go down a path from which there is no return.

Jordan S, Pavan M, Erik M, Jonathan C, Justin T, Jieun K,  Maggie C

     To the general public, pharmacy practice may seem to centre primarily on dispensing medications with minimal patient interaction; a profession that hides behind the little white counter more than arms reach away – impersonal. However this is grossly untrue, reflecting only a small portion of the pharmacists’ role.

     Whilst some aspects of the traditional roles of pharmacists are being transposed to licensed pharmacy technicians, pharmacists are now able to focus more on patient drug counseling and medication management.

     Pharmacists are in a unique position precariously situated between public duty and private enterprise. In evaluating the fundamental components of the pharmacy profession… Pharmacist compensation is a major weakness; an inconsistent component of our public healthcare model. Unlike physicians who are paid per patient visit, pharmacists are currently paid per prescription. This means that pharmacists are not appropriately compensated for time, knowledge and expertise spent on quality patient counseling on prescription, over-the-counter medications, health products and related concerns).

     Pharmacists are the gatekeepers to accessing medicines, the connection between various health professionals (include doctors, all prescribers) whereby issues surrounding proper medication use, safety and effectiveness are addressed. As drug specialists, pharmacists are unique in managing patient health alongside fellow healthcare professionals. Patients are encouraged to take an active role in their health management and pharmacists are in a key position to aid this dynamic relationship.

     As an easily accessible information source, pharmacists are often torn between providing quality patient care and compensation reflective of pharmacy practice.

     As the population ages, demands on pharmaceutical services will increase inevitably.  Without reflective pharmacist compensation, the current pharmacy business model will not be able to sustain quality patient care to the masses.

Written by Eileen Song, Margaret Chan
Group 9

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