If you ask most people to tell you what a pharmacists does, they will likely tell you that a pharmacist spends most of his or her day counting and dispensing medications in a little room at the local drug store. While this may have been true at various times and to various extents over the last hundred years, the duties of today's pharmacist are decidedly more complex.

"If I had to characterize the shift broadly, I would say it's been moved more toward knowledge of the product, and interaction with the patient — so more focus on treatment rather than just the dispensing and the preparation of the product," says Noel Wilken, assistant professor of pharmacy administration at the University of Mississippi. "And how this manifests itself is with more patient contact and more patient counseling, greater involvement in disease state management, greater involvement in assisting patients with managing their disease states and serving a greater information source role for the patient."

Advances in pharmaceuticals have also played a part. "Pharmacists are much more involved in modifying patient behavior and physician prescribing behaviors and practices today than they were 20 years ago," says John A. Gans, executive vice president and chief executive officer of the Washington-based American Pharmaceutical Association. "The major reason is that today, drug therapy is far more complex and comprehensive and challenging to use. We use it far more aggressively and we use it far more often. It has become a primary form of treatment. Where in the past, hospitalization and surgery were more the primary forms of treatment, today it's drug therapy."

OBRA '90

Though environmental factors, like the increasing number of senior citizens or the advancements in pharmaceuticals, have played a role in encouraging this evolution, the change can primarily be traced to the passage of the Omnibus Budget Reconciliation Act of 1990. This legislation, in part, required pharmacists to perform a drug use review, patient counseling and documentation in some form of patient profile.

According to Stephen L. Foster and Jerry R. Phipps in their paper "Counseling on new drugs," the law required pharmacists to screen for:

• Therapeutic appropriateness.

• Over- and underutilization.

• Appropriateness of generic products.

• Therapeutic duplication.

• Drug-disease contraindications.

• Drug-drug interactions.

• Incorrect drug dosage or duration of drug treatment.

• Drug-allergy interactions.

• Clinical abuse or misuse.

In addition, patient consultation was mandated to include:

• The name and description of the medication.

• The route, dosage form, route of administration and duration of therapy.

• Special directions and precautions for preparation, administration and use by the patient.

• Common severe side effects, adverse effects, interactions or therapeutic complications that may be encountered, including their avoidance and the action required if they occur.

• Techniques for self-monitoring drug therapy.

• Proper storage.

• Prescription refill information.

• Action to be taken in the event of a missed dose.

Information to be documented on each patient was specified to include:

• Name.

• Address.

• Telephone number.

• Date of birth (or age) and gender.

• Individual history where significant, including disease state or states, known allergies and drug reactions.

• A comprehensive list of medications and relevant devices.

• Pharmacist's comments relevant to drug therapy.

While OBRA '90 pertained only to Medicaid patients, many states followed suit with similar legislation requiring pharmacists to provide these services for all their patients.

To fulfill these additional duties, pharmacists must complete increasing educational requirements. Over the last decade, according to the American Society of Health-System Pharmacists, colleges of pharmacy have become more clinically oriented — offering advanced education and training in drug therapy management — and have shifted from a baccalaureate degree to a six-year doctor of pharmacy. And in 2002, all pharmacy students will graduate with the Pharm.D. degree. An increasing number of pharmacy graduates are also participating in post-graduate residency programs to further add to their clinical skills.

Expanded duties

OBRA '90 may have pushed the profession into more of a patient counseling role, but pharmacists are doing more than just talking with patients. "In most states now, pharmacists can do laboratory tests," says Gans. "And there's now automated equipment that the pharmacist can use to do blood glucose levels, hemoglobin A1c levels, liver function tests, entire lipid profiles or measurements of anticoagulant therapy. So there's a lot of devices now that have evolved that are available to the pharmacist, so they can actually give objective readings to the patients to see how well they're doing. You can also feed that information back to the physician, because he's only seeing that patient maybe once or twice a year for a chronic disease, so the physicians really like it."

Pharmacists say that these additional roles are important because, with medication use, the weakest link in achieving positive outcomes is usually the patient. "When the pharmaceutical industry evaluates a product at the clinical trial level in investigations, that's under the most ideal conditions, where a large number of people are ensuring that everyone is doing the right thing," says J. Lyle Bootman, dean of the college of pharmacy at the University of Arizona, Tucson. "That's not what happens in the real world. In the real world, a lot of error occurs, a lot of too low of a dose, no one monitoring [the patients'] proper outcomes with the therapy, etc."

Adds Gans: "Have you ever heard a surgeon say the surgery failed? No. You hear that drug therapy fails all the time. Most of that failure is not the product's fault; it's the patients' fault because they didn't know how to use it."

In cases where the pharmacist is more involved in patient care, patients have fewer adverse events and experience improved outcomes — not to mention the fact that overall healthcare costs decline as well. "Where we run demonstration projects in diabetes, or in lipid management, four or five things always happen," says Gans. "First, a lot more money is spent on drugs because people are a lot more compliant. For example, in a lipid management program we do, people went from being [compliant] somewhere between 20% and 40% at the end of one year (and it takes about a year and a half for these drugs to work) to 94% at the end of two years." Though Gans concedes that these programs mean that more drugs and physician visits are required, he claims that they also result in better outcomes and fewer hospitalizations.

A question of compensation

The current challenge for pharmacists is to find a business model or financial support for those types of counseling services. One piece of this puzzle is a bill before Congress that would allow Medicare to reimburse pharmacists for high-level patient services. Currently, pharmacists are only able to bill "incident to" a physician's service, a process that requires meeting a considerable regulatory burden. The bill, called the Medicare Pharmacist Services Coverage Act, would amend the Social Security Act to include pharmacists on the list of healthcare professionals classified as "healthcare providers."

"This legislation would amend Medicare to recognize pharmacists as healthcare providers and make drug therapy management services available to beneficiaries," says Sen. Tim Johnson (D-SD), sponsor of the bill. "These services, which are provided in collaboration with physicians and other healthcare professionals, help patients make the best use of medications."

Marketing focus

As pharmacists expand their roles, is the profession likely to become a larger target for pharmaceutical company marketing efforts?

"As they increase their role in the provision and monitoring of drug therapy, it's a definite yes," says Bootman. "In fact, you see certain companies who have already made a major effort in calling on pharmacists."

One company Bootman says is targeting pharmacists well is New York-based Pfizer Inc. "We're taking the approach that pharmacists are decision makers, and you have to talk to people who are decision makers," says Bob Sikora, vice president, clinical education consultants for Pfizer. "They're influential just like physicians are influential."

Sikora, who is also a pharmacist, says that reps are relating the same information to pharmacists that they give to doctors. "[Pharmacists are] getting reasonably the same information," he says. "[Reps] have got to detail off of approved pieces, so they're basically detailing so the pharmacist is aware of the product, how it's being used, what the normal dose is, that type of thing."

According to Gans, sales reps should recognize that their primary role is to deliver information. "Pharmaceutical reps, a lot of times, think they're salesmen," says Gans. "And a lot of the time their outcomes are measured via sales. But the reality is that what they're selling is information and knowledge. And the more of that information that they can get out there and get applied successfully, the more successful they will be, and their company will be, long-term."

For example, if representatives can provide pharmacists with information that can help them increase patient compliance, it will improve both the patients' outcomes and the representative's sales. "It's important to get patients to start a product, but it's just as important to keep them compliant," says Gans. "Pharmacists are going to be the ones to keep people compliant by motivating, educating, monitoring and showing them that taking this product is making a difference. If you take somebody who takes a product for six months versus someone who takes that product for the rest of their lives, there's a sale every month." PR