Today’s pharmacy workflows in both the community and health-system settings sometimes baffle me given they have remained largely the same for decades. Recently, on a trip to Montreal, I visited a community pharmacy. Despite being a short drive from the US border, it seemed as though I was in a different world altogether. The entire layout and design of the pharmacy area was completely different. The atmosphere conveyed professionalism from the moment I walked into the building, from the layout, sounds, and how the staff carried out their work. This was in a Jean Coutu group pharmacy, one of the largest chains in Quebec.
Despite the pharmacy filling about 1,200 prescriptions a day, the environment was organized, polished, and not at all chaotic. Behind the pharmacy counters, pharmacists were working, not standing but seated at computers, assessing patient profiles and ensuring appropriateness of prescribed therapies. Technicians were engaged in another area, aided tremendously by robotic technologies, and dispensing medications. Interestingly, pharmacists in the pharmacy are actually told NOT to touch the medications…their role is medication therapy expert, meaning their focus is on medication safety and optimal outcomes from patient-specific therapies. Reimbursement includes calculation of the pharmacist’s time to conduct the clinical accuracy assessment. As such, the health care system appropriately reimburses the practice sufficiently for the product and the cognitive clinical services provided by the pharmacist.
When a patient needs to consult with a pharmacist, or the pharmacist needs to speak with a patient, the conversation doesn’t happen at the cash register. Pharmacists aren’t permitted to be there either—the technician or clerk makes a quick patient care assignment to the pharmacist in queue, the patient has a seat, and the pharmacist calls the patient to a more private consultation window for the conversation. Depending upon the nature of the consult, the pharmacist may need to do further assessment, may schedule the patient for an in-depth encounter, and then may prescribe the necessary treatment or refer. This also results in payment from the health plan. The patient knows and feels that health care has been provided. This doesn’t feel like “retail” at all…it feels very much like a professional pharmacy practice. I learned that this pharmacy and experience is the norm in Quebec, and in most Canadian provinces.
Many US pharmacies can feel, quite simply, a little chaotic. I wish there were a gentler way to say it, but for many Americans, a trip to the pharmacy often feels more like a retail transaction than a personal interaction. The goal is simple: help me get what I need and, with a little luck, get me on my way quickly. I may even give the drive-through a try!
(Did you know that in Quebec, pharmacists do not provide advice or consultation at the drive-through? If you have a question for the pharmacist, you can call for a telephone consultation or you can come into the pharmacy for a visit.)
Why is it that we have such a dichotomy of experiences in North America? You’d think that the border between our countries was an ocean and not simply a check point! At the risk of putting it too simply, if we want America’s community pharmacies to feel a little more like their Canadian counterparts, we’ll need to get comfortable with some meaningful change. It may not be easy, but it is a conversation worth having.
First, we must separate the act of dispensing medications from the cognitive clinical care provided by the pharmacist. I know this sounds like a broken record and just exactly like what your university professor told you might happen someday, but the time is here. We’ve got to take a critical look at the science of safely dispensing patient-optimized medications and recognize that pharmacists being involved in the physical act of filling prescriptions isn’t the most critical role they have in health care. With an aging population and a pharmacist shortage, we can no longer afford to have pharmacists routinely handle prescriptions. We need pharmacists to fulfill their role as the medication expert by ensuring appropriate medication outcomes and optimizing medication therapy to help patients live their best lives.
Secondly, state boards of pharmacy need to act now. We can’t wait any longer. The purpose of a state board of pharmacy is to protect the public’s health and well-being. Limiting the use of technology in dispensing in any way at all is simply unfounded. In fact, it may be putting patients in danger of greater harm. Without technology and the effective use of pharmacy technicians, pharmacists are left performing tasks well below their level of education, training, and experience. Burdening them with a tedious process, growing workloads, and inadequate staffing takes time away from their true public health role: protecting patient safety and promoting the appropriate use of medications.
If we want to solve the staffing crisis in pharmacy, we must optimize technology in practice while lifting the roles of pharmacists and technicians. Corporations will integrate technology optimally when there are no regulatory barriers to doing so.
Third, state boards need to rethink the pharmacy technician equation. Ratios for staffing are not the solution. The solution is to ensure technicians have the education, training, and certifications necessary to support the pharmacist and verify that medications are dispensed safely and appropriately to the patient. This teamwork affords the pharmacist the time to provide comprehensive medication-related care to the patient. This may mean increasing our commitment to PTCB certification, increasing our expectations for education and training of technicians, and supporting the practice of technicians based upon science of safety and not based upon emotion or fear. It also means that employers must pay pharmacy technicians a living wage with consistent hours.
Given the country’s severe shortage of primary care professionals—and growing calls for pharmacists to help fill that gap—there is little reason to fear that pharmacy technicians will take pharmacists’ jobs. The goal is not to shift work away from pharmacists, but to ensure pharmacists can devote more time and attention to the patient care activities that only they are trained and licensed to provide.
I’m certain this blog has stirred some emotions. Solving this problem will take far more than the three ideas I’ve outlined here. My aim isn’t to make people angry, but to get them thinking. If the Canadians have found a way forward (and they have), surely America can, too. Join us, at APhA, collaborating across the profession to create solutions.
For all of pharmacy.