ehealth Services for Enhanced Pharmaceutical care Provision: From Counseling to Patient Education

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1 ehealth Services for Enhanced Pharmaceutical care Provision: From Counseling to Patient Education LUIS Velez Lapao a, b, 1, Joao Gregorio a, Tiago Ferreira a, Afonso Cavaco cod, Christian Lovis e, Giuliano Russo a, Miguel Mira da Silva f a International Public Health and Biostatistics, WHO Collaborating Center for Health Workforce Policy and Planning. Centro para a Malaria e Doenc;as Tropicais, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa Rua da Junqueira, Lisboa Portugal luis.lapao@ihmt. un!. pt b CINTESIS - Center for Research in Information Systems and Technology in Health, Porto, Portugal C Research Institute for Medicines and Pharmaceutical Sciences, Faculdade de Farmacia da Universidade de Lisboa ' Portugal and d Department of Soczal Pharmacy, School of Pharmacy, University of Oslo, Norway. e H6pitaux Universitaires de Geneve, Switzerland f Instituto Superior Tecnico, Lisboa, Portugal Abstract epharmacare project aims at assessing the potential of ehealth services in the provision of cognitive pharmaceutical services by interacting actively with patients. There is the awareness that patient education will be vital. Collection of data on pharmaceutical services and diagnosis of the use of IT in pharmacy settings was made with the application of a survey. A set of pharmacies was selected to study the pattern of services' provision supported by observational studies to evaluate the economic and clinical value of services to patients. The results will allow a better understanding of pharmaceutical services' delivery and a new perspective for pharmaceutical services integration with the health system. Due to the shortage of physicians, the development of a new internet based pharmaceutical service with educational components could be an important contribution to an effective chronic diseases' management and to change the role of patients. Furthermore there is the necessity of rethinking the community pharmacy business model to effectively integrate within future health systems. 1. Introduction epharmacare project aims at estimating and validating the health gains in efficiency and quality from the integration of pharmaceutical services; and to assess the potential of ehealth services in the provision of cognitive pharmaceutical services by actively interacting with patients, and promoting their education. [t is generally recognized that community pharmacies, and their professionals, could play a more active role in healthcare systems. Recent healthcare reforms on primary-care, due to both the shortage of human resources and the costs associated with medicines, are starting to rethink the role of community pharmacists and the value of interacting with patients. The easy accessibility to pharmacies and the perceived affordability positions pharmacists at the first line of contact within the healthcare system [1] /13/$ IEEE

2 A clear demographic and epidemiological transition in Europe is leading to a growing burden of complex and chronic diseases. To trail new trends in business innovation and technological development, few pharmacy practices have started to try to shift its focus from a disease oriented to a (value added) patient oriented practice [I]. This orientation towards the patient has become the new paradigm of pharmacy practice, and has led to the development of pharmaceutical services concept, information services, the development of a clinical role for the community pharmacists and a more active role of patients. It implies a change in the focus of practice to ensure the delivery of longitudinal value added services, the raise of Pharmacy's level of responsibility and to establish cooperative relationships with other healthcare professionals. These pharmaceutical services have been considered extremely valuable for professionals, patients and health systems, not only because there are economic savings but also due to a greater efficiency and improvement in health services quality and in patient health related outcomes. Nevertheless, this promise is yet to be accomplished [2]. Innovativeness of pharmacy is positively associated with the number of pharmacy services being offered, according to Doucette et al. [2]. This is supported by having observant personnel in close contact with customers to help identify new opportunities. Costa et al. [3] have described the status and outline the trends of community pharmacy services in the Portugal. Investing in information technologies (IT) and modernizing the architecture of pharmacies was envisioned as a necessary and critical step. Recent political changes seem to reinforce the need to pursue the strategies already defined: to expand the traditional scope of pharmacy business to a wider range of health services; however this process has been very slow [3, 4]. It seems there is a need for IT support, in developing an extended role for community pharmacies and furthermore to include the interaction with patients [5]. Calabretto et al. [6] studied the socio-technical implications for information technology related interventions in community, including medication management, and found out that we are still in the "infancy" of using IT technologies in community pharmacies. Greg6rio & Lapao [7] explored different scenarios for the future of community pharmacists in Portugal, with the use of IT and ehealth technologies emerging as one innovation that may develop in next years to harvest the full potential of these professionals to enhance the primary care network, with a leverage role for patients. ehealth can be defined as "the utilization of IT to support health services' provision, complying with the needs of citizens, patients, health professionals and other providers" [8]. The development, adoption and implementation of ehealth promises to promote a better access to information by patients and providers, improve the quality, efficacy and safety of healthcare, and to encourage healthier lifestyles [9, 10]. The main problem addressed by this project is how pharmaceutical services in the community pharmacy could help patient management, and learning, in order to improve quality of care while integrating with primary health care services. Furthermore, we want to study the actual use of technologies and ehealth for supporting services, including the study patterns of value-added services (in the context of demography and chronic diseases trends) among those delivered by a community service, and to develop a web-based prototype, design to improve quality and level of service, thus establishing its acceptability, feasibility, sustainability, and adaptability to future changes. 2. Methods The hypothesis addressed in this project research is that the community pharmacist will only be able to effectively add value, and provide pharmaceutical services (i.e., communicate with patients and other health professionals involved in the disease management process), by using information technologies and ehealth concepts, that allow a continuous interaction with patients. In order to address this hypothesis and to involve patients, we selected the Design Science Research Methodology (DSRM). DSRM studies the connection between research and professional practice by constructing and evaluating products or artifacts that address a specific need [II]. In this way, we will also improve our knowledge about the use of DSRM to develop new innovations based on the technical, social and informational resources of a health organization.

3 Revner et al. [11] have established the rules for DSRM in the form of guidelines. These guidelines support six activities, each with a specific set of tasks. In this paper, we will focus on the first and second activities necessary to start a DSRM work: diagnose of current situation and identify the problem relevance and opportunities. Thus, the objective of this research paper is to analyze and describe the utilization of IT in the community pharmacy setting, focusing on current state of pharmaceutical services provision and on the education and role of patients. To achieve our objectives, a mixed method approach was used. A literature review was performed using MEDLINE and Google Scholar to search for "pharmaceutical services", the main findings are presented in the introduction. Then we launched an online survey to both collect data on pharmaceutical services and to diagnose the use of IT in community pharmacy setting. An with instructions and a linl<- to the survey was sent to 323 pharmacies associated with the Portuguese Association of Pharmacies (AFP). Additionally, a set of four pharmacies was selected to study the patterns of pharmaceutical services provided, supported by observational studies and socio-networking analysis, which will allow the economical and clinical evaluation of pharmaceutical services [12]. The survey was based on two validated surveys used in previous studies in other contexts. These surveys focused on the characterization of current pharmaceutical services provision and IT use in the community pharmacy setting, as well as exploring perceptions about possible barriers for ehealth pharmaceutical services. After translation, our survey was piloted in two pharmacies by a total of 5 pharmacists, and minor adjustments were made. To better describe the current state and patterns of pharmaceutical services provision, we choose an exploratory observational time and motion study, using the shadowing method. This part of the study was made in four pharmacies during a weekday's full 8 hour shift. All the pharmacies were in the metropolitan Lisbon area and were selected by convenience. Informed consent by the observed subjects was formally obtained. The data collector was free to move and observe all the staff, but was mainly focused on the provision of pharmaceutical services. An Excel database (Microsoft Corporation ) spreadsheet on a laptop PC and a stopwatch were used to record the duration of each activity performed, as well by who, where and how it was performed. A list of 73 possible single tasks was tested in a previous pilot observation. Due to the large number of multitasking activities it was decided to reduce the number to 51 tasks and allow the possibility of multitasking recording by adding more columns on the spreadsheet. These tasks were then validated by the pilot study's observed pharmacists, and divided in 3 broad categories (Table 1). To diminish the possibility of affecting behavior by the staff s awareness of participating in a research study, the data collector stood at least two meters from the staff member and was informed not to initiate conversation with him or her, nor with the pharmacy's customers. Data and Statistical analysis was conducted in Excel and SPSS Software Package for Social Sciences; Version All data were kept anonymous and confidential. This study was performed in strict accordance with the good research practices and code of ethics of Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. The study protocol was approved by the Committee on the Ethics of Instituto de Rigiene e Medicina Tropical, Universidade Nova de Lisboa (Permit Number: PN). Table 1 - Examples of tasks within the main categories. Categories Administr ative tasks Dispensing tasks Pharmaceuti cal services Tasks Ordering and Storage of medicines Checking prescriptions for dispensing errors Controlling expiration dates Billing and factoring of prescriptions Meetings with vendors and salespersons Dispensing of prescriptions Dispensing of medical devices (bandages, Glucometers, IUD, thermometers, sphygmomanometer). OTC dispensing Home delivery Administration of non-injectable medicines Provision of first aid Pharmaceutical consultation Pharmaceutical counseling on medicines and health issues Provision of screening services Production and control of compounded drugs Smoking Cessation Program Disease Management Programs Therapeutic review Veterinary pharmacy service

4 3. Results 3.1. Online Survey Directly Observed therapy with Methadone The online survey had a final response rate of 4.76%, comparable with other pharmacy research surveys response rate. From this survey, we highlight the following results (figure 1): The average number of computers per pharmacy is 5 (min: 2; max: 10), in a ratio of 2.5 computers per pharmacist. The main use of the installed information systems is for dispensing medicines and administrative tasks (stock management, reimbursement activities). 84% of the pharmacies are satisfied with the use of Information Systems for management activities. 90% of the pharmacies allow access to health information resources on the internet. All pharmacies claim to check their daily, although only 15% use it to answer to patients' queries, and do so less than 5 times a month. 23% of the pharmacies have an internet site and 38% have a site in some social network (ex: Facebook ). All the pharmacies considered important or very important, the use of information systems for the management of the pharmacies and for the provision of pharmaceutical services. Also, more than 60% of these pharmacies do not provide any disease management, pharmaceutical care or smoking cessation programs. The dispensing of medicines and the collection of used medicines are the only services that all the pharmacies provided. 38.5% of the pharmacies refer that more than 60% of the customers have chronic conditions. From a set of possible new services, the ones related to the provision of information (medicine information kiosk, health promotion campaigns and thematic workshops, sms alerts) were the ones that pharmacies would like to provide the most in the future... " I:,. Fig. 1. Use of IT systems in the community pharmacy setting. Also important to highlight are the main barriers to the implementation of ehealth solutions in Community Pharmacy. The respondents claim that no financial incentive for the implementation of ehealth solutions and not enough support and guidance from professional organizations are the most important barriers (figure 2) t. ".- _....-1IIt 1II1ItrI... -,,--,..., Fig. 2. Most important barriers identified in the online survey Observational Study The observational study took place in four pharmacies. In aggregate, 108 hours of working time were recorded, including all staffs tasks. A total of 894 tasks were recorded (average of 223 per pharmacy) (table 2). The average total aggregated time observed per pharmacy was 27h1Omin (min: 21h14m; max: 31h 34m). 85% of the tasks were performed by pharmacists,

5 corresponding to 65% of the total recorded time. An average of 481 minutes per pharmacy (76 minutes per employee) was not used in any tasks. Table 2. Professionals and tasks observed. Number of Observed Numbe individuals time r of (hh:mm:ss) Tasks (and %) Pharmacy 4 12:24:1 85 technician 7 (9,5) Pharmacy 3 17:46:4 21 assistant interns 3 (2,4) Other 2 7:29:55 23 professionals (2,6) Pharmacists 16 70:50: (85,6) Total :31 : (100) Concerning activities performed by pharmacists, almost 50 % of their time is used in interaction with pharmacy customers and 38% is used in administrative tasks, including ordering and storage of medicines, checking for errors in the dispensed prescriptions, preparing prescriptions for reimbursement issues and meetings with vendors and salespersons. Considering that 20% of the unused time is spent in socialization among workers and other minor tasks (ex: "surfing the net", coffeebreaks, etc), we calculated an average of 38,40 minutes of available time per pharmacist (figure 3). When considering the medicine dispensing process only, 35.4% of patients received some form of pharmaceutical counseling, that usually involved provision of therapeutic information: for whom is it, what is it for, daily dosages, possible side-effects that can happen or might have happened in the past, market availability and prices. In 44.6% of the observed dispenses, at least one chronic use medicine was dispensed. When a chronic use medicine was dispensed, 29.3% of patients got pharmaceutical counseling. Instead, when a non-chronic medicine was dispensed, 46.7% of patients got this counseling. Fig. 3. Distribution of total activity time per pharmacist. In the recorded observations, the only pharmaceutical service provided with the use of an information system (IS) was the dispensing service. It was used to support the sale, while detecting possible interactions and identifying the main adverse effects of the medicines dispensed. In these cases the patient never intervenes. The pharmacy's IS was used in 95.6% of medicine dispensing processes, in 80.4% of patients queries about health issues and medicine availability and in 27.2% of administrative tasks. 4. Discussion The results thus far allow for a good characterization of pharmaceutical services' provision. Although there was a low response rate, possibly showing a lack of interest in participating, the results from the survey suggest that the potential to develop web-based services is there, since all the community pharmacies in Portugal have an information system installed and the staff is capacitated to use it. The use of IT system for patient management, the presence in web-based social networks and the use of to communicate with patients are possible indicators that pharmacies are moving to a more web-based approach to provide information and services to patients.

6 The main barriers found for the development of IT solutions for the community pharmacy may reflect a biased vision of what a true ehealth solution might be. The perception that "the is not a good wcry to share data about my patient's health status" may indicate some renitence in using a web platform to share information that some may consider sensitive. Also, the fact that all the respondents claim that they need more support from the professional organizations may point to the need of a strong leadership in order to implement such services. As it was expected, the dispensing of medicines is still the most significant service provided. Although some pharmacies report to provide a medication management service, it was without surprise that we observed no structured medication management service or any other disease management service. One possibility for this is that neither the medication management is really provided or at best is a very informal service. We can discuss if it is a service or activity, since it is made with no registrations and done verbally in a non-systematic way. The causes for this have long been discussed within the profession and the reasons range from the lack of payment for these services to the professional inertia regarding the adoption of new forms of practice. It is not in the scope of this research to investigate such reasons, but this work may provide new clues in order to better understand the best strategy for incrementing the provision of enhanced pharmaceutical services. So far patients have still little role in the process. The available time we have found is an indication that there may be an opportunity to develop web-based services. Despite such notice, one of the barriers pointed out to this development has been the "lack of time" reported by pharmacists. It would be important to fmd the reasons behind this gap of perception. One possibility may be the fact that the pharmacist spends almost 40% of the time in administrative tasks that prevent the professional to take a more clinical role. Another question that arises from the observational study fmdings is the necessity to reorganize the internal functioning of community pharmacies, with more clear roles for each of the professionals. Weather these professionals do have the necessary education regarding the provision of enhanced pharmaceutical services, on a web-platform (e.g., using game-based learning, practicing cases from daily actlvitles, etc.) is an aspect that needs to be further explored. The social abilities that these professionals do have may be used as complementary tools to better interact with patients in a new web-based service. This can be important considering that customer relationships is one of the key aspects of the new services provided through the internet. Still, one can argue that, for these developments to be beneficial, they should be considered in an integrated and longitudinal perspective of services provision, requiring service's events registerring, comprehensive analysis of the data and interactive dialogue with patients. Furthermore, since pharmacy services suffer from lack of change and a significant inefficiency, which affects the delivery of sustainable services, the introduction of other channels can create new opportunities to improve services. In this regard, the use of methods based on DEMO to find non value-added transactions can be also used in the pharmacy context to redesign and simplify processes [13]. Modeling methodologies can provide an additional understanding of the dynamics of an organization and to allow a better alignment between the pharmacy services design and operati on [14]. 5. Conclusion The evolution of information technologies is developing, and probably will continue to develop, an important opportunity towards the integration of new roles for community pharmacists that will allow a more active role from patients in their disease management. The use of "smart" technological solutions in the medicine dispensing process could relief pharmacists' workload, leaving more free time to assume other functions, boosting the possibility to accomplish such enhanced pharmacy care provision. It is likely that the introduction of new information technologies will face some resistance, especially from older professionals and senior patients, but the potential value of these technologies to improve the health system efficiency (and the interaction with patients), could make pharmaceutical-related expertise and knowledge an important competence and a valued asset in the healthcare system. Another possible conclusion of this study is the necessity to rethink the community pharmacy business model in order to effectively and coherently integrate it

7 into the future health system models where patients will have an increasing role. Currently, the epharmacare project is carrying on with the next phases of DSRM, moreover developing a web-based platform to interact and educate patients and pharmacist enabling also to collect data on the value of pharmaceutical services for both patient and health system. 6. Acknowledgements The epharmacare research project is funded by Fundac;ao para a Ciencia e Tecnologia ( ) under the number PTDCICCI-CINI122690/2010. This support and the individual grants to J. Gregorio and T. Ferreira are gratefully acknowledged. 7. References [1] MA Chisholm-Burns, 1.S. Graff Zivin, 1.K. Lee, C.A. Spivey, M. Slack, R.N. Herrier. Economic effects of pharmacists on health outcomes in the United States: A systematic review. AmJ Health Syst Pharm. 2010; 67(19): [2] W. R. Doucette, D.H. Kreling, 1.C. Schommer, C.A. Gaither. D.A. Mott & C.A. Pedersen: Evaluation of Community Pharmacy Service Mix: Evidence From the 2004 National Pharmacist Workforce Study. JAm Pharm Assoc. 2006; 46(3): J S. Costa, C. Santos & J. Silveira: Community pharmacy services in Portugal. Ann Pharmacother, 2006, 40, [4] R.M. Gallagher & H.C. Gallagher: Improving the working relationship between doctors and pharmacists: is interprofessional education the answer? 2010 Adv Health Sci Educ Theory Pract [5] P.P. George, lad. Molina. J. Cheah. S.c. Chan. B.P. Lim: Evolving Roles of the Community Pharmacist - A Literature Review. Annals Academy of Medicine Vo!. 39 No. 11. [6] 1.P. Calabretto. 1. Warren. K. Darzanos & B. Fry. Building common ground for communication between patients and community pharmacists with an internet medicine cabinet In: 35th Hawaii International Conference on System Sciences. [7] J. Greg6rio & L.V. Lapao: Portuguese community pharmacists in 2020: survival of the fittest. Revista Portuguesa de Farmacia (5 supp!.): [8] S Callens: The EU legal framework on ehealth. In Health Systems Governance in Europe: The Role of EU Law and Policy Edited by Mossialos E. Permanand G. Baeten R. Hervey TK. Cambridge: Cambridge University Press; [9] D.W. Bates. A.A. Gawande: Improving safety with information technology. N Engl J Med (25): [10] L. Neuhauser. G.L.Kreps: ehealth communication and behavior change: promise and performance. Social Semiotics (1):9-27. [11] A.R. Hevner S.T. March. J. Park. S. Ram: Design Science in Information Systems Research. MIS Quarterly ( 1 ): [12] S. Mache. C. Scutaru. K. Vitzthum. D. Quarcoo. N. SchOffel. T. Welte. Does type of hospital ownership influence physicians' daily workschedules? An observational real-time study in German hospital departments. Hum Resour Health 2009; 7(41) [13] D. Dias. L.V. Lapao and M. Mira da Silva: Using Enterprise Ontology for Improving Emergency Management in Hospitals. Stud Health Technol Inform. 20 I 2; I 80: [14] P. Gomes. L.V. Lapao: The Role of a Nation-Wide Information System in Improving the Access to Surgery in Portugal Stud Health Technol Inform. 2009;