Monday, December 3, 2007

Pharmacists as Triage

Jim Plagakis is hard-hitting and frequently acerbic, but that's what makes bloggers like P.Z. Myers the moguls that they are. Jim's most recent entry on pharmacists as the ultimate kings and queens of triage is a rather interesting read, and I really couldn't agree with him more.

I don't have a lot of the bitterness Jim does, likely because the system hasn't chewed on me for quite as long. Jim still remembers the days when it was illegal for pharmacists to discuss medication with patients. Nowadays, many physicians are starting to recognize the value of good pharmacists in the healthcare network. Not just the pharmacists that work in their hospitals, mind you, but the pharmacists manning drugstore counters at retail outlets.

The healthcare system is dramatically inefficient; the Buckeye Surgeon recently related a case that was an appalling waste of resources. You can't possibly appreciate the number of people who use their drugstore pharmacist as a first resource for medical advice unless you've worked in a community pharmacy. Pharmacists are accessible, abundant, and best of all from the public's point of view, free. There's no office fee, no receptionist, and no paperwork. Pharmacists are available at all hours. Your pharmacy may not be open 24/7, but in all likelihood there is another pharmacy that is within 20 minutes' driving distance. And distance is arguably irrelevant with the telephone; pharmacies recieve calls at all hours of the night. Getting a phone call at 9:30 from a concerned mother or a constipated senior is a regular part of the job.

But if pharmacists are going go wind up being a major point-of-triage by default, we must ask if they're doing a good job. Most of the pharmacists I've known have been good medical professionals on this point. They know what they can and cannot handle. Being a community pharmacist is really all about knowing what illnesses are self-treatable and being willing to take a thorough history to rule out cases that are inappropriate for self-care. We refer many patients to their physicians or even to the hospital, but we save many more from trips to the ED over upset stomachs. The problem is that from a documentation and communication standpoint, this absolutely sucks. In 99% of cases, the only surviving record of care provided by a pharmacist is in both parties' short-term memory. Patients, then, have to pass on care that a pharmacist has suggested verbally. Many of them will forget to do so, leaving gaps in the patient's medical history.

Granted, it isn't necessary for patient records to be bogged down by entries like "on November 14th I had a headache and the pharmacist recommended Excedrin." But wouldn't it be wonderful if pharmacists had a way to keep accurate records of patient self-treatment? When hospitals perform medication reconciliation for recently admitted patients, they call pharmacies to confirm records. If only there were a mechanism for pharmacists to store more detailed information about a patient's history of illness and attempted therapy! It would be particularly handy for pharmacies to have a record of patients who take supplements or herbal products. A counseling record wouldn't have to be particularly complicated or long to be useful; most records would be the result of about 5 minutes' worth of conversation.

"Patient reported to pharmacy on [date] with [chief complaint]. Reports [symptoms]. Medical history includes [x and y]. Recommended [course of action]. Known action taken by patient includes [z]." These records could be passed on to the patient's primary care physician. This is the 21st century! We have the technology!

Of course, in accordance with privacy laws and to keep everything easily retrievable, computerized data is the way to go. The problem is that this could get ugly; patients new to the particular pharmacy would not have established records, and the process of setting up a patient profile is a time-consuming task for staff. In reality, most pharmacies can collect information for a full patient profile in minutes, but this assumes adequate staffing--and most busy pharmacies are not adequately staffed. "Having time to do thorough and appropriate patient counseling" already feels like a pipe dream for many pharmacists, and adding an additional step to the process would require time that numbers-obsessed retail giants are not willing to spare. And then there are the patients are talking to pharmacists specifically because they want to avoid drawn-out meetings or filling out paperwork. In today's drive-through society, the idea of having to wait for anything just sets some people's pants on fire. Would patients be willing to take an extra 3-5 minutes to improve the quality of their healthcare by getting proper advice and attention from their pharmacist?

An oddity of this whole situation is that patients want more counseling but that they're unwilling to pay for it. Cost is apparently the number one factor in choosing a pharmacy. Hm. But costs being equal, patients prefer pharmacies where they feel that the pharmacist is involved in their health. They want a rapport with their pharmacist. Many patients at my store actually bypass closer retail outlet locations because they like our staff better--and they say so.

Pharmacists are becoming a bigger part of the healthcare team every day. How can they possibly cope with this increased responsibility or use their knowledge effectively if they neither have access to patient medical records nor have a means to communicate patient information with PCPs? As it stands, pharmacists are huge contributors to patient well-being but are effectively severed from the main body of patient information. They are an island, and messages are neither recieved nor sent, creating a black space where pharmacists are forced to grope around in the dark and hope patients have all the information they need to do their jobs.

I had a man approach me the other day saying he wanted to purchase a particular product. Before simply directing him to the product, I wanted to make sure his decision was sound, so I inquired as to his symptoms and his medical history. He said he was in good health and taking no other medication, so I agreed that the product was a good choice and sold it to him. He came back some three hours later saying he wanted to return the (unopened) product because he had read on the label that it should not be used by patients with thyroid disease--and he apparently had some manner of thyroid disease. Apparently thyroid disease doesn't count as an "existing medical problem." Maybe he was ignoring me, or he could've somehow forgotten. No harm came to the patient, but the case illustrates my point. Universal patient records would've prevented this problem in entirety, and it would also safeguard against more serious ones.

Patients are fallible. Doctors and pharmacists are fallible, too. We would be able to prevent more mistakes and provide a higher standard of care if we could improve communication and implemented a system for pharmacists to keep detailed records of patient counseling sessions. The biggest cost would be in time--in the long run, the prevention of errors and the streamlining of pharmacists as triage agents would ultimately save the medical system a great deal of money. So why aren't we doing it already?


Bad said...

I've actually spent a decent amount of time trying to theorize a mathematical way in which we could store and update literally every single piece of patient data such that it could be used to generate aggregate measures... but at the same time make it 100% impossible to ever pull out a "person's" history from whatever megadatabase this would involve (this second condition, is, I think what it would take in order to convince people that the privacy concerns weren't serious enough to worry).

To explain it another way: some way to track highly detailed data views without ever being able to reconstruct the underlying individual connections that make up the view.

At this point, I've yet to think up a foolproof way for this to be possible, and yet, probably the more interesting mathematical problem is whether or not we can prove it's impossible.

If it were possible, it would be incredibly, incredibly cool and useful. Imagine having not just statistical data laboriously collected here and there, but all, literally all, of the data about medical care and outcomes everywhere in the country. It still wouldn't be quite perfect (since lots of things happen that do not directly get recorded by medical record systems), but it would still be an incredible tool.

samiam said...

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I will, however, tag this URL for future mind stretching. Well done!

Sam Haynes