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I Pharmaceutical care requires the pharmacist to work toward definite drug therapy outcomes, to collect more information and apply more judgment, and to work more closely with patients, physicians, and other health care professionals. by Charles D. Hepler, PhD
he environment of pharmacy practice is providing unprecedented opportunity for pharmacy to develop rapidly into a new profession. Technological and market changes will virtually force a fundamental transformation of most pharmacists' practices in the coming 10 to 20 years. 1 The question for pharmacists is not whether they will change, but how they will change to maintain their ability to make a satisfactory living by practicing pharmacy. For
their practice to succeed, even to survive, most pharmacists will need a new sense of purpose and a clear plan to reach it. If pharmacists are to shape their own futures, they need to identify and serve people's real needs. The greatest public need that pharmacists should address is the need for safe and effective drug therapy. Pharmacists can thrive if they will accept that purpose. Providing safe and effective drug products is a necessary part of that purpose, but
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much more is needed. Providing safe and effective drug therapy requires the traditional pharmacist to revise his basic understanding of pharmacy, the way he practices, and the way he manages that practice. This in turn requires bold leadership from pharmaceutical associations and educators.
Marketplace Forces Great worldwide changes are afoot, symbolized by the destruction of the Berlin Wall, the completion of the European Economic Community, and the industrial growth of Japan and the other Pacific Rim nations. Foreign trade and other world-class forces are causing the restructuring of the medical marketplace in the United States. Health maintenance organizations (HMOs), diagnosisrelated groups, Medicaid cuts, physician dispensing, and mail order pharmacy all are signs of this restructuring. We can understand how international forces affect pharmacy by considering the automobile industry. Because of competition from imported cars, American manufacturers are fighting for business. They can no longer pass on unbridled health care costs to the automobile buyer. One result is that General Motors (GM) uses mail order pharmacies. GM's health benefits manager has told community pharmacists that mail order gives GM health care plans equal value for a lower price. 2 Decisions like these, made by thousands of health care programs, will force radical change in health care markets and in pharmacy practice. Solo practice, fee-for-service health care is going to be in an even tougher race with prepaid comprehensive group practices (PCGPs) similar to today's Kaiser model HMO. A smart pharmacist will not mutter about "socialized Inedicine" and ignore these changes. The reorganization of care and the change in pricing methods represented by PCGPs will affect pharmacists tremendously. PCGPs can be organized either to improve or to downgrade the role of the pharmacist. It depends on whether the PCGPs recognize that safe and effective drug therapy does more to 24
reduce total health care costs than bargain-basement prescription prices. PCGPs could provide pharmacists, physicians, and nurses common economic objectives and could ease communication and cooperation. If pharmacy does not teach PCGP management about their options, however, they could just as likely relegate the pharmacist to the role of purchaser and dispenser of drugs with no need to improve communication and cooperation with patients, physicians, and nurses. Automated mail order pharmacy would appear reasonable in reaching this limited purpose. 1 Trends in prepaid medical plans and other organizational structures emphasize patient outcomes rather than products and procedures, and long-range, not immediate, patient care objectives. If pharmacists can show that they can improve patient health, they will be welcome in the new medical marketplace.
Technological and market changes will virtually force a fundamental transformation of most pharmacists' practices in the coming 10 to 20 years. Technology is also changing the pharmaceutical profession. New ways to provide drug therapy will be possible because of advances in dosage forms, computers, communications, and robotics. Fax machines, pharmacy computers, smart cards, automatic unit dose packaging machines, and even implantable, programmable pumps can be linked by computers and optics to produce automatic, remote drug-dispensing machines in physicians' offices, at shopping malls, on street corners, and even in the body itself. The third major factor in pharmacy's future is social. Public trust in social institutions and in leadership is weaker than it used to be. Yesterday's "patient" is today's "consumer." He has his prescription order dispensed by the physician's receptionist, by the mailman, or in a
general mercantile establishment called a drugstore where he may often have to decide for himself whether he needs to see the pharmacist. The modern health care consumer, who now feels less like a patient and more like the object of a health care business, may now expect health care providers to accept the rules of business and live with hardnosed competition on price and specific services. The consumer may be less willing to allow the profession to dictate what he needs, how he will get it, and what he will pay for it. 3 Drug technology has outstripped the drug therapy process. Despite the fact that every drug product now marketed in the United States has been proven safe and effective (when taken as directed), research shows that many people are not helped, and often are made worse, by prescribed drugs. The economic cost of additional care due to treatment failure and drug injury may be staggering: upwards of $4 billion annually. 4 The problem is not with the drug products or FDA or with physicians. The problem is the drug therapy process. At least half of drug injuries can be prevented, and research shows that pharmacists and physicians working together can reduce costs dramatically.5 We have focused too much on drug products and on adverse effects, and too little on the drug product as part of a drug use process that is intended to make patients well. It is time for pharmacists to acknowledge that drug products are one component of the drug use process, and to understand that drugrelated disease and treatment failure are hazards of the process. That means, however, that pharmacists will have to accept some responsibility for the undesired consequences of the drugs that they dispense. It is time for pharmacists to learn how they can help people to obtain safe and effective drug therapy instead of safe and effective drug products or drug procedures. That is how pharmacists can shape their future.
Changing Pharmacy for the Future Pharmacists have been influenced by the clinical pharmacy movement
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over the past 20 years. 6 Some have responded negatively, often with fear. Others recognized the power of the clinical movement and set out to harness it. Pioneering phannacists developed great new powers and professional diversity.7 Today, some phannacists build clinical functions into their daily practices in hospitals and in community phannacies. They ask clinically trained phannacists to train their colleagues in their new skills. They are moving their practices forward to meet the future. Clinical pharmacy is spreading, and changes in the marketplace seem to favor it. However, clinical phannacy is, like "dispensing" pharmacy, a temporary stage of development in phannacy's long professional adolescence. Each developed in response to the environment and now must change to meet future needs. In order for phannacists to perform clinical functions successfully in the future health care marketplace, our concept of clinical pharmacy itself will have to mature into an understanding of pharmacists as selfcontrolling, truly patient-oriented professionals who devote their efforts to improving therapeutic outcomes and who willingly accept their direct responsibility to patients. We will not find the path to the future by worrying about ourselves. Trying to list the functions that pharmacists should perform and technicians should not, or quarreling about phannacy's "rights" to distribute drugs or about titles and degrees and specialization is secondary to a larger question. The primary element needed to move beyond dispensing and clinical models of practice is a clear concept of our purpose and our responsibilities to patients. Phannacy will remain stuck in its professional adolescence until it takes this step. 5 Organized pharmacy, as represented by the American Pharmaceutical Association (APhA) , has endorsed a basic professional creed for more than 20 years. The APhA Code of Ethics states: ''A pharmacist should hold the health and safety of patients to be of first consideration and should render to each patient the full measure of professional ability as an essential health practitioner. "8
To accept responsibility for that mandate, the mission of pharmacy practice is not only what we have come to call clinical pharmacy. In addi tion to clinical know ledge and basic dispensing skill, there must be an appropriate philosophy of practice and organizational structure within which to practice. Hepler and Strand have proposed such a philosophy of practice, called pharmaceutical care, and an organizational structure to facilitate the provision of that care, called a pharmaceutical care system. 5
Pharmaceutical Care Phannaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. These outcomes are: (1) cure of a disease, (2) elimination or reduction of a patient's symptomatology, (3) arrest or slowing of a disease process, or (4)
The individual pharmacist must see patients progress. That is what drug therapy monitoring and the prevention, detection, and resolution of drug..related problems should mean. prevention of a disease or symptomatology. Phannaceutical care involves designing, implementing, and monitoring a therapeutic plan that the pharmacist believes will optimally produce the therapeutic objective. Implementing and monitoring require the pharmacist to identify, resolve, and prevent drug-related problems arising from undertreatment, overtreatment, and inappropriate treatment. Pharmaceutical care should be carried out in cooperation with physicians and patients, but it is provided for the direct benefit of patients. Phannacists accept direct responsibility for any aspect of care that they could have affecMd. 5 Pharmacists already have suffi-
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cient educational preparation and legal authority to carry out this mandate in partnership with physicians and patients. It is time for each pharmacist to decide whether or not to accept this mandate, and whether or not to adopt phannaceutical care as a professional mission. There are limits, however, to what individuals can accomplish alone. Therefore, it is also time for pharmaceutical organizations, educational institutions, and patient care corporations to decide whether they want to be part of the problem of drug-related morbidity or part of the solution. If we can turn from self-examination toward public responsibility, we can proceed to professional maturity. Phannacists cannot wait for APhA or any other phannacy organization to implement phannaceutical care. Phannaceutical care has been and will be implemented by individual practitioners who change their sense of professional purpose. Pharmacy organizations can do much to facilitate the process, but can do little unless individual members initiate change at the level of individual practice. Once a phannacist has accepted a new purpose and new responsibility, he or she must consider what is involved in changing his practice (see box, p. 26). Some questions that he must ask are personal, some are organizational. They involve the pharmacist, the patient, and other professionals, especially physicians, employers (pharmacies, hospitals, corporations, etc.), and professional associations.
Professional Maturation Professional maturation requires soul-searching. Each phannacy practitioner must decide what his purpose should be for his patients. Likewise, phannacy program managers must decide the objectives of their programs. One major question illustrates the process offinding your purpose: What professional services do your patients need from you to achieve their therapeutic objectives? Other questions follow: What kinds of drug-related problems do your patients commonly have?9-22 Is your practice really set up to detect and solve them? How many of your patients may be 25
experiencing G I bleeding from NSAID therapy? How many of your patients are dizzy or disoriented right now because of antihypertensives or psychoactive drugs that you dispensed to them? Whom did you dispense norfloxacin to recently? Does he take magnesium-aluminum antacids?23 Do you have a systematic way to know that? Do you have a responsibility to know that? What are you and your immediate colleagues going to do about it? The general answers to these questions give your new purpose. Do you have the ability to carry out your new purpose? This depends on competence - the ability to use personal and environmental resources to reach one's objectives (see sidebar). In addition to knowledge and skill, it requires operative procedures (a practice model) and an attitude of responsibility to the client for achieving a purpose. You must examine what your resources are and w ha t additional resources are needed.
Practice Management Once you have defined your new purpose, determined what you are competent to do, and established a rational, consistent way to do it, you may begin to move into the realm of practice management: the realm of relationships, resources, and rewards.
Developing Relationships Establishing a relationship with patients is central to development as a pharmacist. Patients are your connection with reality. A highly respected Florida community pharmacist was happy as a businessman for 20 years because most of his patients were basically healthy. However, when hospitals in his area began to discharge patients "quicker and sicker," he began to meet terminal cancer patients and patients on long-term intravenous nutrition or antibiotics or peritoneal dialysis. Then, he had to become a professional health care provider. He could see a whole future for himself as a professional as well as a businessman and was thrilled and awed by that changing sense of purpose. He got his purpose from his patients. 26
Steps Toward Professional Change 1. Develop awareness of new purpose and responsibilities. 2. Examine personal competence to accomplish purpose. 3. Identify resources available. 4. Develop working relationships to achieve new purpose. 5. Create outcome, experience reward. 6. Return to step 1 with renewed motivation and commitment.
Developing relationships is critical to gathering clinical information, too. A hospital or nursing home keeps a medical record, but in a pharmacy there is only the prescription order. The rest of the information a pharmacist needs comes from the physician's office and the patient or his family. This brings us to the second point about relationships: expectations. Your relationship with physicians and patients usually has to change when your purpose changes, because they may not be able to cooperate with you until it does. Do your physician colleagues and your patients understand you as an authoritative, responsible professional who is primarily concerned with the success of their therapy? Do they expect you to aggressively c¥e for patients? Would your physicians understand why you were asking them to order a phenytoin serum level or a prothrombin time? Would your patients understand why you started taking drug histories, telephoned the second day after they started taking a prescription drug product, or asked them to show you their shins or nail beds? If they would, you are ready to move on to the next step: finding the resources of time and money that you need to practice pharmaceutical care. If not, you should expect to work to change relationships as you implement pharmaceutical care.
Obtaining Resources Perhaps the most frequently mentioned barrier to professional maturation is resources, especially time and money. This may be expressed as "too many prescriptions,"
or "too little technician support," or "wrong reimbursement system." Suppose that you could change your reimbursement system tomorrow, so that you could be paid on the basis of the outcomes of drug therapy instead of prescriptions sold. How much would your patients and practice really benefit? Are your purpose, competence, and relationships such that you could take advantage of that opportunity? If the answer is no, then changing the reimbursement system may not be the only answer. Some pharmacists are in a box; they won't change their practices because they assume that the resources will never become available to them. Of course, modern health care purchasers are unwilling to give those resources unless they understand what they will get for the money. Each side waits for the other to move first. Meanwhile, pharmacy becomes less and less relevant in health care, and patients continue to suffer preventable drug-related morbidity. It is time for pharmacists to get out of their box. To get out of the box, you ask the following questions: Do you know the research evidence that demonstrates the value of integrated patient-specific pharmaceutical services in reducing total costs of care?24-31 Can you develop the evidence into presentations relevant to specific purchasers? Can you specifically enumerate the purpose of the service and the procedures to be carried out for patients? Would you share in the financial risk of the insurance company for a share of the surplus? New ventures are risky, it is true, but consider the alternatives.
Managing Resources In addition to obtaining resources, the manager must use them effectively and efficiently to achieve definite purposes. Pharmaceutical care will require a different organization and management approach from the approaches used in dispensing pharmacy. Pharmaceutical care requires the pharmacist (1) to work toward definite drug therapy outcomes for patients (not only to perform procedures for the patients), (2) to collect more information and to apply more judgment, and (3) to
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work in closer cooperation with patients, physicians, and other health care professionals. Traditionally, pharmacy program managers might have expected the pharmacist to bring a personal concept of purpose and competence into the management system. 3 The pharmacist might have assumed that the management system would be designed without much attention to professional purpose and competence. In a pharmaceutical care system, however, those traditional lines should be crossed, so that managers become more responsive to professional purposes and more active in developing and operating the systems. It will be essential that pharmaceutical care managers truly understand pharmaceutical care and that pharmacists truly expect the system to facHitate their work. A mBnager should design a management model, a pharmaceutical ·care~ system, to achieve clear purposes.3 ,32-34 Those purposes should be communicated to everyone - technicians, other pharmacists, patients, nurses, physicians - whose cooperation the pharmacist needs in order to do his work. The system should clarify and assign responsibility and foster necessary relationships both inside the system and with patients and other professionals. Four important issues are: (1) how to organize the work of pharmacists and technicians; (2) how to use experts and consultants, e.g., pharmacist-specialists; (3) how to assign shared responsibility for outcomes when the pharmacist cannot completely control them - for example, because he does not have prescribing authority; and (4) how to assign responsibility when different pharmacists may be caring for a patient at different times. The system should provide and effectively use resources, especially people, information, and space. What information about patients and drugs do pharmacists need to provide pharmaceutical care? When do they need it? How can it be captured, organized, and communicated as an effective clinical decision support system? What can your system already do? How can you share clinical information with physicians and other pharmacists?
Are You Competent?
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ust as personal competence is essential in daily life, competence is essential for a professional life, and the idea that one may not be competent is frightening. Professional competence is meaningful, however, only in the context of purpose, so the competence you require depends on what you are proposing to do. On the one hand, this limits the amount of competence required by anyone practice. We have to be competent only to do those things that come up in our practice. On the other hand, it takes courage to decide what our patients need from us, and then to decide what our competencies should be. It is essential, however, that we not turn this around and limit our purpose to what we imagine we are already competent to do for our patients.
What Is Competence? Professional competence is such a sensitive subject to most professionals that it is easy to misunderstand. Competence is not the absence of incompetence. Competence is not what is left over after you have enumerated everything you cannot do. Competence is what you can do, related to your purpose. Second, competence is not academic degrees; examples of either one without the other are everywhere. Third, competence is not self-esteem. Basic self-esteem, praise, and pep talks can be very useful as encouragement to take the necessary risks, but flattery gives short-term boosts that lack a valid basis in real ability to perform. This is also true of public relations programs. Although it is often helpful to raise public expectations, the claims must be validated when a patient walks into a pharmacy. Are you already competent to talk to all patients to find out whether they understand how to take their medications; to call a patient at home a day or two after he has started a new medication, just to ask how he's doing; to send an occult blood test kit home with a patient receiving long-term NSAID therapy; to look for evidence of drug-induced dementia or depression in elderly patients; to monitor blood pressure; and to look for bruises and nail-bed bleeding in patients receiving anticoagulants? Most pharmacists could answer yes to all these questions. If you can answer yes, you are already competent to prevent significant amounts of drug-related morbidity in your patients.
Seven Steps to Better Outcomes Do you have a basic routine procedure that you consistently use to evaluate your patients' progress toward specific outcomes? Strand and her colleagues have developed such a procedure, which they call the Pharmacists' Workup of Drug Therapy (PWDT).* It exists in two versions, one for inpatients and one for outpatients, but the basic procedure is the same: seven steps direct the pharmacist's decision making about the use of drugs. It demonstrates· how the concept of pharmaceutical care can actually be realized for any patient and in any practice setting. The steps call on pharmacists to: 1. Collect and interpret relevant patient information to determine whether the patient has drug-related problems. 2. Identify drug-related problems. 3. Describe the desired therapeutic goals. 4. Describe feasible therapeutic alternatives. 5. Select and individualize the most appropriate treatment regimen. 6. Implement the decisions about drug use. 7. Design a monitoring plan to achieve desired therapeutic goals.
* Strand LM,
Cipolle RJ, Morley PA. Documenting the clinical pharmacist's activities: back to basics. Drug Intel Clin Pharm. 1988;22:63-6.
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Finally, the pharmaceutical care system should recognize, evaluate, and reward outcomes consistent with its purpose. How can the clinical decision support system be designed to provide managers with the data they need to evaluate important aspects of care?
Evaluating Performance and Outcomes Obtaining resources and maintaining the pharmaceutical care system will require the manager to evaluate patient care outcomes that involved (or should have involved) drug therapy. This may require significant changes in managing pharmacists' work. The individual pharmacist must be able to see patients progress. That is what drug therapy monitoring (the prevention, detection, and resolution of drug-related problems) should mean. In addition, management should provide all pharmacists with summaries of their practice and outcome patterns. Each pharmacist may want to change certain patterns in his practice, and management should then be prepared to support those changes, as long as they are consistent with the overall purpose of the group practice. Pharmacists also will obtain professional satisfaction directly from their work. This constant feedback will motivate, direct, and sustain the efforts of those who like their work and who care about patients and may lead many pharmacists to identify even greater purpose and accept more responsibility. Once the initial clinical and economic benefits of pharmaceutical care have become a normal part of care, will it be necessary for the pharmacists and managers to prove effectiveness again and again, in order to keep the necessary resources? How does a manager do that? These questions expand our perspective even beyond the level of the employer of pharmacists to the level of the professional organization and the general society in which the pharmacist practices.
An Organizational Perspective Reaching for new responsibilities and developing new competence
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requires courage to put oneself in unfamiliar situations. Colleges of pharmacy and professional associations can influence this process by providing education and training, by guiding, and by validating the individual pharmacist's passage through the stages of professional maturation. Professional associations can help pharmacists clarify their sense of purpose and can provide forums for exchanging ideas. Professional associations can carry out strategic planning to help their members understand ways they can change their practices to meet future needs. Most important, however, professional associations can take their members' individual concepts of purpose and competence, translate them into practice standards, and then communicate those standards back to their members and outward to the greater society.
The primary element needed to move beyond dispensing and clinical models of practice is a clear concept of our purpose and our responsibilities to patients. Such standards should express what their members' purpose should be and what their members should be competent to do. They can convert the concept of a practice model and a pharmaceutical care system into standards for the structure and processes of practice, including the resources that employers should provide. The pharmacy standards of the Joint Commission on Accreditation of Healthcare Organizations are examples. Publicizing these documents might succeed in raising the expectations of the public and other professions more than any public relations attempt and might establish pharmaceutical care as an integral part of future health care systems. These are not easy tasks, however. Rapid changes in the health care
marketplace are stressful, forcing pharmacists to change their practices, fragmenting pharmacy organizations, and creating confusion. Pharmacy organizations will continue to experience internal conflict as long as external stress and rapid professional change continue. Strategic planning, while not a panacea, can help to control and direct the conflict.
To Be Resolved Pharmacy's organizations need a strategic vision and courageous leadership to move toward that vision. This paper has outlined a series of steps that individual practitioners might follow to work their way toward professional maturation. The following questions can be addressed to the leaders of professional organizaLions as they . consider those issues: After carpful consideration of market changes, what social purpose and responsibility (mission) will provide your members with the best professional future? What is the best way to help your members accept that mission? Who can lead toward the new mission? What will happen if some members do not accept the mission right away? What is the association's members' current range of competence to carry out that mission, e.g., what can the top 800/0-90% accomplish? How can your organization help those who need to increase their competence? How can the colleges of pharmacy help? How can your organization develop and teach a practice model, a management model, prescriptive standards of practice? Who can help pharmacists foster pharmaceutical care? How can the organization help pharmacists establish relationships "vith them? What does pharmaceutical care have to offer insurance companies, hospitals, HMOs, chain pharmacies? What evidence is needed? How do we get it? What do employed members need from their employers to reach the new mission? How can the association help pharmacists obtain those resources? Is legislative permission needed? Would a legislative mandate help? A crucial issue that every pharmacy organization must consider
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throughout this period of stress is its process for addressing questions about change. In other words, how does it understand and respond to diversity? Is your organization in a "learning" mode or "fighting" mode? What can your organization learn from the innovative community practitioner, ambulatory clinic practitioner, consulting pharmacist, hospital pharmacist, chain pharmacist, clinical pharmacist? Can the leadership really hear innovative ideas about the future instead of reacting defensively to their proponents as competitors? Are there any modernday pioneers to whom the organization cannot be open, against whom it must defend or actually attack? How do association leaders act in times of stress? How sensitive are they to the ideas of a visionary minority over the roar of a confused but politically powerful majority? And how courageous can they be in placing long-term purpose above short-term success?
Constant f back will motivate, direct, and sustain the efforts of those who Ii their work who care about patients and may lead many pharmaCists to ider1tifv even.greater purpose and accept more res nsibility. The future success of each professional association depends on the success of its members. The number of pharmacists who will be able to effectively serve their patients and survive as professionals will depend in part on the sagacity and courage of pharmacy's associations. The reprofessionalization of pharmacy will start with individual practitioners, but its ultimate success will depend on pharmacy's leadership. Pharmacists at every level, however, can contribute to the continued maturation of pharmacy as a clinical profession. Acknowledgments: This paper is based in part on a presentation at the
SecondPhannacy in the 21st Century Conference, Williamsburg, Va., October 11, 1989. It includes ideas developed by faculty and graduate students in seminars of the Department of Phannacy Health Care Administration at the University of Florida. Charles D. Hepler, PhD, is professor and chairman of the Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, Gainesville, FL 32610.
References 1. Hepler CD. Unresolved issues in the future of pharmacy. Am J Hosp Pharm. 1988;45:1071-81. 2.GM exec bashes pharmacy. Am Druggist. September 1988; 28,30. 3. Hepler CD. Pharmacy as a clinical profession. Am J Hosp Pharm. 1985;42: 1298-1306. 4. Southwick K. A prescription for trouble: drugs to counteract drugs. Health Week. August 8, 1988;2:1,12. 5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J HospPharm. 1990;47:533-43. 6. Hepler CD. The third wave in pharmaceutical education: the clinical movement.AmJPharmEduc.1987;51:369--85. 7. Angaran DM, Hepler CD, Bjornson DC, et al. Career patterns of pioneer clinical pharmacists. Am J Hosp Pharm. 1988; 45:101-8. 8. Control of the Practice of Pharmacy. In: Smith MC, Knapp DA, eds. Pharmacy, Drugs and Medical Care. Baltimore: Williams & Wilkins; 1987:226-7. 9. Manasse HR Jr. Medication use in an imperfect world: drug misadventuring as an issue of public policy, part 1. Am J Hosp Pharm. 1989; 46:926-44. 10. Manasse HR Jr. Medication use in an imperfect world: drug misadventuring as an issue of public policy, part 2. Am J Hosp Pharm. 1989; 46:1141-52. 11. Strand LM, Cipolle R, Morley PC. Drug related problems: their structure and function. Submitted to DICP: Annals of Pharmacotherapy. 12. McKenney JM, Harrison WL. Drugrelated hospital admissions. Am J Hosp Pharm. 1976;33:792-5. 13. Stewart RB, Springer P, Adams J. Drug related hospitalizations to an inpatient psychiatry unit. Am J Psychiat. 1980;137:1093-5. 14. Burnum JF. Preventability of adverse drug reactions. Ann Intern Med. 1976; 85:80-1. 15. Trunet P, LeGall JR, Lhoste F, et al. The role of iatrogenic disease in admissions to intensive care. JAMA. 1980;244: 2617-20. 16. Trunet P, Borda IT, Rouget AV, et al. The role of drug-induced illness in admissions to an intensive care unit. Intensive Care Med. 1986;12:43-6. 17. Lakshmanan MC, Hershey CO, Breslau
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D. Hospital admissions caused by iatrogenic disease. Arch Intern Med. 1986;146:1931-4. 18. Ives TJ, Bentz EJ, Gwyther RE. Drugrelated admissions to a family medicine service. Arch Intern Med. 1987;147: 1117-20. 19. Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109:582-9. 20. Knapp DE, Knapp DA, Speedie MK, et al. Relationship of inappropriate drug prescribing to increased length of hospital stay. Am J Hosp Pharm. 1979; 36:1334-7. 21. Knapp DA, Speedie MK, Yaeger DM, et al. Drug prescribing and its relation to length of hospital stay. Inquiry. 1980;17:254-9. 22. Eisenberg JM, Koffer H, Glick HA, et al. What is the cost of nephrotoxicity associated with aminoglycosides? Ann Intern Med. 1987;107:900--9. 23. Noyes M, Polk RE. Norfloxacin and absorption of magnesium-aluminum. Ann Intern Med. 1988;109:168-9. 24. Black BL. Resource Book on Progressive Pharmaceutical Services. Bethesda, Md: American Society of Hospital Pharmacists; 1986. 25. McKenney JM, Wasserman AJ. Effect of advanced pharmaceutical services on the incidence of adverse drug reactions. Am J Hosp Pharm. 1979; 36:1691-7. 26. Herfindal ET, Bernstein LR, Kishi DT. Effect of clinical pharmacy services on prescribing on an orthopedic unit. Am J Hosp Pharm. 1983;40:1945-51. 27. Kelly KL, Covinsky JO, Fendler K, et al. The impact on clinical pharmacist activity on intravenous fluid and medication administration. Drug Intel Clin Pharm. 1980;14:51&-20. 28. Clapham CE, Hepler CD, Reinders TP, et al. Economic consequences oftwo druguse control systems in a teaching hospital. Am J Hosp Pharm. 1988; 45:2329-40. 29. Kidder SW. Cost-benefit of pharmacistconducted drug-regimen reviews. Consult Pharm. 1987;2:394-8. 30. Thompson JF, McGhan WF, Ruffalo RL, et al. Clinical pharmacists prescribing drug therapy in a geriatric setting. JAm Geriatr Soc. 1984;32:154-9. 31. Cummings DM, Corson M, Seaman JJ. The effect of clinical pharmacy services provided to ambulatory patients on hospitalization.AmJ Pharm. 1984;156:44-50. 32. Directions for clinical practice in pharmacy, session II workshops removing barriers to clinical practice. Am J Hosp Pharm. 1985;42:1332-5. 33. Phillips JO, Strand LM, Chesteen SA, et al. Functional and structural prerequisites for the delivery of clinical pharmacy services. Am J Hosp Pharm. 1987;44: 1598-1605. 34. Hepler CD, Pierpaoli PG. Introduction to ACCRUE Level II: management of pharmaceutical care systems. In: Nimmo CM, ed. ACCRUE LevellI Pharmacy Management Curriculum, Purchasing and Inventory Control. Bethesda, Md: American Society of Hospital Pharmacists; 1990:1-34.
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I Pharmaceutical care requires the pharmacist to work toward definite drug therapy outcomes, to collect more information and apply more judgment, and to work more closely with patients, physicians, and other health care professionals. by Charles D. Hepler, PhD
he environment of pharmacy practice is providing unprecedented opportunity for pharmacy to develop rapidly into a new profession. Technological and market changes will virtually force a fundamental transformation of most pharmacists' practices in the coming 10 to 20 years. 1 The question for pharmacists is not whether they will change, but how they will change to maintain their ability to make a satisfactory living by practicing pharmacy. For
their practice to succeed, even to survive, most pharmacists will need a new sense of purpose and a clear plan to reach it. If pharmacists are to shape their own futures, they need to identify and serve people's real needs. The greatest public need that pharmacists should address is the need for safe and effective drug therapy. Pharmacists can thrive if they will accept that purpose. Providing safe and effective drug products is a necessary part of that purpose, but
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much more is needed. Providing safe and effective drug therapy requires the traditional pharmacist to revise his basic understanding of pharmacy, the way he practices, and the way he manages that practice. This in turn requires bold leadership from pharmaceutical associations and educators.
Marketplace Forces Great worldwide changes are afoot, symbolized by the destruction of the Berlin Wall, the completion of the European Economic Community, and the industrial growth of Japan and the other Pacific Rim nations. Foreign trade and other world-class forces are causing the restructuring of the medical marketplace in the United States. Health maintenance organizations (HMOs), diagnosisrelated groups, Medicaid cuts, physician dispensing, and mail order pharmacy all are signs of this restructuring. We can understand how international forces affect pharmacy by considering the automobile industry. Because of competition from imported cars, American manufacturers are fighting for business. They can no longer pass on unbridled health care costs to the automobile buyer. One result is that General Motors (GM) uses mail order pharmacies. GM's health benefits manager has told community pharmacists that mail order gives GM health care plans equal value for a lower price. 2 Decisions like these, made by thousands of health care programs, will force radical change in health care markets and in pharmacy practice. Solo practice, fee-for-service health care is going to be in an even tougher race with prepaid comprehensive group practices (PCGPs) similar to today's Kaiser model HMO. A smart pharmacist will not mutter about "socialized Inedicine" and ignore these changes. The reorganization of care and the change in pricing methods represented by PCGPs will affect pharmacists tremendously. PCGPs can be organized either to improve or to downgrade the role of the pharmacist. It depends on whether the PCGPs recognize that safe and effective drug therapy does more to 24
reduce total health care costs than bargain-basement prescription prices. PCGPs could provide pharmacists, physicians, and nurses common economic objectives and could ease communication and cooperation. If pharmacy does not teach PCGP management about their options, however, they could just as likely relegate the pharmacist to the role of purchaser and dispenser of drugs with no need to improve communication and cooperation with patients, physicians, and nurses. Automated mail order pharmacy would appear reasonable in reaching this limited purpose. 1 Trends in prepaid medical plans and other organizational structures emphasize patient outcomes rather than products and procedures, and long-range, not immediate, patient care objectives. If pharmacists can show that they can improve patient health, they will be welcome in the new medical marketplace.
Technological and market changes will virtually force a fundamental transformation of most pharmacists' practices in the coming 10 to 20 years. Technology is also changing the pharmaceutical profession. New ways to provide drug therapy will be possible because of advances in dosage forms, computers, communications, and robotics. Fax machines, pharmacy computers, smart cards, automatic unit dose packaging machines, and even implantable, programmable pumps can be linked by computers and optics to produce automatic, remote drug-dispensing machines in physicians' offices, at shopping malls, on street corners, and even in the body itself. The third major factor in pharmacy's future is social. Public trust in social institutions and in leadership is weaker than it used to be. Yesterday's "patient" is today's "consumer." He has his prescription order dispensed by the physician's receptionist, by the mailman, or in a
general mercantile establishment called a drugstore where he may often have to decide for himself whether he needs to see the pharmacist. The modern health care consumer, who now feels less like a patient and more like the object of a health care business, may now expect health care providers to accept the rules of business and live with hardnosed competition on price and specific services. The consumer may be less willing to allow the profession to dictate what he needs, how he will get it, and what he will pay for it. 3 Drug technology has outstripped the drug therapy process. Despite the fact that every drug product now marketed in the United States has been proven safe and effective (when taken as directed), research shows that many people are not helped, and often are made worse, by prescribed drugs. The economic cost of additional care due to treatment failure and drug injury may be staggering: upwards of $4 billion annually. 4 The problem is not with the drug products or FDA or with physicians. The problem is the drug therapy process. At least half of drug injuries can be prevented, and research shows that pharmacists and physicians working together can reduce costs dramatically.5 We have focused too much on drug products and on adverse effects, and too little on the drug product as part of a drug use process that is intended to make patients well. It is time for pharmacists to acknowledge that drug products are one component of the drug use process, and to understand that drugrelated disease and treatment failure are hazards of the process. That means, however, that pharmacists will have to accept some responsibility for the undesired consequences of the drugs that they dispense. It is time for pharmacists to learn how they can help people to obtain safe and effective drug therapy instead of safe and effective drug products or drug procedures. That is how pharmacists can shape their future.
Changing Pharmacy for the Future Pharmacists have been influenced by the clinical pharmacy movement
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over the past 20 years. 6 Some have responded negatively, often with fear. Others recognized the power of the clinical movement and set out to harness it. Pioneering phannacists developed great new powers and professional diversity.7 Today, some phannacists build clinical functions into their daily practices in hospitals and in community phannacies. They ask clinically trained phannacists to train their colleagues in their new skills. They are moving their practices forward to meet the future. Clinical pharmacy is spreading, and changes in the marketplace seem to favor it. However, clinical phannacy is, like "dispensing" pharmacy, a temporary stage of development in phannacy's long professional adolescence. Each developed in response to the environment and now must change to meet future needs. In order for phannacists to perform clinical functions successfully in the future health care marketplace, our concept of clinical pharmacy itself will have to mature into an understanding of pharmacists as selfcontrolling, truly patient-oriented professionals who devote their efforts to improving therapeutic outcomes and who willingly accept their direct responsibility to patients. We will not find the path to the future by worrying about ourselves. Trying to list the functions that pharmacists should perform and technicians should not, or quarreling about phannacy's "rights" to distribute drugs or about titles and degrees and specialization is secondary to a larger question. The primary element needed to move beyond dispensing and clinical models of practice is a clear concept of our purpose and our responsibilities to patients. Phannacy will remain stuck in its professional adolescence until it takes this step. 5 Organized pharmacy, as represented by the American Pharmaceutical Association (APhA) , has endorsed a basic professional creed for more than 20 years. The APhA Code of Ethics states: ''A pharmacist should hold the health and safety of patients to be of first consideration and should render to each patient the full measure of professional ability as an essential health practitioner. "8
To accept responsibility for that mandate, the mission of pharmacy practice is not only what we have come to call clinical pharmacy. In addi tion to clinical know ledge and basic dispensing skill, there must be an appropriate philosophy of practice and organizational structure within which to practice. Hepler and Strand have proposed such a philosophy of practice, called pharmaceutical care, and an organizational structure to facilitate the provision of that care, called a pharmaceutical care system. 5
Pharmaceutical Care Phannaceutical care is defined as the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient's quality of life. These outcomes are: (1) cure of a disease, (2) elimination or reduction of a patient's symptomatology, (3) arrest or slowing of a disease process, or (4)
The individual pharmacist must see patients progress. That is what drug therapy monitoring and the prevention, detection, and resolution of drug..related problems should mean. prevention of a disease or symptomatology. Phannaceutical care involves designing, implementing, and monitoring a therapeutic plan that the pharmacist believes will optimally produce the therapeutic objective. Implementing and monitoring require the pharmacist to identify, resolve, and prevent drug-related problems arising from undertreatment, overtreatment, and inappropriate treatment. Pharmaceutical care should be carried out in cooperation with physicians and patients, but it is provided for the direct benefit of patients. Phannacists accept direct responsibility for any aspect of care that they could have affecMd. 5 Pharmacists already have suffi-
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cient educational preparation and legal authority to carry out this mandate in partnership with physicians and patients. It is time for each pharmacist to decide whether or not to accept this mandate, and whether or not to adopt phannaceutical care as a professional mission. There are limits, however, to what individuals can accomplish alone. Therefore, it is also time for pharmaceutical organizations, educational institutions, and patient care corporations to decide whether they want to be part of the problem of drug-related morbidity or part of the solution. If we can turn from self-examination toward public responsibility, we can proceed to professional maturity. Phannacists cannot wait for APhA or any other phannacy organization to implement phannaceutical care. Phannaceutical care has been and will be implemented by individual practitioners who change their sense of professional purpose. Pharmacy organizations can do much to facilitate the process, but can do little unless individual members initiate change at the level of individual practice. Once a phannacist has accepted a new purpose and new responsibility, he or she must consider what is involved in changing his practice (see box, p. 26). Some questions that he must ask are personal, some are organizational. They involve the pharmacist, the patient, and other professionals, especially physicians, employers (pharmacies, hospitals, corporations, etc.), and professional associations.
Professional Maturation Professional maturation requires soul-searching. Each phannacy practitioner must decide what his purpose should be for his patients. Likewise, phannacy program managers must decide the objectives of their programs. One major question illustrates the process offinding your purpose: What professional services do your patients need from you to achieve their therapeutic objectives? Other questions follow: What kinds of drug-related problems do your patients commonly have?9-22 Is your practice really set up to detect and solve them? How many of your patients may be 25
experiencing G I bleeding from NSAID therapy? How many of your patients are dizzy or disoriented right now because of antihypertensives or psychoactive drugs that you dispensed to them? Whom did you dispense norfloxacin to recently? Does he take magnesium-aluminum antacids?23 Do you have a systematic way to know that? Do you have a responsibility to know that? What are you and your immediate colleagues going to do about it? The general answers to these questions give your new purpose. Do you have the ability to carry out your new purpose? This depends on competence - the ability to use personal and environmental resources to reach one's objectives (see sidebar). In addition to knowledge and skill, it requires operative procedures (a practice model) and an attitude of responsibility to the client for achieving a purpose. You must examine what your resources are and w ha t additional resources are needed.
Practice Management Once you have defined your new purpose, determined what you are competent to do, and established a rational, consistent way to do it, you may begin to move into the realm of practice management: the realm of relationships, resources, and rewards.
Developing Relationships Establishing a relationship with patients is central to development as a pharmacist. Patients are your connection with reality. A highly respected Florida community pharmacist was happy as a businessman for 20 years because most of his patients were basically healthy. However, when hospitals in his area began to discharge patients "quicker and sicker," he began to meet terminal cancer patients and patients on long-term intravenous nutrition or antibiotics or peritoneal dialysis. Then, he had to become a professional health care provider. He could see a whole future for himself as a professional as well as a businessman and was thrilled and awed by that changing sense of purpose. He got his purpose from his patients. 26
Steps Toward Professional Change 1. Develop awareness of new purpose and responsibilities. 2. Examine personal competence to accomplish purpose. 3. Identify resources available. 4. Develop working relationships to achieve new purpose. 5. Create outcome, experience reward. 6. Return to step 1 with renewed motivation and commitment.
Developing relationships is critical to gathering clinical information, too. A hospital or nursing home keeps a medical record, but in a pharmacy there is only the prescription order. The rest of the information a pharmacist needs comes from the physician's office and the patient or his family. This brings us to the second point about relationships: expectations. Your relationship with physicians and patients usually has to change when your purpose changes, because they may not be able to cooperate with you until it does. Do your physician colleagues and your patients understand you as an authoritative, responsible professional who is primarily concerned with the success of their therapy? Do they expect you to aggressively c¥e for patients? Would your physicians understand why you were asking them to order a phenytoin serum level or a prothrombin time? Would your patients understand why you started taking drug histories, telephoned the second day after they started taking a prescription drug product, or asked them to show you their shins or nail beds? If they would, you are ready to move on to the next step: finding the resources of time and money that you need to practice pharmaceutical care. If not, you should expect to work to change relationships as you implement pharmaceutical care.
Obtaining Resources Perhaps the most frequently mentioned barrier to professional maturation is resources, especially time and money. This may be expressed as "too many prescriptions,"
or "too little technician support," or "wrong reimbursement system." Suppose that you could change your reimbursement system tomorrow, so that you could be paid on the basis of the outcomes of drug therapy instead of prescriptions sold. How much would your patients and practice really benefit? Are your purpose, competence, and relationships such that you could take advantage of that opportunity? If the answer is no, then changing the reimbursement system may not be the only answer. Some pharmacists are in a box; they won't change their practices because they assume that the resources will never become available to them. Of course, modern health care purchasers are unwilling to give those resources unless they understand what they will get for the money. Each side waits for the other to move first. Meanwhile, pharmacy becomes less and less relevant in health care, and patients continue to suffer preventable drug-related morbidity. It is time for pharmacists to get out of their box. To get out of the box, you ask the following questions: Do you know the research evidence that demonstrates the value of integrated patient-specific pharmaceutical services in reducing total costs of care?24-31 Can you develop the evidence into presentations relevant to specific purchasers? Can you specifically enumerate the purpose of the service and the procedures to be carried out for patients? Would you share in the financial risk of the insurance company for a share of the surplus? New ventures are risky, it is true, but consider the alternatives.
Managing Resources In addition to obtaining resources, the manager must use them effectively and efficiently to achieve definite purposes. Pharmaceutical care will require a different organization and management approach from the approaches used in dispensing pharmacy. Pharmaceutical care requires the pharmacist (1) to work toward definite drug therapy outcomes for patients (not only to perform procedures for the patients), (2) to collect more information and to apply more judgment, and (3) to
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work in closer cooperation with patients, physicians, and other health care professionals. Traditionally, pharmacy program managers might have expected the pharmacist to bring a personal concept of purpose and competence into the management system. 3 The pharmacist might have assumed that the management system would be designed without much attention to professional purpose and competence. In a pharmaceutical care system, however, those traditional lines should be crossed, so that managers become more responsive to professional purposes and more active in developing and operating the systems. It will be essential that pharmaceutical care managers truly understand pharmaceutical care and that pharmacists truly expect the system to facHitate their work. A mBnager should design a management model, a pharmaceutical ·care~ system, to achieve clear purposes.3 ,32-34 Those purposes should be communicated to everyone - technicians, other pharmacists, patients, nurses, physicians - whose cooperation the pharmacist needs in order to do his work. The system should clarify and assign responsibility and foster necessary relationships both inside the system and with patients and other professionals. Four important issues are: (1) how to organize the work of pharmacists and technicians; (2) how to use experts and consultants, e.g., pharmacist-specialists; (3) how to assign shared responsibility for outcomes when the pharmacist cannot completely control them - for example, because he does not have prescribing authority; and (4) how to assign responsibility when different pharmacists may be caring for a patient at different times. The system should provide and effectively use resources, especially people, information, and space. What information about patients and drugs do pharmacists need to provide pharmaceutical care? When do they need it? How can it be captured, organized, and communicated as an effective clinical decision support system? What can your system already do? How can you share clinical information with physicians and other pharmacists?
Are You Competent?
J
ust as personal competence is essential in daily life, competence is essential for a professional life, and the idea that one may not be competent is frightening. Professional competence is meaningful, however, only in the context of purpose, so the competence you require depends on what you are proposing to do. On the one hand, this limits the amount of competence required by anyone practice. We have to be competent only to do those things that come up in our practice. On the other hand, it takes courage to decide what our patients need from us, and then to decide what our competencies should be. It is essential, however, that we not turn this around and limit our purpose to what we imagine we are already competent to do for our patients.
What Is Competence? Professional competence is such a sensitive subject to most professionals that it is easy to misunderstand. Competence is not the absence of incompetence. Competence is not what is left over after you have enumerated everything you cannot do. Competence is what you can do, related to your purpose. Second, competence is not academic degrees; examples of either one without the other are everywhere. Third, competence is not self-esteem. Basic self-esteem, praise, and pep talks can be very useful as encouragement to take the necessary risks, but flattery gives short-term boosts that lack a valid basis in real ability to perform. This is also true of public relations programs. Although it is often helpful to raise public expectations, the claims must be validated when a patient walks into a pharmacy. Are you already competent to talk to all patients to find out whether they understand how to take their medications; to call a patient at home a day or two after he has started a new medication, just to ask how he's doing; to send an occult blood test kit home with a patient receiving long-term NSAID therapy; to look for evidence of drug-induced dementia or depression in elderly patients; to monitor blood pressure; and to look for bruises and nail-bed bleeding in patients receiving anticoagulants? Most pharmacists could answer yes to all these questions. If you can answer yes, you are already competent to prevent significant amounts of drug-related morbidity in your patients.
Seven Steps to Better Outcomes Do you have a basic routine procedure that you consistently use to evaluate your patients' progress toward specific outcomes? Strand and her colleagues have developed such a procedure, which they call the Pharmacists' Workup of Drug Therapy (PWDT).* It exists in two versions, one for inpatients and one for outpatients, but the basic procedure is the same: seven steps direct the pharmacist's decision making about the use of drugs. It demonstrates· how the concept of pharmaceutical care can actually be realized for any patient and in any practice setting. The steps call on pharmacists to: 1. Collect and interpret relevant patient information to determine whether the patient has drug-related problems. 2. Identify drug-related problems. 3. Describe the desired therapeutic goals. 4. Describe feasible therapeutic alternatives. 5. Select and individualize the most appropriate treatment regimen. 6. Implement the decisions about drug use. 7. Design a monitoring plan to achieve desired therapeutic goals.
* Strand LM,
Cipolle RJ, Morley PA. Documenting the clinical pharmacist's activities: back to basics. Drug Intel Clin Pharm. 1988;22:63-6.
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Finally, the pharmaceutical care system should recognize, evaluate, and reward outcomes consistent with its purpose. How can the clinical decision support system be designed to provide managers with the data they need to evaluate important aspects of care?
Evaluating Performance and Outcomes Obtaining resources and maintaining the pharmaceutical care system will require the manager to evaluate patient care outcomes that involved (or should have involved) drug therapy. This may require significant changes in managing pharmacists' work. The individual pharmacist must be able to see patients progress. That is what drug therapy monitoring (the prevention, detection, and resolution of drug-related problems) should mean. In addition, management should provide all pharmacists with summaries of their practice and outcome patterns. Each pharmacist may want to change certain patterns in his practice, and management should then be prepared to support those changes, as long as they are consistent with the overall purpose of the group practice. Pharmacists also will obtain professional satisfaction directly from their work. This constant feedback will motivate, direct, and sustain the efforts of those who like their work and who care about patients and may lead many pharmacists to identify even greater purpose and accept more responsibility. Once the initial clinical and economic benefits of pharmaceutical care have become a normal part of care, will it be necessary for the pharmacists and managers to prove effectiveness again and again, in order to keep the necessary resources? How does a manager do that? These questions expand our perspective even beyond the level of the employer of pharmacists to the level of the professional organization and the general society in which the pharmacist practices.
An Organizational Perspective Reaching for new responsibilities and developing new competence
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requires courage to put oneself in unfamiliar situations. Colleges of pharmacy and professional associations can influence this process by providing education and training, by guiding, and by validating the individual pharmacist's passage through the stages of professional maturation. Professional associations can help pharmacists clarify their sense of purpose and can provide forums for exchanging ideas. Professional associations can carry out strategic planning to help their members understand ways they can change their practices to meet future needs. Most important, however, professional associations can take their members' individual concepts of purpose and competence, translate them into practice standards, and then communicate those standards back to their members and outward to the greater society.
The primary element needed to move beyond dispensing and clinical models of practice is a clear concept of our purpose and our responsibilities to patients. Such standards should express what their members' purpose should be and what their members should be competent to do. They can convert the concept of a practice model and a pharmaceutical care system into standards for the structure and processes of practice, including the resources that employers should provide. The pharmacy standards of the Joint Commission on Accreditation of Healthcare Organizations are examples. Publicizing these documents might succeed in raising the expectations of the public and other professions more than any public relations attempt and might establish pharmaceutical care as an integral part of future health care systems. These are not easy tasks, however. Rapid changes in the health care
marketplace are stressful, forcing pharmacists to change their practices, fragmenting pharmacy organizations, and creating confusion. Pharmacy organizations will continue to experience internal conflict as long as external stress and rapid professional change continue. Strategic planning, while not a panacea, can help to control and direct the conflict.
To Be Resolved Pharmacy's organizations need a strategic vision and courageous leadership to move toward that vision. This paper has outlined a series of steps that individual practitioners might follow to work their way toward professional maturation. The following questions can be addressed to the leaders of professional organizaLions as they . consider those issues: After carpful consideration of market changes, what social purpose and responsibility (mission) will provide your members with the best professional future? What is the best way to help your members accept that mission? Who can lead toward the new mission? What will happen if some members do not accept the mission right away? What is the association's members' current range of competence to carry out that mission, e.g., what can the top 800/0-90% accomplish? How can your organization help those who need to increase their competence? How can the colleges of pharmacy help? How can your organization develop and teach a practice model, a management model, prescriptive standards of practice? Who can help pharmacists foster pharmaceutical care? How can the organization help pharmacists establish relationships "vith them? What does pharmaceutical care have to offer insurance companies, hospitals, HMOs, chain pharmacies? What evidence is needed? How do we get it? What do employed members need from their employers to reach the new mission? How can the association help pharmacists obtain those resources? Is legislative permission needed? Would a legislative mandate help? A crucial issue that every pharmacy organization must consider
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throughout this period of stress is its process for addressing questions about change. In other words, how does it understand and respond to diversity? Is your organization in a "learning" mode or "fighting" mode? What can your organization learn from the innovative community practitioner, ambulatory clinic practitioner, consulting pharmacist, hospital pharmacist, chain pharmacist, clinical pharmacist? Can the leadership really hear innovative ideas about the future instead of reacting defensively to their proponents as competitors? Are there any modernday pioneers to whom the organization cannot be open, against whom it must defend or actually attack? How do association leaders act in times of stress? How sensitive are they to the ideas of a visionary minority over the roar of a confused but politically powerful majority? And how courageous can they be in placing long-term purpose above short-term success?
Constant f back will motivate, direct, and sustain the efforts of those who Ii their work who care about patients and may lead many pharmaCists to ider1tifv even.greater purpose and accept more res nsibility. The future success of each professional association depends on the success of its members. The number of pharmacists who will be able to effectively serve their patients and survive as professionals will depend in part on the sagacity and courage of pharmacy's associations. The reprofessionalization of pharmacy will start with individual practitioners, but its ultimate success will depend on pharmacy's leadership. Pharmacists at every level, however, can contribute to the continued maturation of pharmacy as a clinical profession. Acknowledgments: This paper is based in part on a presentation at the
SecondPhannacy in the 21st Century Conference, Williamsburg, Va., October 11, 1989. It includes ideas developed by faculty and graduate students in seminars of the Department of Phannacy Health Care Administration at the University of Florida. Charles D. Hepler, PhD, is professor and chairman of the Department of Pharmacy Health Care Administration, College of Pharmacy, University of Florida, Gainesville, FL 32610.
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D. Hospital admissions caused by iatrogenic disease. Arch Intern Med. 1986;146:1931-4. 18. Ives TJ, Bentz EJ, Gwyther RE. Drugrelated admissions to a family medicine service. Arch Intern Med. 1987;147: 1117-20. 19. Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109:582-9. 20. Knapp DE, Knapp DA, Speedie MK, et al. Relationship of inappropriate drug prescribing to increased length of hospital stay. Am J Hosp Pharm. 1979; 36:1334-7. 21. Knapp DA, Speedie MK, Yaeger DM, et al. Drug prescribing and its relation to length of hospital stay. Inquiry. 1980;17:254-9. 22. Eisenberg JM, Koffer H, Glick HA, et al. What is the cost of nephrotoxicity associated with aminoglycosides? Ann Intern Med. 1987;107:900--9. 23. Noyes M, Polk RE. Norfloxacin and absorption of magnesium-aluminum. Ann Intern Med. 1988;109:168-9. 24. Black BL. Resource Book on Progressive Pharmaceutical Services. Bethesda, Md: American Society of Hospital Pharmacists; 1986. 25. McKenney JM, Wasserman AJ. Effect of advanced pharmaceutical services on the incidence of adverse drug reactions. Am J Hosp Pharm. 1979; 36:1691-7. 26. Herfindal ET, Bernstein LR, Kishi DT. Effect of clinical pharmacy services on prescribing on an orthopedic unit. Am J Hosp Pharm. 1983;40:1945-51. 27. Kelly KL, Covinsky JO, Fendler K, et al. The impact on clinical pharmacist activity on intravenous fluid and medication administration. Drug Intel Clin Pharm. 1980;14:51&-20. 28. Clapham CE, Hepler CD, Reinders TP, et al. Economic consequences oftwo druguse control systems in a teaching hospital. Am J Hosp Pharm. 1988; 45:2329-40. 29. Kidder SW. Cost-benefit of pharmacistconducted drug-regimen reviews. Consult Pharm. 1987;2:394-8. 30. Thompson JF, McGhan WF, Ruffalo RL, et al. Clinical pharmacists prescribing drug therapy in a geriatric setting. JAm Geriatr Soc. 1984;32:154-9. 31. Cummings DM, Corson M, Seaman JJ. The effect of clinical pharmacy services provided to ambulatory patients on hospitalization.AmJ Pharm. 1984;156:44-50. 32. Directions for clinical practice in pharmacy, session II workshops removing barriers to clinical practice. Am J Hosp Pharm. 1985;42:1332-5. 33. Phillips JO, Strand LM, Chesteen SA, et al. Functional and structural prerequisites for the delivery of clinical pharmacy services. Am J Hosp Pharm. 1987;44: 1598-1605. 34. Hepler CD, Pierpaoli PG. Introduction to ACCRUE Level II: management of pharmaceutical care systems. In: Nimmo CM, ed. ACCRUE LevellI Pharmacy Management Curriculum, Purchasing and Inventory Control. Bethesda, Md: American Society of Hospital Pharmacists; 1990:1-34.
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