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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 319–326
Exploring opportunities for providing pharmacists with feedback on their practice and performance around the electronic Minor Ailments Service in Scotland Vibhu Paudyal, Denise Hansford, Scott Cunningham and Derek Stewart School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
Keywords E-MAS; feedback; information; minor ailment service; pharmacists Correspondence Professor Derek Stewart, School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB10 7QJ, UK. E-mail: [email protected] Received June 13, 2013 Accepted December 2, 2013 doi: 10.1111/ijpp.12088
Abstract Background The electronic Minor Ailments Service (e-MAS), implemented in all community pharmacies in Scotland since 2006, allows pharmacists to manage minor ailments at no charge to patients including provision of medication, advice or referral. E-MAS is supported through an electronic network, ‘E-pharmacy’, which is managed by National Health Service Scotland. E-pharmacy has the capacity to remotely record e-MAS activities, such as details of medicines supply and patient registration allowing provision of feedback to community pharmacies. Objective The aim of this research was to explore community pharmacists’ views on potential utility of e-MAS performance data as a source of feedback on the quality of their own practice. Method Focus groups and telephone interviews with community pharmacists from four geographical Health Board areas in Scotland were utilised. Key findings Twenty community pharmacists took part in the study. Pharmacists highlighted potential for feedback to support practice in areas related to medicines supply (for example, formulary adherence and reimbursements to pharmacies from the Health Boards), patient registration and the impact of the new guidelines on their practice. Participants deemed individualised feedback to be potentially more useful than local or national aggregated data sets. Issues of confidentiality and participants’ disinterest in feedback were potential barriers to the use of the data. Conclusions This qualitative study has identified potential benefits of performance feedback data to pharmacists’ practice. Key barriers to the use of the feedback, such as the issues of privacy and confidentiality need to be addressed by National Health Service information providers. Findings warrant further large scale evaluation of their application to practice.
Introduction Enhanced community pharmacy management of minor ailments is high on the UK healthcare agenda.[1] The electronic Minor Ailments Service (e-MAS) was introduced nationwide in Scottish community pharmacies in 2006.[2] E-MAS allows eligible members of the public to register with one community pharmacy of their choice and have their minor ailments managed by pharmacists. This includes free supply of non-prescription medicines, or where appropriate, to get advice or onward referral to other health professionals.[3] Approximately 50% of the Scottish population are eligible.[4] Examples of eligible patients include pregnant women, children (≤16 years) and the elderly (≥60 years). Pharmacies © 2014 Royal Pharmaceutical Society
are reimbursed for the price of the medicines supplied and receive a capitation fee based on the number of patients registered from their geographical Health Boards areas (note: Minor Ailment Services in England operate on a fee-per-consultation basis). Medicine supply under e-MAS is guided by local and national formularies specifically developed for the service by the Health Boards[5] and Community Pharmacy Scotland (association of pharmacy proprietors of Scotland)] respectively.[6] Health Boards in Scotland are responsible for the delivery of health care services at the local level in line with the national healthcare agenda.[7] International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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Delivery of e-MAS is supported by a national information technology network system managed by Information Service Division (ISD) of National Health Service (NHS), Scotland, ‘E-pharmacy’, which enables patient registration in pharmacies using the patient’s unique NHS Community Health Index number.[8] As a data-capturing system, E-pharmacy also enables details of e-MAS activities (e.g. medicines supplied, patient consultations) to be recorded remotely within the National Medicines Utilisation Unit. There is potential for these data to be disseminated to pharmacies or individual pharmacists as feedback for the purpose of supporting their professional practice. Feedback is defined as a summary of healthcare practitioner performance over a specified period.[9] Evidence from research with physicians suggests that feedback of practice performance could be useful as a persuasive or educational strategy in supporting professional practice[10] in a similar way to the use of other educational strategies, such as printed educational materials, outreach visits, seminars and workshops, training sessions and medicine information centres.[11] Some of the electronic sources that are being used to provide feedback to physicians on prescribing activities include Scottish Prescription Analysis[12] and Prescribing Analysis and Cost data[13] in the UK. Pharmacists’ skills are often utilised to support physicians’ medicines supply practices through feedback.[14] However, research exploring community pharmacists’ feedback needs is sparse.[15–18] E-MAS is a novel service route for the management of minor ailments incorporating new elements of practice such as patient registration, provision of formulary to inform supply of medicines and the use of technology. Effective capture of e-MAS activity data means there is a prospect of supporting pharmacists’ practice of e-MAS with this new service. Understanding the needs of potential users is essential to enable information providers to accurately plan and disseminate feedback.[14,19] The aim of this research was to explore community pharmacists’ views of the potential utility of performance data generated from e-MAS as a source of feedback on the quality of their own practice.
Method Focus group was considered the method of choice, primarily to stimulate and encourage discussion among the participants. Four focus groups were planned. However, because of low recruitment rates, only two focus groups were possible. The other two planned focus groups resulted in two one-toone interviews. To address the problem with recruitment into focus groups, semi-structured telephone interviews were used to collect further data. Sampling was informed by the Scottish Health Boards Minor Ailment Scheme (e-MAS) utilisation data. Four of the 14 geographical Health Boards areas in Scotland were © 2014 Royal Pharmaceutical Society
Providing practice feedback to pharmacists
selected, representing low and high e-MAS service utilisation.[20] Fifty pharmacies were randomly selected from these four Health Boards using Minitab® statistical software Version 16 (Minitab Inc. Pennsylvania, PA, USA). All invitations were addressed to pharmacists responsible for nonprescription medicines supply. Signed consent and copyright clearance forms (allowing the permission to use participants’ quotes anonymously for publication) were obtained. Focus groups were planned to last no more than 90 min based on a topic guide (Supporting Information Appendix S1). The topic guide was developed and reviewed for validity of content and clarity of terminology by five community pharmacists who were also pharmacy educators. In addition to the pharmacists’ perspectives on the feedback data, the focus groups also explored barriers and facilitators to the delivery of e-MAS (awaiting separate publication) and other interventions aimed at enhanced management of minor ailments through community pharmacies such as the reclassification of ‘prescription only’ medicines to ‘pharmacy only’ and ‘general sales list’ categories.[21] Examples of e-MAS feedback were generated by the ISD in collaboration with the researchers. Microsoft Power Point software was used to demonstrate these data to the focus group participants to facilitate discussion. Data sets represented aspects of service delivery, such as therapeutic category of medicines supplied and number of patients registered by individual community pharmacies/groups of community pharmacies. Focus group participants were provided with a light supper in addition to reimbursement of travel expenses at standard rates. No other incentives were offered. Because of low recruitment to the focus groups, a further 35 pharmacists from two of these Health Boards were invited to participate in telephone interviews. The telephone interviews followed the same topic guide as the focus groups with the same examples of data sets posted or faxed in advance of the interview date. The telephone interviews lasted a maximum of 20 min. All conversations were audio recorded and transcribed verbatim by VP. Health Boards, pharmacies and participants were anonymised. Two researchers were present in each focus group, a moderator and a note taker. One researcher (VP) conducted all telephone interviews. The reliability of all transcripts was checked by a second researcher (DS). The analytical process began during transcribing by listening/relistening and reading/rereading the transcript for the researcher to become immersed in the data. The framework approach[22] was used for the data analysis and facilitated using QSR NVivo8® qualitative data management software (QSR international, Melbourne, Australia). The framework technique is named from the ‘thematic framework’ where data are categorised into a matrix system based on emergent themes and subthemes.[22] A basic step involved in this technique is coding where data are reduced to a smaller number of themes. The International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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construction of the initial thematic framework is guided by the research aims and objectives, and questions to participants from the topic guides. Any new themes emerging during the analysis process are then added.[22] Two researchers (VP and DS) independently analysed one focus group transcript. All other transcripts were coded only by one researcher (VP). Focus group and telephone interview data were analysed together as they aimed to answer common research questions. The North of Scotland Research Ethics Committee classified this research as ‘service evaluation’ and hence advised that the research was exempt from formal NHS ethical review.
Results Participants Twenty community pharmacists took part, nine in two focus groups (n = 5 and n = 4); one pharmacist each in two face-toface interviews, (n = 1; n = 1) (note: these were initially scheduled as focus groups, low participation resulted in one to one interviews) and nine participants in the telephone interviews (Table 1). Data saturation led to no further
Table 1
recruitment. Participants provided a variation in terms of age, geographical representation and type of pharmacy ownerships (Table 1).
Key themes Key themes and subthemes identified are presented with illustrated quotes.
Awareness of feedback as a source of information Participants demonstrated different levels of awareness about performance data feedback as a source of information for reflection on their own professional practice. A few participants were aware of feedback from electronic prescribing to general practitioners (GPs) in Scotland. ‘This is like the SPA [Scottish Prescribing Analysis] data, the doctors get back from the prescribing, is that right?. . . GPs have a lot information they get feedback from prescriptions . . .’ Female, 46 years, Small multiple
Characteristics of study participants (n = 20)
Characteristics Employer/employee Employer Employee Prescriber Size of pharmacy ownership Independent (1–4 pharmacies) Small chain (5–30 pharmacies) Large chain (>30 pharmacies) Experiences (years) ≤5 6–10 11–15 16–20 > 20 With postgraduate qualification Age (years) ≤ 25 26–35 36–45 46–55 56–65 > 65 Practice geographical area Urban Suburban Rural Mixed (‘Relief’ pharmacist)
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Number of participants
5 15 3 9 5 6 7 1 2 2 8 6 2 6 4 6 1 1 7 6 6 1
Types of potentially useful data Aspects of data on medicine supplies and patient registration with e-MAS were discussed.
Feedback related to therapeutic categories of medicines supplied With regard to medicine supplies data, most participants preferred feedback on the volume of medicines supplied specific to each therapeutic class (as per the British National Formulary chapters) over a given time interval. ‘What I prescribe [supply medicines under e-MAS], which I kind of already know but seeing it in writing, you know makes you more aware.And may be also look at areas where you don’t prescribe enough. May be because we don’t understand or you know . . . just not many patients are coming in for that ailment.’ Female, 43 years, Small Multiple ‘Yeah, it would be good to really know you have been prescribing right things for the right reasons, isn’t it? Its good for CPD [Continuous Professional Development]. . .’ Female, 26 years, Small Multiple International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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Feedback related to service reimbursements to pharmacies Some participants had concerns that medicines supplied through e-MAS were not being appropriately reimbursed by their Health Boards. For these participants, having regular feedback on the list of medicines supplied along with reimbursement details would allow them to inform future practice. ‘Certainly would be worthwhile . . . so that we don’t do it [supply the medicines disallowed] again.’ Female, 55 years, Small Multiple Feedback related to adherence to the e-MAS formulary Feedback data regarding the extent to which individual pharmacists were complying with service formularies were regarded potentially useful to those who deemed formulary compliance being important to practice. ‘. . . your compliance relation to the formulary related to anti-infective skin preparations and emollients and corticosteroids, for example, even if it is split down even further than that, but you just then knew that there was an area where I’m really not that compliant. So, let’s go and review the formulary, review that what should I be giving out. So, you then know that, that’s the area which I need to do some CPD and do some training . . .’ Female, 25 years, Large Multiple Participants were aware of the cost savings (from the perspective of the Health Boards) that could potentially be brought about by following generic medicine supply practices. However, feedback in this area was regarded as potentially more useful if formulary adherence and generic supplies were incentivised. ‘The GPs get incentivised for being percentage over guidelines [for cost-effective prescribing]. We don’t. But, if we get incentive payments, it’ll be very helpful.’ Male, 37 years, Independent Some participants, however, were less concerned regarding adoption of such cost-effective generic medicines supply practices and hence the feedback would be less relevant. As long as decision making was ethical and centred around the best interests of their patients, cost-effective medicine supply was deemed less of an issue for them. ‘I don’t think that’s [feedback on generic medicines supplies] of any benefit because if you are prescribing ethically, anyway, then the price shouldn’t be an issue. © 2014 Royal Pharmaceutical Society
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The number of items shouldn’t either be, and I’m prescribing something because it’s necessary not [to get the figures right].’ Male, 55 years, Large Multiple
Feedback related to patient registration data Some participants raised the issue regarding anomalies between the number of patients registered with the service as recorded and displayed by pharmacy computers to the capitation payments they were receiving from the Health Boards. Regular feedback regarding patient registration data was hence deemed to be useful to ensure that accurate remuneration was being received from the Health Boards. The prospect of feedback data comparing patient registration data across pharmacies were received with caution. Such data were deemed as confidential information. ‘I don’t think Minor Ailment [Service, e-MAS] is a competitive thing. It is not you know you are trying to do more than just down the road. We are trying to serve our customers as best as we can.’ Female, 47 years, Small Multiple
Feedback related to impact of changes in guidelines to pharmacy practice Participants were asked to express their opinion regarding whether they were interested in receiving feedback around how changes in national guidelines, such as amendments of service formulary or introduction of newly reclassified medicines for pharmacy supplies, reflect changes in their practice with e-MAS. Low interest in such feedback was noted. ‘I don’t need to be informed up to date. Your practice, don’t think changes dramatically over short space of time.’ Male, 28 years, Large Multiple
Individualised versus aggregated feedback Participants identified that feedback data generated at the level of individual pharmacist or pharmacy were more relevant to inform practice than feedback at the local or national level. Such low level of interest in local or national e-MAS data sets was mainly attributed to the lack of relevance of such aggregated data sets to individual practice. Aggregated data sets was only deemed relevant if comparisons of national or local averages were made with individual pharmacy/ pharmacist’s performance. Moreover, such comparisons were regarded to be potentially most useful where individual International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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practice would appear to be very different from national or local performances allowing pharmacists to reflect on such differences. ‘It would be nice to see region-wide analysis and that of specific shop analysis and the two could be laid, literally one on top of the other . . .’ Male, 66 years, Independent A few participants were cautious about the way such comparisons could be interpreted. For them, every pharmacy was unique in terms of patient demography and hence the types of minor ailments that were managed or the medicines supplied through e-MAS. ‘Obviously, I think, every pharmacy is different. You know we are a small independent (pharmacy ownership) in a local community and you know, so comparing our data to a busy city centre pharmacy is pointless, I would think. But (comparison with) other pharmacies in a similar situation would perhaps . . . kind of similar to yourself, [with] similar GP surgeries, similar sort of social, deprivation or affluence in an area (would be meaningful). . .’ Female, 44 years, Small Multiple Aggregated data sets at the Health Board or smaller geographical local level were regarded by some participants to be more useful to stakeholders in supporting pharmaceutical public health initiatives, such as by enabling the Health Boards to set up and review performances around local and national targets for diseases areas covered by e-MAS. Barriers to the use of feedback data Concerns were raised regarding the potential issues of privacy and confidentiality that might arise with the gathering and dissemination of feedback data. The potential risk for the use of such data by pharmacy management personnel or by the Health Boards to mandate changes to pharmacists’ practice were expressed; for example, in setting targets aimed at increasing performance. ‘I’ll be little bit worried about one angle of having this. Now working for multiple [pharmacy ownership], this may or may not happen but if . . ., put on e-MAS further up the chain, so, well you, you have to achieve X numbers products in this category you supply in given period of time. Why you are not doing ‘cause there are so many folk registered, you’re, you’re below, below the national average or something like that.’ Male, 28 years, Large Multiple Other participants, however, viewed such issues to be less relevant to their own situation. © 2014 Royal Pharmaceutical Society
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‘Not, certainly not, where I am working at the moment. I don’t think that [disseminating information to others] would be an issue. I think possibly if you are working for the big multiple, then that would be more of an issue. Certainly, in my situation, I don’t think that really is an issue . . .’ Female, 47 years, Small Multiple A few participants expressed high level of confidence about their practice with e-MAS and showed little motivation towards the potential use of feedback. They perceived that although feedback data would be potentially ‘interesting’, it was unlikely to serve any benefits. ‘. . . we know what we are prescribing [supplying]. It’s interesting, but it’s not something I would need to look at.’ Female, 46 years, Small Multiple
Discussion Discussion of key findings Various aspects of medicines supplies and patient registration activities by pharmacists related to e-MAS could be potentially supported through the provision of feedback. Evidence from research with physicians suggests that cost-effective and guideline-adherent medicine supplies could be supported by the use of feedback data generated through the electronic prescribing systems (National Services Scotland, personal communication, 2012).[23,24] However, feedback information is known to most effective in changing practice where current practices are inconsistent with standard guidelines or widely adopted practice.[25] Views of participants in this study were consistent with these findings in the literature. This study also identified the potential barriers to the use of feedback. Information providers should address the concerns raised by participants regarding the issues of privacy and confidentiality. A few participants in this study doubted the usefulness of feedback data to their practice. Reasons for such doubts matched those identified by published research with physicians. These included doubts about usefulness of the information to practice[26] and lack of individual motivation.[27] Barriers such as lack of time,[26,28,29] convenience of access,[26,30] issues about reliability of the source[29] and difficulty in interpreting the available information[26,30] have been also reported by the published literature. A study with Nebraska community pharmacists on web-based patient safety event reporting system using rapid feedback to improve the reporting process also highlighted similar barriers to the use of the feedback information.[31] International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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No study has previously looked at pharmacists’ perspectives of feedback with e-MAS. A few published research have evaluated the impact of feedback to pharmacists in other areas of practice. A randomised controlled trial with 60 pharmacists in Quebec, Canada aimed to optimise medication therapy in asthma patients.[17] Pharmacists in the intervention group received three letters over the course of 9 months on their patients’ appropriate use of asthma medication. Although feedback improved guideline compliance by pharmacists, differences in the changes in practice of those receiving the intervention were not significantly different to the control group. An Australian study measured the impact of feedback in influencing guideline adherence by community pharmacists while making sales of analgesic, such as in identifying potential misusers.[32] Those receiving feedback (n = 30) were significantly more likely to identify potential misusers of analgesics than those not receiving such feedback (n = 30).[32] Another study with 20 community pharmacists in London, England, investigated the potential of feedback in enabling pharmacists to identify drug-related problems through a clinical medication review programme.[33] This study showed that those who regularly received feedback about their performance were more likely to have identified the drug-related problems more accurately compared with those not receiving such feedback.[33] A study by Bell et al.[34] in Kansas, USA, aimed to measure the impact of an educational programme and electronic feedback on pharmacistrelated medication order entry errors (MOEEs, defined as an error caused by incomplete or incorrect entry of a medication by a licensed prescriber[35]) at an academic medical centre involving 46 clinical pharmacists. The number and type of pharmacist-related MOEEs were collected at two different times: immediately following implementation of an electronic medical record (baseline) and following completion of the educational programme. Significant benefits were reported in minimising MOEEs by community pharmacists.
Strengths and limitations This is the first qualitative evaluation of pharmacists’ views on the potential application of feedback using electronically generated data to support their practice in the UK. A wide range of participants took part in the research. Difficulties encountered in recruitment raise the possibility that the majority of pharmacists who received the invitation to participate in the research might have been disinterested about aspects of receiving such feedback. Duplicate coding of a sample of transcripts enabled enhancement in the clarity of the data analyses procedure. Lack of participants’ experiences with the use of such feedback means all benefits and barriers to the use of such information might not have been fully realised. © 2014 Royal Pharmaceutical Society
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Future research A consensus exercise with diverse pharmacy stakeholders could be useful in investigating the type of feedback most relevant to pharmacists’ practice with e-MAS. In addition, research in this area should also gather the views of a larger number of pharmacists such as by using a survey method. Research should also be conducted subsequent to provision of such feedback in routine practice in order for the benefits and barriers to their use by pharmacists to be fully realised also by using large-scale surveys. Long-term evaluations are needed to assess the impact of such feedback to specific areas of practice as well as to estimate whether provision of feedback provides value for money for the information providers.
Conclusion This qualitative study has identified pharmacists’ perceptions of potential benefits to their practice derived through provision of performance feedback data. These areas of practice included medicines supply, formulary adherence and patient registration activities. Participants identified that individualised feedback could be more relevant to practice than aggregated data sets. Participants’ concerns regarding confidentiality and ownership of such feedback data needs to be addressed to ensure that pharmacists have credence in the potential usefulness of such feedback. Pharmacists’ perceived barriers to the use of feedback data in everyday practice, for example, the aspects of confidentiality and data ownership are relevant to other services supported by e-Pharmacy system.
Declarations Conflicts of interests The Author(s) declare(s) that they have no conflicts of interests to disclose.
Funding VP was partly supported by Community Pharmacy Scotland and the Information Statistics Division of NHS Scotland.
Acknowledgements We would like to thank Dr Lorna McHattie and Dr Lesley Diack for taking notes during the focus groups, ISD Scotland for generating and providing the exemplar data sets and participating community pharmacists.
Authors’ contributions VP was the PhD student for the project and led the preparation of manuscript. DS was the principal supervisor for the International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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PhD project and contributed to the preparation of the manuscript. DH and SC were co-supervisors for the PhD project and contributed to the preparation of the manuscript. All
References 1. Paudyal V et al. Pharmacy assisted patient self care of minor ailments: a chronological review of UK health policy documents and key events 1997– 2010. Health Policy 2011; 101: 253–259. 2. Scottish Executive. National Health Service (Scotland) ACT 1978 Health Board Additional Pharmaceutical Services (Minor Ailment Service) (Scotland) Directions. Edinburgh: Primary Care Division, 2006. 3. Bellingham C. Introducing the new Scottish contract. Pharm J 2005; 275: 637. 4. Scottish Government. Review of NHS prescription charges and exemption arrangements in Scotland: consultation. http://www.scotland.gov.uk/ Publications/2006/01/30125542/2 (accessed 15 January 2006). 5. NHS Grampian. Community Pharmacy Minor Ailment Service (MAS) Formulary. Aberdeen: NHS Grampian, 2007. 6. Community Pharmacy Scotland (CPS). MAS National Formulary. Edinburgh: CPS, 2006. 7. The Scottish Government. NHS Boards. http://www.scotland.gov.uk/ Topics/Health/NHS-Scotland/Boards (accessed 24 February 2011). 8. Community Pharmacy Scotland. E-MAS walkthrough. http://www .communitypharmacy.scot.nhs.uk/ documents/epharmacy/mas/ (accessed 23 March 2010). 9. Jamtvedt G et al. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care 2006; 15: 433–436. 10. Davey P et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013; (4): CD003543. 11. Le Grand A et al. Intervention research in rational use of drugs: a review. Health Policy Plan 1999; 14: 89–102.
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authors listed above contributed to the design, data collection and data analyses and all had complete access to the data that supports this publication.
12. Information Service Division (National Services Scotland). Prescription cost analysis for Scotland. http:// www.isdscotland.org/isd/2241.html (accessed 20 March 2008). 13. McNulty CAM et al. Does laboratory antibiotic susceptibility reporting influence primary care prescribing in UTI and other infections? J Antimicrob Chemother 2011; 66: 1396– 1404. 14. Elliott RA et al. Determining economic impact of a pharmacist-led it-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices (pincer). Value Health 2013; 16: A206. 15. Neto A. Changing pharmacy practice: the Australian experience. Pharm J 2003; 270: 235–236. 16. Watson MC et al. A systematic review of the use of simulated patients and pharmacy practice research. Int J Pharm Pract 2006; 14: 83–93. 17. Blais R et al. Effect of feedback letters to physicians and pharmacists on the appropriate use of medication in the treatment of asthma. J Asthma 2008; 45: 227–231. 18. Berger K et al. Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany. J Clin Pharm Ther 2005; 30: 45–57. 19. Korjonen-Close H. The information needs and behaviour of clinical researchers: a user-needs analysis. Health Info Libr J 2005; 22: 96–106. 20. Information Service Division (National Services Scotland). Minor Ailment Service (MAS). http://www .isdscotland.org/isd/5033.html (accessed 3 February 2011). 21. Paudyal V et al. Over-the-counter prescribing and pharmacists’ adoption of new medicines: diffusion of innovations. Res Soc Admin Pharm 2013; 9: 251–262.
22. Ritchie J et al. Carrying out Qualitative Analysis. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: SAGE publications, 2003: 219–262. 23. Walker J, Mathers N. The impact of a general practice group intervention on prescribing costs and patterns. Br J Gen Pract 2002; 52: 181–186. 24. Berger J et al. Electronic prescribing system delivers more than just drug information. Manag Care Outlook 2006; 12 (online). 25. Jamtvedt G et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006; (2): CD000259. 26. Dawes M, Sampson U. Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians. Int J Med Inform 2003; 71: 9–15. 27. Boissin FG. Information-seeking behaviour and use of the Internet by French general practitioners: a qualitative study. Health Info Libr J 2005; 22: 173–181. 28. Chan TY et al. The needs and sources of drug information among pharmacists in Hong Kong. J Clin Pharm Ther 1996; 21: 325–330. 29. Revere D et al. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomed Info 2007; 40: 410–421. 30. Byrd GD. Can the profession of pharmacy serve as a model for health informationist professionals? J Med Libr Assoc 2002; 90: 68–75. 31. Faber J et al. Developing a rapidfeedback patient safety improvement system for pharmacists. J Am Pharm Assoc 2011; 51: 249. 32. Neto AC et al. Novel educational training program for community pharmacists. Am J Pharm Educ 2000; 64: 302– 306.
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33. Laaksonen R et al. Performance of community pharmacists in providing clinical medication reviews. Ann Pharmacother 2010; 44: 1181–1190. 34. Bell C et al. The use of individualized pharmacist performance reports to reduce pharmacist-related medication order entry errors following electronic medical record implementation. Hosp Pharm 2012; 47: 771–775. 35. Robeznieks A. Data entry is top cause of medication errors. AMNews. January
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24, 2005. http://www.ama-assn.org/ amednews/2005/01/24/prsa0124.htm (accessed 5 August 2008).
Appendix S1 Summary of the topic guide (relevant to pharmacists’ perspective of feedback data).
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site:
International Journal of Pharmacy Practice 2014, 22, pp. 319–326
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 319–326
Exploring opportunities for providing pharmacists with feedback on their practice and performance around the electronic Minor Ailments Service in Scotland Vibhu Paudyal, Denise Hansford, Scott Cunningham and Derek Stewart School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
Keywords E-MAS; feedback; information; minor ailment service; pharmacists Correspondence Professor Derek Stewart, School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen AB10 7QJ, UK. E-mail: [email protected] Received June 13, 2013 Accepted December 2, 2013 doi: 10.1111/ijpp.12088
Abstract Background The electronic Minor Ailments Service (e-MAS), implemented in all community pharmacies in Scotland since 2006, allows pharmacists to manage minor ailments at no charge to patients including provision of medication, advice or referral. E-MAS is supported through an electronic network, ‘E-pharmacy’, which is managed by National Health Service Scotland. E-pharmacy has the capacity to remotely record e-MAS activities, such as details of medicines supply and patient registration allowing provision of feedback to community pharmacies. Objective The aim of this research was to explore community pharmacists’ views on potential utility of e-MAS performance data as a source of feedback on the quality of their own practice. Method Focus groups and telephone interviews with community pharmacists from four geographical Health Board areas in Scotland were utilised. Key findings Twenty community pharmacists took part in the study. Pharmacists highlighted potential for feedback to support practice in areas related to medicines supply (for example, formulary adherence and reimbursements to pharmacies from the Health Boards), patient registration and the impact of the new guidelines on their practice. Participants deemed individualised feedback to be potentially more useful than local or national aggregated data sets. Issues of confidentiality and participants’ disinterest in feedback were potential barriers to the use of the data. Conclusions This qualitative study has identified potential benefits of performance feedback data to pharmacists’ practice. Key barriers to the use of the feedback, such as the issues of privacy and confidentiality need to be addressed by National Health Service information providers. Findings warrant further large scale evaluation of their application to practice.
Introduction Enhanced community pharmacy management of minor ailments is high on the UK healthcare agenda.[1] The electronic Minor Ailments Service (e-MAS) was introduced nationwide in Scottish community pharmacies in 2006.[2] E-MAS allows eligible members of the public to register with one community pharmacy of their choice and have their minor ailments managed by pharmacists. This includes free supply of non-prescription medicines, or where appropriate, to get advice or onward referral to other health professionals.[3] Approximately 50% of the Scottish population are eligible.[4] Examples of eligible patients include pregnant women, children (≤16 years) and the elderly (≥60 years). Pharmacies © 2014 Royal Pharmaceutical Society
are reimbursed for the price of the medicines supplied and receive a capitation fee based on the number of patients registered from their geographical Health Boards areas (note: Minor Ailment Services in England operate on a fee-per-consultation basis). Medicine supply under e-MAS is guided by local and national formularies specifically developed for the service by the Health Boards[5] and Community Pharmacy Scotland (association of pharmacy proprietors of Scotland)] respectively.[6] Health Boards in Scotland are responsible for the delivery of health care services at the local level in line with the national healthcare agenda.[7] International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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Delivery of e-MAS is supported by a national information technology network system managed by Information Service Division (ISD) of National Health Service (NHS), Scotland, ‘E-pharmacy’, which enables patient registration in pharmacies using the patient’s unique NHS Community Health Index number.[8] As a data-capturing system, E-pharmacy also enables details of e-MAS activities (e.g. medicines supplied, patient consultations) to be recorded remotely within the National Medicines Utilisation Unit. There is potential for these data to be disseminated to pharmacies or individual pharmacists as feedback for the purpose of supporting their professional practice. Feedback is defined as a summary of healthcare practitioner performance over a specified period.[9] Evidence from research with physicians suggests that feedback of practice performance could be useful as a persuasive or educational strategy in supporting professional practice[10] in a similar way to the use of other educational strategies, such as printed educational materials, outreach visits, seminars and workshops, training sessions and medicine information centres.[11] Some of the electronic sources that are being used to provide feedback to physicians on prescribing activities include Scottish Prescription Analysis[12] and Prescribing Analysis and Cost data[13] in the UK. Pharmacists’ skills are often utilised to support physicians’ medicines supply practices through feedback.[14] However, research exploring community pharmacists’ feedback needs is sparse.[15–18] E-MAS is a novel service route for the management of minor ailments incorporating new elements of practice such as patient registration, provision of formulary to inform supply of medicines and the use of technology. Effective capture of e-MAS activity data means there is a prospect of supporting pharmacists’ practice of e-MAS with this new service. Understanding the needs of potential users is essential to enable information providers to accurately plan and disseminate feedback.[14,19] The aim of this research was to explore community pharmacists’ views of the potential utility of performance data generated from e-MAS as a source of feedback on the quality of their own practice.
Method Focus group was considered the method of choice, primarily to stimulate and encourage discussion among the participants. Four focus groups were planned. However, because of low recruitment rates, only two focus groups were possible. The other two planned focus groups resulted in two one-toone interviews. To address the problem with recruitment into focus groups, semi-structured telephone interviews were used to collect further data. Sampling was informed by the Scottish Health Boards Minor Ailment Scheme (e-MAS) utilisation data. Four of the 14 geographical Health Boards areas in Scotland were © 2014 Royal Pharmaceutical Society
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selected, representing low and high e-MAS service utilisation.[20] Fifty pharmacies were randomly selected from these four Health Boards using Minitab® statistical software Version 16 (Minitab Inc. Pennsylvania, PA, USA). All invitations were addressed to pharmacists responsible for nonprescription medicines supply. Signed consent and copyright clearance forms (allowing the permission to use participants’ quotes anonymously for publication) were obtained. Focus groups were planned to last no more than 90 min based on a topic guide (Supporting Information Appendix S1). The topic guide was developed and reviewed for validity of content and clarity of terminology by five community pharmacists who were also pharmacy educators. In addition to the pharmacists’ perspectives on the feedback data, the focus groups also explored barriers and facilitators to the delivery of e-MAS (awaiting separate publication) and other interventions aimed at enhanced management of minor ailments through community pharmacies such as the reclassification of ‘prescription only’ medicines to ‘pharmacy only’ and ‘general sales list’ categories.[21] Examples of e-MAS feedback were generated by the ISD in collaboration with the researchers. Microsoft Power Point software was used to demonstrate these data to the focus group participants to facilitate discussion. Data sets represented aspects of service delivery, such as therapeutic category of medicines supplied and number of patients registered by individual community pharmacies/groups of community pharmacies. Focus group participants were provided with a light supper in addition to reimbursement of travel expenses at standard rates. No other incentives were offered. Because of low recruitment to the focus groups, a further 35 pharmacists from two of these Health Boards were invited to participate in telephone interviews. The telephone interviews followed the same topic guide as the focus groups with the same examples of data sets posted or faxed in advance of the interview date. The telephone interviews lasted a maximum of 20 min. All conversations were audio recorded and transcribed verbatim by VP. Health Boards, pharmacies and participants were anonymised. Two researchers were present in each focus group, a moderator and a note taker. One researcher (VP) conducted all telephone interviews. The reliability of all transcripts was checked by a second researcher (DS). The analytical process began during transcribing by listening/relistening and reading/rereading the transcript for the researcher to become immersed in the data. The framework approach[22] was used for the data analysis and facilitated using QSR NVivo8® qualitative data management software (QSR international, Melbourne, Australia). The framework technique is named from the ‘thematic framework’ where data are categorised into a matrix system based on emergent themes and subthemes.[22] A basic step involved in this technique is coding where data are reduced to a smaller number of themes. The International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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construction of the initial thematic framework is guided by the research aims and objectives, and questions to participants from the topic guides. Any new themes emerging during the analysis process are then added.[22] Two researchers (VP and DS) independently analysed one focus group transcript. All other transcripts were coded only by one researcher (VP). Focus group and telephone interview data were analysed together as they aimed to answer common research questions. The North of Scotland Research Ethics Committee classified this research as ‘service evaluation’ and hence advised that the research was exempt from formal NHS ethical review.
Results Participants Twenty community pharmacists took part, nine in two focus groups (n = 5 and n = 4); one pharmacist each in two face-toface interviews, (n = 1; n = 1) (note: these were initially scheduled as focus groups, low participation resulted in one to one interviews) and nine participants in the telephone interviews (Table 1). Data saturation led to no further
Table 1
recruitment. Participants provided a variation in terms of age, geographical representation and type of pharmacy ownerships (Table 1).
Key themes Key themes and subthemes identified are presented with illustrated quotes.
Awareness of feedback as a source of information Participants demonstrated different levels of awareness about performance data feedback as a source of information for reflection on their own professional practice. A few participants were aware of feedback from electronic prescribing to general practitioners (GPs) in Scotland. ‘This is like the SPA [Scottish Prescribing Analysis] data, the doctors get back from the prescribing, is that right?. . . GPs have a lot information they get feedback from prescriptions . . .’ Female, 46 years, Small multiple
Characteristics of study participants (n = 20)
Characteristics Employer/employee Employer Employee Prescriber Size of pharmacy ownership Independent (1–4 pharmacies) Small chain (5–30 pharmacies) Large chain (>30 pharmacies) Experiences (years) ≤5 6–10 11–15 16–20 > 20 With postgraduate qualification Age (years) ≤ 25 26–35 36–45 46–55 56–65 > 65 Practice geographical area Urban Suburban Rural Mixed (‘Relief’ pharmacist)
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Number of participants
5 15 3 9 5 6 7 1 2 2 8 6 2 6 4 6 1 1 7 6 6 1
Types of potentially useful data Aspects of data on medicine supplies and patient registration with e-MAS were discussed.
Feedback related to therapeutic categories of medicines supplied With regard to medicine supplies data, most participants preferred feedback on the volume of medicines supplied specific to each therapeutic class (as per the British National Formulary chapters) over a given time interval. ‘What I prescribe [supply medicines under e-MAS], which I kind of already know but seeing it in writing, you know makes you more aware.And may be also look at areas where you don’t prescribe enough. May be because we don’t understand or you know . . . just not many patients are coming in for that ailment.’ Female, 43 years, Small Multiple ‘Yeah, it would be good to really know you have been prescribing right things for the right reasons, isn’t it? Its good for CPD [Continuous Professional Development]. . .’ Female, 26 years, Small Multiple International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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Feedback related to service reimbursements to pharmacies Some participants had concerns that medicines supplied through e-MAS were not being appropriately reimbursed by their Health Boards. For these participants, having regular feedback on the list of medicines supplied along with reimbursement details would allow them to inform future practice. ‘Certainly would be worthwhile . . . so that we don’t do it [supply the medicines disallowed] again.’ Female, 55 years, Small Multiple Feedback related to adherence to the e-MAS formulary Feedback data regarding the extent to which individual pharmacists were complying with service formularies were regarded potentially useful to those who deemed formulary compliance being important to practice. ‘. . . your compliance relation to the formulary related to anti-infective skin preparations and emollients and corticosteroids, for example, even if it is split down even further than that, but you just then knew that there was an area where I’m really not that compliant. So, let’s go and review the formulary, review that what should I be giving out. So, you then know that, that’s the area which I need to do some CPD and do some training . . .’ Female, 25 years, Large Multiple Participants were aware of the cost savings (from the perspective of the Health Boards) that could potentially be brought about by following generic medicine supply practices. However, feedback in this area was regarded as potentially more useful if formulary adherence and generic supplies were incentivised. ‘The GPs get incentivised for being percentage over guidelines [for cost-effective prescribing]. We don’t. But, if we get incentive payments, it’ll be very helpful.’ Male, 37 years, Independent Some participants, however, were less concerned regarding adoption of such cost-effective generic medicines supply practices and hence the feedback would be less relevant. As long as decision making was ethical and centred around the best interests of their patients, cost-effective medicine supply was deemed less of an issue for them. ‘I don’t think that’s [feedback on generic medicines supplies] of any benefit because if you are prescribing ethically, anyway, then the price shouldn’t be an issue. © 2014 Royal Pharmaceutical Society
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The number of items shouldn’t either be, and I’m prescribing something because it’s necessary not [to get the figures right].’ Male, 55 years, Large Multiple
Feedback related to patient registration data Some participants raised the issue regarding anomalies between the number of patients registered with the service as recorded and displayed by pharmacy computers to the capitation payments they were receiving from the Health Boards. Regular feedback regarding patient registration data was hence deemed to be useful to ensure that accurate remuneration was being received from the Health Boards. The prospect of feedback data comparing patient registration data across pharmacies were received with caution. Such data were deemed as confidential information. ‘I don’t think Minor Ailment [Service, e-MAS] is a competitive thing. It is not you know you are trying to do more than just down the road. We are trying to serve our customers as best as we can.’ Female, 47 years, Small Multiple
Feedback related to impact of changes in guidelines to pharmacy practice Participants were asked to express their opinion regarding whether they were interested in receiving feedback around how changes in national guidelines, such as amendments of service formulary or introduction of newly reclassified medicines for pharmacy supplies, reflect changes in their practice with e-MAS. Low interest in such feedback was noted. ‘I don’t need to be informed up to date. Your practice, don’t think changes dramatically over short space of time.’ Male, 28 years, Large Multiple
Individualised versus aggregated feedback Participants identified that feedback data generated at the level of individual pharmacist or pharmacy were more relevant to inform practice than feedback at the local or national level. Such low level of interest in local or national e-MAS data sets was mainly attributed to the lack of relevance of such aggregated data sets to individual practice. Aggregated data sets was only deemed relevant if comparisons of national or local averages were made with individual pharmacy/ pharmacist’s performance. Moreover, such comparisons were regarded to be potentially most useful where individual International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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practice would appear to be very different from national or local performances allowing pharmacists to reflect on such differences. ‘It would be nice to see region-wide analysis and that of specific shop analysis and the two could be laid, literally one on top of the other . . .’ Male, 66 years, Independent A few participants were cautious about the way such comparisons could be interpreted. For them, every pharmacy was unique in terms of patient demography and hence the types of minor ailments that were managed or the medicines supplied through e-MAS. ‘Obviously, I think, every pharmacy is different. You know we are a small independent (pharmacy ownership) in a local community and you know, so comparing our data to a busy city centre pharmacy is pointless, I would think. But (comparison with) other pharmacies in a similar situation would perhaps . . . kind of similar to yourself, [with] similar GP surgeries, similar sort of social, deprivation or affluence in an area (would be meaningful). . .’ Female, 44 years, Small Multiple Aggregated data sets at the Health Board or smaller geographical local level were regarded by some participants to be more useful to stakeholders in supporting pharmaceutical public health initiatives, such as by enabling the Health Boards to set up and review performances around local and national targets for diseases areas covered by e-MAS. Barriers to the use of feedback data Concerns were raised regarding the potential issues of privacy and confidentiality that might arise with the gathering and dissemination of feedback data. The potential risk for the use of such data by pharmacy management personnel or by the Health Boards to mandate changes to pharmacists’ practice were expressed; for example, in setting targets aimed at increasing performance. ‘I’ll be little bit worried about one angle of having this. Now working for multiple [pharmacy ownership], this may or may not happen but if . . ., put on e-MAS further up the chain, so, well you, you have to achieve X numbers products in this category you supply in given period of time. Why you are not doing ‘cause there are so many folk registered, you’re, you’re below, below the national average or something like that.’ Male, 28 years, Large Multiple Other participants, however, viewed such issues to be less relevant to their own situation. © 2014 Royal Pharmaceutical Society
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‘Not, certainly not, where I am working at the moment. I don’t think that [disseminating information to others] would be an issue. I think possibly if you are working for the big multiple, then that would be more of an issue. Certainly, in my situation, I don’t think that really is an issue . . .’ Female, 47 years, Small Multiple A few participants expressed high level of confidence about their practice with e-MAS and showed little motivation towards the potential use of feedback. They perceived that although feedback data would be potentially ‘interesting’, it was unlikely to serve any benefits. ‘. . . we know what we are prescribing [supplying]. It’s interesting, but it’s not something I would need to look at.’ Female, 46 years, Small Multiple
Discussion Discussion of key findings Various aspects of medicines supplies and patient registration activities by pharmacists related to e-MAS could be potentially supported through the provision of feedback. Evidence from research with physicians suggests that cost-effective and guideline-adherent medicine supplies could be supported by the use of feedback data generated through the electronic prescribing systems (National Services Scotland, personal communication, 2012).[23,24] However, feedback information is known to most effective in changing practice where current practices are inconsistent with standard guidelines or widely adopted practice.[25] Views of participants in this study were consistent with these findings in the literature. This study also identified the potential barriers to the use of feedback. Information providers should address the concerns raised by participants regarding the issues of privacy and confidentiality. A few participants in this study doubted the usefulness of feedback data to their practice. Reasons for such doubts matched those identified by published research with physicians. These included doubts about usefulness of the information to practice[26] and lack of individual motivation.[27] Barriers such as lack of time,[26,28,29] convenience of access,[26,30] issues about reliability of the source[29] and difficulty in interpreting the available information[26,30] have been also reported by the published literature. A study with Nebraska community pharmacists on web-based patient safety event reporting system using rapid feedback to improve the reporting process also highlighted similar barriers to the use of the feedback information.[31] International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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No study has previously looked at pharmacists’ perspectives of feedback with e-MAS. A few published research have evaluated the impact of feedback to pharmacists in other areas of practice. A randomised controlled trial with 60 pharmacists in Quebec, Canada aimed to optimise medication therapy in asthma patients.[17] Pharmacists in the intervention group received three letters over the course of 9 months on their patients’ appropriate use of asthma medication. Although feedback improved guideline compliance by pharmacists, differences in the changes in practice of those receiving the intervention were not significantly different to the control group. An Australian study measured the impact of feedback in influencing guideline adherence by community pharmacists while making sales of analgesic, such as in identifying potential misusers.[32] Those receiving feedback (n = 30) were significantly more likely to identify potential misusers of analgesics than those not receiving such feedback (n = 30).[32] Another study with 20 community pharmacists in London, England, investigated the potential of feedback in enabling pharmacists to identify drug-related problems through a clinical medication review programme.[33] This study showed that those who regularly received feedback about their performance were more likely to have identified the drug-related problems more accurately compared with those not receiving such feedback.[33] A study by Bell et al.[34] in Kansas, USA, aimed to measure the impact of an educational programme and electronic feedback on pharmacistrelated medication order entry errors (MOEEs, defined as an error caused by incomplete or incorrect entry of a medication by a licensed prescriber[35]) at an academic medical centre involving 46 clinical pharmacists. The number and type of pharmacist-related MOEEs were collected at two different times: immediately following implementation of an electronic medical record (baseline) and following completion of the educational programme. Significant benefits were reported in minimising MOEEs by community pharmacists.
Strengths and limitations This is the first qualitative evaluation of pharmacists’ views on the potential application of feedback using electronically generated data to support their practice in the UK. A wide range of participants took part in the research. Difficulties encountered in recruitment raise the possibility that the majority of pharmacists who received the invitation to participate in the research might have been disinterested about aspects of receiving such feedback. Duplicate coding of a sample of transcripts enabled enhancement in the clarity of the data analyses procedure. Lack of participants’ experiences with the use of such feedback means all benefits and barriers to the use of such information might not have been fully realised. © 2014 Royal Pharmaceutical Society
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Future research A consensus exercise with diverse pharmacy stakeholders could be useful in investigating the type of feedback most relevant to pharmacists’ practice with e-MAS. In addition, research in this area should also gather the views of a larger number of pharmacists such as by using a survey method. Research should also be conducted subsequent to provision of such feedback in routine practice in order for the benefits and barriers to their use by pharmacists to be fully realised also by using large-scale surveys. Long-term evaluations are needed to assess the impact of such feedback to specific areas of practice as well as to estimate whether provision of feedback provides value for money for the information providers.
Conclusion This qualitative study has identified pharmacists’ perceptions of potential benefits to their practice derived through provision of performance feedback data. These areas of practice included medicines supply, formulary adherence and patient registration activities. Participants identified that individualised feedback could be more relevant to practice than aggregated data sets. Participants’ concerns regarding confidentiality and ownership of such feedback data needs to be addressed to ensure that pharmacists have credence in the potential usefulness of such feedback. Pharmacists’ perceived barriers to the use of feedback data in everyday practice, for example, the aspects of confidentiality and data ownership are relevant to other services supported by e-Pharmacy system.
Declarations Conflicts of interests The Author(s) declare(s) that they have no conflicts of interests to disclose.
Funding VP was partly supported by Community Pharmacy Scotland and the Information Statistics Division of NHS Scotland.
Acknowledgements We would like to thank Dr Lorna McHattie and Dr Lesley Diack for taking notes during the focus groups, ISD Scotland for generating and providing the exemplar data sets and participating community pharmacists.
Authors’ contributions VP was the PhD student for the project and led the preparation of manuscript. DS was the principal supervisor for the International Journal of Pharmacy Practice 2014, 22, pp. 319–326
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PhD project and contributed to the preparation of the manuscript. DH and SC were co-supervisors for the PhD project and contributed to the preparation of the manuscript. All
References 1. Paudyal V et al. Pharmacy assisted patient self care of minor ailments: a chronological review of UK health policy documents and key events 1997– 2010. Health Policy 2011; 101: 253–259. 2. Scottish Executive. National Health Service (Scotland) ACT 1978 Health Board Additional Pharmaceutical Services (Minor Ailment Service) (Scotland) Directions. Edinburgh: Primary Care Division, 2006. 3. Bellingham C. Introducing the new Scottish contract. Pharm J 2005; 275: 637. 4. Scottish Government. Review of NHS prescription charges and exemption arrangements in Scotland: consultation. http://www.scotland.gov.uk/ Publications/2006/01/30125542/2 (accessed 15 January 2006). 5. NHS Grampian. Community Pharmacy Minor Ailment Service (MAS) Formulary. Aberdeen: NHS Grampian, 2007. 6. Community Pharmacy Scotland (CPS). MAS National Formulary. Edinburgh: CPS, 2006. 7. The Scottish Government. NHS Boards. http://www.scotland.gov.uk/ Topics/Health/NHS-Scotland/Boards (accessed 24 February 2011). 8. Community Pharmacy Scotland. E-MAS walkthrough. http://www .communitypharmacy.scot.nhs.uk/ documents/epharmacy/mas/ (accessed 23 March 2010). 9. Jamtvedt G et al. Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback. Qual Saf Health Care 2006; 15: 433–436. 10. Davey P et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013; (4): CD003543. 11. Le Grand A et al. Intervention research in rational use of drugs: a review. Health Policy Plan 1999; 14: 89–102.
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authors listed above contributed to the design, data collection and data analyses and all had complete access to the data that supports this publication.
12. Information Service Division (National Services Scotland). Prescription cost analysis for Scotland. http:// www.isdscotland.org/isd/2241.html (accessed 20 March 2008). 13. McNulty CAM et al. Does laboratory antibiotic susceptibility reporting influence primary care prescribing in UTI and other infections? J Antimicrob Chemother 2011; 66: 1396– 1404. 14. Elliott RA et al. Determining economic impact of a pharmacist-led it-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices (pincer). Value Health 2013; 16: A206. 15. Neto A. Changing pharmacy practice: the Australian experience. Pharm J 2003; 270: 235–236. 16. Watson MC et al. A systematic review of the use of simulated patients and pharmacy practice research. Int J Pharm Pract 2006; 14: 83–93. 17. Blais R et al. Effect of feedback letters to physicians and pharmacists on the appropriate use of medication in the treatment of asthma. J Asthma 2008; 45: 227–231. 18. Berger K et al. Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany. J Clin Pharm Ther 2005; 30: 45–57. 19. Korjonen-Close H. The information needs and behaviour of clinical researchers: a user-needs analysis. Health Info Libr J 2005; 22: 96–106. 20. Information Service Division (National Services Scotland). Minor Ailment Service (MAS). http://www .isdscotland.org/isd/5033.html (accessed 3 February 2011). 21. Paudyal V et al. Over-the-counter prescribing and pharmacists’ adoption of new medicines: diffusion of innovations. Res Soc Admin Pharm 2013; 9: 251–262.
22. Ritchie J et al. Carrying out Qualitative Analysis. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: SAGE publications, 2003: 219–262. 23. Walker J, Mathers N. The impact of a general practice group intervention on prescribing costs and patterns. Br J Gen Pract 2002; 52: 181–186. 24. Berger J et al. Electronic prescribing system delivers more than just drug information. Manag Care Outlook 2006; 12 (online). 25. Jamtvedt G et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006; (2): CD000259. 26. Dawes M, Sampson U. Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians. Int J Med Inform 2003; 71: 9–15. 27. Boissin FG. Information-seeking behaviour and use of the Internet by French general practitioners: a qualitative study. Health Info Libr J 2005; 22: 173–181. 28. Chan TY et al. The needs and sources of drug information among pharmacists in Hong Kong. J Clin Pharm Ther 1996; 21: 325–330. 29. Revere D et al. Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system. J Biomed Info 2007; 40: 410–421. 30. Byrd GD. Can the profession of pharmacy serve as a model for health informationist professionals? J Med Libr Assoc 2002; 90: 68–75. 31. Faber J et al. Developing a rapidfeedback patient safety improvement system for pharmacists. J Am Pharm Assoc 2011; 51: 249. 32. Neto AC et al. Novel educational training program for community pharmacists. Am J Pharm Educ 2000; 64: 302– 306.
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33. Laaksonen R et al. Performance of community pharmacists in providing clinical medication reviews. Ann Pharmacother 2010; 44: 1181–1190. 34. Bell C et al. The use of individualized pharmacist performance reports to reduce pharmacist-related medication order entry errors following electronic medical record implementation. Hosp Pharm 2012; 47: 771–775. 35. Robeznieks A. Data entry is top cause of medication errors. AMNews. January
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24, 2005. http://www.ama-assn.org/ amednews/2005/01/24/prsa0124.htm (accessed 5 August 2008).
Appendix S1 Summary of the topic guide (relevant to pharmacists’ perspective of feedback data).
Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site:
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