It is useful to look at the evolution of drug information practice from the perspective of drug information centers and practicing pharmacists. Calculating accurate numbers of drug information centers nationally or internationally (e.g., Puerto Rico, Japan, Saudi Arabia, Africa) is difficult, because no agency or organization is responsible for maintaining a list. Well-defined criteria are not established for using the titles of drug information centers/services. Some centers specialize in a particular area of drug information, and their name may reflect that specific function (e.g., center of drug policy and drug information, drug and poison information center, and drug information and wellness center). Some centers limit their practice to a subset of clients (e.g., pharmacists, physicians, nurses, other health professionals, attorneys, faculty, consumers) based on their source of funding (e.g., pharmaceutical manufacturer, government, college of pharmacy, managed care organization, law firm, law enforcement agencies), and some drug information centers are available for all consumers, 7 days a week, 24 hours a day, as is the case for a drug and poison information center. The center may provide services via telephone, through a Web site, face-to-face with their clients, or other methods.
One study conducted in 2008 and published in 2009 examined 89 drug information centers to test if there were changes in number or type of questions, and time spent on activities compared to 5 years earlier.11 Eighty-four percent of the drug information centers were still in existence. There was an increase in time spent educating students (53%) and supporting adverse drug reaction reporting initiatives (44%). Seventy-six reported an increase in the number of complex questions, with 53% documenting an increase in the time required to answer questions.
When examining the availability of a drug information center specifically in the hospital setting, a 2010 survey that examined over 1950 U.S. hospitals, found that 5% had a formal drug information center as their source to provide objective drug information.12 In an earlier survey,13 it was found that the availability of a formal drug information center was more prevalent in larger hospitals. For instance, when examining a subset of the hospitals with more than 400 beds, 28.2% of hospitals reported that they had a formal drug information center.
A few studies have described the economic benefit of maintaining a drug information center or related activity in an academic institution or hospital. One such study examined the economic impact of drug information services responding to patient-specific requests.14 The resultant cost-benefit ratio was found to be 2.9:1 to 13.2:1. Most of the cost savings resulted from a decreased need for monitoring (e.g., laboratory tests) or a decreased need for additional treatment related to an adverse effect. Another study examined the drug cost avoidance and revenue associated with the provision of investigational drug services, which was not part of drug information center in this study, but may be the responsibility of a drug information center.15 The annualized drug cost avoidance plus revenue was $2.6 million. Studies of this nature are becoming increasingly important in an era of cost containment. Although these studies were completed several years ago, the basic premise of the design and results are applicable today and can be used to provide a foundation for assessment of the value of a particular center based on location, clientele, and funding. Other literature also exists that evaluates the economic return on investment for clinical services, which can help provide a framework for how to assess the value of a drug information center.16
DRUG INFORMATION—FROM CENTERS TO PRACTITIONERS
The responsibilities of individual pharmacists regarding the provision of medication information have changed substantially over the years. The impetus for this change was provided not only by the development of drug information centers and the clinical pharmacy concept, but also by the Study Commission on Pharmacy.17 This external group was established to review the state of the practice and education of pharmacists and report its findings. One of the findings and recommendations stated that
“… among deficiencies in the health care system, one is the unavailability of adequate information for those who consume, prescribe, dispense and administer drugs. This deficiency has resulted in inappropriate drug use and an unacceptable frequency of drug-induced disease. Pharmacists are seen as health professionals who could make an important contribution to the health care system of the future by providing information about drugs to consumers and health professionals. Education and training of pharmacists now and in the future must be developed to meet these important responsibilities.”
The report of the Commission was issued in 1975, and since that time drug information practice has changed for both drug information centers and individual pharmacists. The development of clinical pharmacy has helped move pharmacy forward in recognizing its capabilities to contribute to the care of patients. Clinical pharmacy was thought of primarily as an institutional patient care process and did not gain widespread acceptance outside of hospitals. Over time, the activity of the pharmacist as a medication expert for patients has gained acceptance in a variety of practice settings including community pharmacies, nursing homes, and primary and specialty clinics. Pharmacists who provide patient-specific information with a goal of improving patient outcomes use the medical literature to support their choices.18
Pharmacists involved in patient care areas (e.g., hospitals, clinics, long-term care, home health care) now frequently answer medication information questions, participate in evaluating a patient’s drug therapy, and conduct medication usage evaluation activities. In one survey of more than 1960 hospitals, approximately 97% have staff pharmacists routinely answer drug information questions.12 The provision of medication information may be on a one-on-one basis or may occur using a more structured approach, such as a presentation to a class of patients with diabetes or a group of nurses in the practice facility. In either case, the pharmacist educates those who are the beneficiaries of the medication information. Pharmacists may also participate in precepting students in patient care or pharmacy environments. In any of these roles, the pharmacist must use appropriate information retrieval and evaluation skills to make sure that the most current and accurate information is provided to make decisions about medication use for those they are serving. This role of the pharmacist as a provider of medication information continues to be an important component of the educational outcomes developed by the Center for the Advancement of Pharmaceutical Education (CAPE). These outcomes are initiated and maintained by the American Association of Colleges of Pharmacy (AACP) to help transform the pharmacy curriculum to support education of the future.10,19 There is a well-described systematic approach to answering drug information questions (see Chapter 2). It is important to obtain the necessary background information including pertinent patient factors, disease factors, and medication-related factors to determine the true question. Good problem-solving skills are required to fully assess the situation, develop a search strategy (see Chapter 3), evaluate the information (see Chapters 4 and 5), and then formulate and communicate a response. Good communication skills are essential to respond in a clear and concise manner, using terminology that is consistent with the patients’, caregivers’, or health professionals’ level of understanding. Table 1–2 lists the medication information skills a pharmacist should possess when confronted with a medication information need.
MEDICATION INFORMATION SKILLS
||Download (.pdf) TABLE 1–2.
MEDICATION INFORMATION SKILLS
Assess available information and gather situational data needed to characterize question or issue.
Formulate appropriate question(s).
Use a systematic approach to find needed information.
Evaluate information critically for validity and applicability.
Develop, organize, and summarize response for question or issue.
Communicate clearly when speaking or writing, at an appropriate level of understanding.
Anticipate other information needs.
Opportunities continue to grow for pharmacist participation in the continuum of care including home health care and long-term care that require a solid therapeutic knowledge base, an understanding of the medical literature, and the ability to communicate the information through either verbal or written consultation. Pharmacists in community settings counsel patients, answer medication information questions, review patient medication regimens for potential problems (medication therapy management), and participate in helping patients manage chronic diseases. The PCMH philosophy has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. Patient care is considered to be comprehensive, team-based, coordinated, and accessible. As a component, the health care team helps improve the quality of care through access to information technology and other tools, to help make sure that both patients and families are making informed choices about their health. Medication information should be administered when they need it, and in a culturally and linguistically appropriate manner.
Opportunities for pharmacists are also available in the area of veterinary pharmacy practice. Information is needed by both the animal owner and the veterinarian. A pharmacist may need to practically apply information from veterinary resources (e.g., Veterinary Drug Handbook, Textbook of Veterinary Internal Medicine, National Animal Poison Control Center) for the benefit of an animal (see Chapter 3).
FACTORS INFLUENCING THE EVOLUTION OF THE PHARMACIST’s ROLE AS A MEDICATION INFORMATION PROVIDER
❷ Medication information provision has evolved in the last 50 years as focus has shifted to medication safety, advances in informatics, evidence-based medicine, and new environments of care. Other factors include new regulations in health care, the changing philosophy of practice (e.g., patient-focused medical home programs), the evaluation of outcomes, the sophistication of medication therapy, and the self-care movement.
As mentioned earlier in this chapter, one of the primary roles for drug information specialists in the beginning was collecting and evaluating adverse drug reactions.5 This role will continue to expand because it is anticipated that the number of adverse drug events (ADEs) will increase in the near future for several reasons: (1) the availability of new medications and new indications with conventional medications, (2) the growing elderly population, (3) the increased use of medications for disease prevention, and (4) the improved insurance coverage for medications.20 Pharmacists perform this function in institutional health systems, managed care, or the pharmaceutical industry. To illustrate how a central area for reporting ADEs, such as a drug information center in an institutional health system, can be beneficial, consider the following unpublished example from an academic medical center. The drug information center received three reports of patients developing methemoglobinemia within a 2-week period. The offending agent was suspected to be benzocaine spray. Upon investigation, the drug information pharmacist recognized that all reports had one thing in common: the administering nurse. The pharmacist witnessed the administration of the drug by the nurse the next time it was ordered for a patient. Instead of a single brief spray as directed by the prescribing information, several sprays were used resulting in a potentially toxic dose of drug. The drug information pharmacist developed a series of in-services for nurses. No reports of benzocaine-induced methemoglobinemia have occurred since. In managed care settings, the same benefit could be achieved on an even larger scale.
The role of the drug information specialist in the pharmaceutical industry as it relates to reporting ADEs is especially important in postmarketing surveillance activities. Because of the specific definition of a study population using inclusion and exclusion criteria in a new drug trial, many ADEs go undetected until the agent is commercially available and used in a broader population. By quickly identifying potential problems and communicating them to health care professionals, patient safety may be improved. The training and expertise of the drug information specialist qualifies them to play a major role in this process.
The importance of maintaining a comprehensive, multidisciplinary, ongoing program for monitoring, reporting, and resolving drug-related problems, and developing mechanisms to prevent future ADEs will continue to be an important element of managing medication use, with the drug information specialist providing leadership, as well as every clinical practitioner (e.g., pharmacists, nurses, physicians) contributing to the overall program. There is an estimated 700,000 emergency room visits and 120,000 hospitalizations annually attributed to ADEs, with an annual extra cost of $3.5 billion to the health care system.21,22 Forty percent of these events are considered to be preventable.22 These numbers are probably even higher in the elderly population because of age-related physiological changes, co-existing conditions, and polypharmacy.23 The prevention of ADEs is important today, and will continue to be a significant health care issue in the future.24
Integration of New Health Information Technologies
Computer technology has drastically changed the ability to store and access information. The focus in medication information is driven toward the use and integration of data, information, knowledge, and technology involved in the medication use process to improve outcomes for patients. Even though the amount of literature is much larger today than in the past, it is more manageable. The Internet allows the user to easily access the scientific literature, government publications, news reports, and many other items, frequently without cost to the clinician or the consumer, and handheld devices (e.g., smartphones, tablets) have allowed practitioners to have a full range of applications (e.g., decision-support tools, medical references) that can be available at the point of care.25 These devices offer the convenience of collecting and accessing information from a unit that can be carried in a user’s pocket. In certain situations, these systems can be used more conveniently than a desktop computer for online searching, calculations, patient tracking, laboratory order entry, and results, to provide medication profiles, to set appointments, as a time-management tool, and to search drug information databases (e.g., general drug information text, medical specialty reference books, drug interaction resources). Patients and health care practitioners can find information on nearly every disease and treatment, and virtual health communities and forums provide a mutually supportive environment for patients and their families, and friends. The use of social media (e.g., Twitter®, Facebook®, LinkedIn), e-mail, Web forums, and blogs has simplified the way in which peers can exchange news and share opinions. Several professional organizations (e.g., American Society of Health-System Pharmacists [ASHP]; http://www.ashp.org) have used technology to maintain awareness of important news affecting pharmacy and the health care environment (e.g., regulatory and health policy issues), drug shortages, and awareness of their meetings. Live continuing education is offered at a clinician’s computer desktop through Webinars.
There is an increasing need by health professionals, as well as consumers, to get more information about medications sooner. Information is needed quickly when a new medication becomes commercially available because of the potential for health and cost implications, when a product is withdrawn from the market for safety reasons, or when data from a new study is released that could have an impact on how common ailments are treated. The lag time that occurs with the print format may not be acceptable for many direct patient care issues. The Internet allows medical information to be available sooner to both health care professionals and the public. The availability of electronic journals and texts has minimized the need to travel to a library. Online repositories for articles, such as BioMed Central (http://www.biomedcentral.com) and PubMed® (http://www.pubmedcentral.nih.gov), have allowed individuals to access millions of articles quickly, easily, and free of charge. The majority of printed medical textbooks with an online version require a subscription; however, there are exceptions (e.g., http://www.merck.com, where eight editions of Merck Manuals can be viewed and searched for free). Registries of ongoing clinical trials, such as ClinicalTrials.gov (http://www.ClinicalTrials.gov), provide information on the purpose and criteria for participation in an ongoing clinical trial. This has allowed pharmacists to anticipate new therapies, and perhaps help their patients receive medications not yet approved by the Food and Drug Administration (FDA) through enrollment in a clinical trial.
In addition to health professionals, patients are also accessing information from the Web, using sites that are sponsored by a variety of companies and individuals with diverse interests. In a recent survey, 85% of physician respondents had experienced a patient bringing Internet information to a visit.26 Information that is either incomplete or inaccurate may result in harmful behavior, such as discontinuing medication or increasing the doses.27 In one study,28 information on medications on Wikipedia was found to be more narrow in scope, and had more errors of omission than the comparator database on the Web (i.e., Medscape Drug Reference, which is a free, online, evidence-based, peer-reviewed database).
There is some effort toward helping consumers accurately assess the quality of information on the Internet. Health on the Net (http://www.hon.ch) is a nonprofit, nongovernment organization that uses criteria to assess the quality of a Web site. The organization will give a seal of approval to those sites that apply and meet the quality criteria. If misinformation or inaccurate information is found on the Web, organizations exist to monitor fraud (e.g., Quackwatch®; http://www.quackwatch.com). One site that may be helpful in providing patients with information on a range of medical conditions and management is healthfinder (http://www.healthfinder.gov). See Chapters 19 and 20 for more information.
Drug information centers have created their own Web sites to post information about their centers and services, to provide links to related sites considered to be of acceptable quality, to accept adverse drug reaction reports, to receive and answer medication information questions conveniently, and to provide information regarding formulary changes, institution-specific therapeutic guidelines, and drug policy initiatives.29 The advantage of having a request form for answering medication information questions or reporting adverse drug reactions on the Web is that physicians, pharmacists, or other health professionals can access computers at their practice site. This information is typically accessible only through an institution’s intranet.30 An intranet is a network that belongs to an organization and is designed to be accessible only by the organization’s members, employees, or others with authorization. The Web site looks and acts just like other Web sites, but has a firewall surrounding it; therefore the center can provide easy access to their primary patrons, without receiving extraneous questions from outside their defined clientele.31-33
There is a massive effort nationally to modernize health care by making all medical records standardized and electronic.34 This is considered to be the cornerstone for improvements in quality of care, patient safety, and efficiencies, all leading to an economic benefit.35,36
A properly configured medical record provides decision support, facilitates workflow, and enables the routine collection of data for performance feedback in an effort to help improve efficiency and quality of care, including patient safety.37-40 ❸ With computerized medical records and order entry systems, medication information specialists can take a leadership role in incorporating automated interventions that improve safety and provide education at the point of prescribing. The use of computer-based clinical decision support systems (CDSS) (see Chapter 24) that provide patient information with recommendations based on the best evidence is shown to be valuable in the patient care setting, including a reported decrease in length of hospital stay.41,42 In one study that examined the value of using a decision support program to assist physicians in using anti-infective agents, the length of hospital stay of patients who used the recommendations was compared with a group of patients who did not always use the recommendations, and compared against a group of patients who were admitted to the unit 2 years before the intervention program.41 The length of hospital stay was statistically different with an average of 10 days, 16.7 days, and 12.9 days.
Although technology affords remote-site access to medication information sources, it is critical that pharmacists have the skills to perceive, assess, and evaluate the information, and apply the information to the situation. One of the most rapidly changing technologies in health care is information technology. ❹ Medication information specialists must keep abreast of advances in information technology in an effort to integrate new and valuable systems in a timely and efficient manner. The need for this type of training is emphasized in an Institute of Medicine (IOM) report.43
FOCUS ON EVIDENCE-BASED MEDICINE AND DRUG POLICY DEVELOPMENT
The pharmacist’s ability to apply their medication information skills to drug policy decisions will be of growing importance in this changing health care environment. This can be done by identifying trends of inappropriate medication use in a group of patients and providing supporting scientific evidence to help change behavior. Continued growth in national health expenditures has raised the concern of government, insurance agencies, health care providers, and the public in identifying strategies to control spending while maintaining access to quality health care. The United States spent more than $307.5 billion on prescription drugs in 2010.2 In 2014, national health spending is projected to raise to 7.4% (approximately 2 percentage points faster than without reform), with the policy changes from the Affordable Care Act (ACA) expecting to result in 22 million fewer uninsured people. There is also an anticipated increase in Medicaid spending of 18% and private health insurance growth of approximately 8%.44 Because drug expenditures are the largest component of the pharmacy operating budget, and a significant portion of the entire health system budget, the pharmacy budget frequently attracts significant attention from leadership. In recent years, there has been a shift from a fee-for-service, inpatient focus, to a capitated, managed care, ambulatory focus.45 Managed care, a process seeking to manage the delivery of high-quality health care in order to improve cost-effectiveness, is consuming an ever-increasing portion of health care delivery. Today, providers are relying less on impressions of what may be happening in a practice setting, and more on data that are actually being collected in that same group of patients (e.g., number of patients receiving appropriate dose of drugs). Goals are set for a particular group of patients (e.g., all patients receive beta-blocker therapy after a myocardial infarction) based on evidence found in the scientific literature. This connection of applying the scientific information to the patient care setting is made through evidence-based medicine. Evidence-based medicine (see Chapter 7) is an approach to practice and teaching that integrates current clinical research evidence with pathophysiological rationale, professional expertise, and patient preferences to make decisions for a population.46 ❺ Medication literature evaluation skills are essential. Pharmacists need to have a solid understanding of medication information concepts and skills, be able to evaluate the medication use issues for a group of patients, be able to search, retrieve, and critically evaluate the scientific literature, and apply the information to the targeted group of patients.
Evidence-based medicine techniques are used in health care organizations in the development and implementation of a variety of quality assurance tools (e.g., therapeutic guidelines, clinical pathways, medication use evaluations, and disease state management) in an effort to improve patient outcomes and decrease costs across the health care system. The goal is to support the appropriate use of medications including correcting the overuse, underuse, or misuse of medicines. In the United States, the IOM designated evidence-based patient-centered health care delivery as a key feature of high-quality medical care.47 All of these situations require pharmacists to use drug information skills and to have various kinds of medication information support at the practice site or easily accessible at a remote site. The process of evidence-based medicine requires that systems be developed to measure and report processes and outcomes that can be used to drive quality improvement efforts. Data can be collected and analyzed by a medication information specialist using scientific methods to support the decision-making process in a managed care organization.48
Outcomes research is a type of investigation that uses scientific rigor to determine which interventions are best for certain types of patients and under certain circumstances. This contrasts with traditional randomized controlled studies to determine efficacy, which examines the success of treatments in controlled environments. Outcomes research, taking place in real-life settings, is called effectiveness research. The branch of outcomes research, pharmacoeconomics, provides tools to assess cost, consequences (e.g., quality of life, patient functionality, patient preferences), and efficiency (see Chapter 6).49,50 These types of publications can help guide the practitioner in developing guidelines on appropriate medication use in their practice settings. This will be discussed more fully in Chapter 7.
Sophistication of Medication Therapy
The sophisticated level of medication therapy that occurs today provides pharmacists much more opportunity to lend their expertise in assessing medication information needs of professionals, patients, or family members, and providing literature to help choose the best medication to use within a class, to convey the appropriate information to help patients correctly and safely use the more potent medications, and to address administration and delivery problems. It is increasingly difficult for health professionals to keep up with all of the developments in medication therapy, as well as keep abreast of the other information required for their practice. It is estimated that over 5400 compounds are in various stages of clinical drug development.51 Nearly 78% of the projects in the pipeline study medications that attack a disease in a way that is unique to any other existing medicine. Several of the drugs in the different stages of development could have a substantial impact on clinical practice and drug expenditures once they are commercially available. For instance, it is anticipated that at least 3400 of these medications are anticancer agents, which could have an impact on life expectancy, quality of life, and the related expenses associated with the potential need for increased ancillary care, additional physician office visits, or hospitalization.51 It is important that drugs in the pipeline be monitored by pharmacists to provide adequate time to identify the patient population that will most benefit from the new drug and to help anticipate the cost of treating these patients compared to traditional therapy.2 See Chapter 17 for more information.
There is also a trend toward individualization of health care using pharmacogenomic profiling to determine potential drug effectiveness.52 Patients may be tested for genomic patterns, and their drug therapy will be altered accordingly. There are several potential benefits of using this pharmacogenomic technique: new effective treatments for a variety of medical conditions could be identified faster and in smaller samples, computer modeling can help eliminate the medications that do not work, and, because this technique can help identify the best candidates for a particular drug, it can help patients sooner.53 Over 155 trials are studying personalized medicine, which uses an individual’s genetic profile to guide decisions on the diagnosis and treatment of disease.51 There are medications that use cell therapy, antisense RNA interference therapy, monoclonal antibodies joined to cytotoxic agents to help target tumor cells, and gene therapy. As the types and sophistication of medication therapy continue to evolve, this will provide challenges in the future for patients, family members, and practitioners who want information on viable candidates for medication therapy, to address administration and delivery issues, and assess outcomes in real-life settings. The ability to assess information needs; search, analyze, and retrieve appropriate literature; and apply the information to patients will be important.
Rise in the Self-Care Movement
Finally, consumers have a continually growing desire for information about their medications (see Chapter 20). The growth of the self-care movement, the increase in focus on health care costs, and the improved accessibility of health information are some of the factors that have influenced patients to participate more fully in health care decisions, including the selection and use of medications. Based on these needs, direct-to-consumer advertising (DTCA) campaigns have appeared in virtually all mediums including magazines, television ads, Web-based ads (e.g., through e-mail, search engine marketing, or banner style ads on specific Web sites), and radio reports (see Chapter 23). There may be some benefits to DTCA for the patient and overall health care system.54,55 The ads could serve to inform patients on the management of a particular disease or condition, or the appropriate use of a medication being marketed. These advertisements can also be viewed as empowering patients to have a more active role in their own health care, and for patients already taking a certain drug, the advertisement could serve as a reminder to take the medication, ultimately improving patient compliance.54
There are also clearly negative aspects of DTCA. There is potential for this information to result in the increased use of the advertised drugs when less expensive alternatives may be more appropriate, resulting in increases in drug spending and utilization. Patients may also lack the skills needed to evaluate comprehensive medical information, even if it has been provided.55,56 This is because the content in DTCA often exceeds the eighth-grade reading level, which is typically recommended for information distributed to the general public. Paradoxically, the inclusion of information about risks and adverse events in DTCA may also promote an unnecessary fear of side effects, which may result in nonadherence. In general, information provided with at least some prescription drugs is not adequately understood by less-informed consumers and does not effectively communicate critical safety messages or directions.56
Health information is one of the most frequently searched topics on the Internet. In 2012, a study conducted by the Pew Research Center examined the use of the Internet for health information online.57 Interestingly, 35% of U.S. adults have used the Internet to research a medical condition, and of these, half have followed up with a medical professional. Eighty-five percent of U.S. adults own a cell phone, and of those 31% say they have used their phones to look for health information online.
Because a single individual is able to serve as an author, editor, and publisher of a Web site, there is no safeguard on the quality of information available on the Internet (see Chapter 3). The end result may be a highly informed or perhaps misinformed consumer.58-60 When a patient finds information about medications that they are either considering to start taking or are currently taking, from the Internet, through the lay press, or by DTCA, a pharmacist can help consumers critically assess the medication information that they find and add to the information based on specific patient-related needs. See Chapter 23 for more information.
The need to critically assess information regarding complementary and alternative medicine (CAM) has become increasingly important, with approximately 38% of U.S. adults aged 18 years and over and approximately 12% of children use some form of CAM.61 The use of CAM (e.g., herbal or dietary supplements, meditation, chiropractic care, and acupuncture) is widespread. The 2007 National Health Interview Survey (NHIS), a nationwide government survey, found that 38% of U.S. adults reported using CAM in the previous 12 months, with the highest rates among people aged 50 to 59 (44%).62 The NHIS data also revealed that approximately 42% of adults who used CAM in the past 12 months disclosed their use of CAM to a physician (MD) or osteopathic physician (DO).63 Because many adults also use nonprescription medications, prescription drugs, or other conventional medical approaches to manage their health, communication between patients and health care providers about CAM and conventional therapies is vital to ensuring safe, integrated use of all health care approaches.
There is a trend toward integrating CAM with conventional medicine. In a survey of over 6400 U.S. hospitals, approximately 37% offered some sort of CAM options. This is increased from 26.5% in 2005.64,65 Eighty-four percent and 67% of respondents claimed that patient demand and clinical effectiveness, respectively, were the primary rationale for offering CAM services. This area presents a challenging situation for pharmacists because of the need to assess relevant outcomes from well-designed clinical trials. Consumers are increasingly interested in finding reliable information regarding these products. Pharmacists are in an excellent position to help provide such information. One drug information center describes its experience with a devoted telephone line to provide information regarding herbal supplements.66 There was an increased demand for the service over time based on a higher call volume. This is consistent with the growing use of CAM nationally. They also described the challenges and limitations of finding reliable information on herbal products. Several resources are available that have information on herbal products.67 It is just as important that the pharmacist provide information from reliable sources, as well as identify information that is lacking in regard to a particular product (see Chapter 5).
Groups like the National Council on Patient Information and Education (NCPIE) encourage patients to seek information when they have questions. The experiences with some public access medication information hotlines have indicated the public desire and need for information.68 Such hotlines, often established by pharmacists, are intended to enhance the relationships between health care professionals and patients.
The changing environment affords the pharmacist many opportunities to use the full spectrum of medication information skills. Factors such as the integration of new technologies, the focus on evidence-based medicine and drug policy development, the sophistication of medication therapy, and the rise in self-care movement require that all pharmacists have a strong foundation in medication information concepts.
EDUCATING STUDENTS ON MEDICATION INFORMATION CONCEPTS
The education of pharmacists continues to evolve in scope and depth. Many of the areas identified earlier as needed by the drug (medication) information specialist are now incorporated into pharmacy curricula and taught to all student pharmacists. In 1991, a consensus conference in New Mexico was held to define a set of objectives for didactic and experiential training in drug information for the year 2000.69 Twenty-three educators and practitioners participated in the conference. There were several key concepts that were developed including: (1) drug information should be a required component of the pharmacy curriculum and include both didactic and competency-based experiential components, (2) drug information concepts and skills should be spread throughout the curriculum, beginning the day the students enter pharmacy school, and (3) problem solving should be a major technique in drug information education, with the goal of developing self-directed learners. Developing these skills should provide the foundation for the pharmacist to be a life-long learner and problem solver. Based upon the work of this conference, as well as changes in the health care system, and the movement toward outcome-based education, colleges of pharmacy are redesigning their curricula to provide a more comprehensive and integrated approach to teaching medication information concepts and skills.70,71 The CAPE outcomes, which are guidelines used for pharmacy education, continue to include a medication information skills for all student pharmacists.19 In a recent survey, all pharmacy schools offered didactic drug information education to first professional year students as either a stand-alone course (70%) or an integrated course throughout the professional curriculum.72 Fifty-one of the 60 colleges offered an advanced pharmacy practice experience (APPE) in drug information, and 62% of these had it as an elective. However, 58% of respondents felt they had an inadequate number of drug information training sites. Communication skills are taught formally to facilitate the pharmacist’s ability to transmit information to both health professionals and patients.
In 2009, the American College of Clinical Pharmacy (ACCP) Drug Information Practice and Research Network (DI PRN) published an opinion paper that provides recommendations regarding the curriculum and instructional methods for teaching drug information in both colleges of pharmacy and advanced training to help meet the needs of the changing health care environment and the changing culture of drug information practice.73 In a follow-up survey examining which recommendations were included in U.S. pharmacy college curricula in the areas of drug information, literature evaluation, and biostatistics, less than half of the core concepts outlined in the opinion paper (i.e., 9 [47%]) were included in curricula of all responding institutions.74 This supports the need to continually reevaluate and update the curriculum that focuses on medication information concepts because of changes in the health care environment. Of note, many respondents identified the areas of evidence-based medicine, medication safety, and informatics as areas of expanded focus. Technology (e.g., Twitter in a pharmacy management course, and use of e-portfolios) is also being integrated in the education process within the colleges of pharmacy.75,76 The evolution in technology and social media has changed the way faculty teach, students learn, and faculty and students communicate in colleges of pharmacy. An academic technologist can support the college faculty and staff in the use of learning management systems, distance education programs, and classroom technology.
Upon graduation, a pharmacist can choose to enter the workforce or continue their education in a practice-based mentorship in a residency or fellowship. Postgraduate training through residencies and fellowship experiences can help prepare a pharmacist to be a skilled clinical practitioner, researcher, educator, and leader in the profession of pharmacy. Medication information and policy development are integrated throughout the three goal areas addressed in the pharmacy practice residency standards. Currently, there are 14 ASHP-accredited specialty practice (PGY-2) residencies in medication information with a total of 19 available positions (http://www.ashp.org/menu/Accreditation/ResidencyDirectory.aspx). These were designed for those who practice in health systems. Individuals who specialize in drug information can practice in a variety of different areas (e.g., scientific writing and medical communications). See Chapter 21 for more information.