Introduction To The Concept Of Medication Information The Evolution

Transcript

AccessPharmacy | Print: The Evolution 1 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... Print | Close Window Note: Large images and tables on this page may necessitate printing in landscape mode. Drug Information: A Guide for Pharmacists, 4e > Chapter 1. Introduction to the Concept of Medication Information > THE EVOLUTION It is useful to look at the evolution of drug information practice from the perspective of drug information centers and of practicing pharmacists. In 2004, one report describes the decline in the number of drug information centers nationally, with the number of drug information pharmacists and other personnel being the lowest in 30 years.12-14 In this survey, 13 151 institutions were identified as having an organized drug information center, which was defined as "a center that regularly accepts a broad scope of requests from health care professionals, regardless of the location or affiliation of those professionals." The mailing list was compiled from several sources (e.g., previously published directory, the Drug Topics Red Book list of DICs). A total of 81 centers returned a completed survey. These numbers appear to be low. Some existing centers are missing from this list, and there has been controversy at meetings of drug information practitioners regarding centers being excluded because of the definition used to describe drug information centers. 13 Another source of drug information center locations, the 2008 Physicians' Desk Reference, lists a total of 100 centers nationally. 15 Calculating accurate numbers is difficult. The centers are identified for these two sources through various listings that have developed over the years, but no agency or organization is responsible for maintaining a list. Well-defined criteria are not established for using the titles of drug information center/service. Some centers have specialized in a particular area of drug information, and their name may reflect that specific function (e.g., center of drug policy). In this case, their practice may be limited to only a particular site based on their source of funding. Likewise, these lists only address drug information centers listed in the United States (including Puerto Rico), and not most of those that have been created internationally. They also exclude centers/services provided by the pharmaceutical industry or those only available via the Internet. Therefore, depending on how one would define a drug information center, the numbers are certainly higher. When examining the availability of a drug information center specifically in the hospital environment, a 2007 survey 16 that examined over 500 U.S. hospitals, found that 8.1% used a formal drug information center as their source to provide objective drug information. Interestingly, this has almost doubled (4.1%) from a similar survey of hospitals conducted 5 years earlier.17 The availability of a formal drug information center was more prevalent in larger hospitals.16 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. This information supports the resurgence of the concept of a formal drug information center affiliated with hospitals. This change may be secondary to the emphasis on cost containment and quality standards through drug policy initiatives. Drug information pharmacists working in centers appear to be better trained than in the past, and a larger percentage have a doctor of pharmacy degree (71% in 2003 and 42% in 1986 and 1992). 13 The number of individuals who have completed a drug information residency, fellowship, or master of science (MS) degree program in drug information has also increased in recent years (11% in 1992 and 29% in 2003). In addition to the responsibility of answering questions, the most commonly reported services in 2003 were preparation of newsletters (80%) and participation in pharmacy and therapeutics committee activities (79%). 13 Teaching students appears to be a growing area of responsibility. Forty-one percent of respondents considered 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 2 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... education to be their primary goal. There was an increase in the percentage of drug information centers that participated in any type of residency program training (83% in 2003). This is compared to 1976, 1980, 1986, and 1992 in which the number of centers that participated in any residency program ranged from 54% to 66%. There was also a larger number of drug information centers used for experiential training as part of a doctor of pharmacy program (95% in 2003 compared to 59% in 1992). 13 One college described their need to increase resources in their drug information center because of the growing number of students requiring experiential drug information education during their experiential training. 18 In one survey of U.S. colleges of pharmacy, 58% of respondents felt they had an inadequate number of drug information training sites.19 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. The resultant benefit-to-cost 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. 20 Another study examined the drug cost avoidance and revenue associated with the provision of investigational drug services, which was not part of drug information centers in this study, but may be the responsibility of a drug information center. The annualized drug cost avoidance plus revenue was $2.6 million. 21 Studies of this nature are becoming increasingly important in an era of cost containment. Drug Information—From Centers to Practitioners The responsibilities of individual pharmacists regarding the provision of medication information have changed substantially over the years. 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. 22 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 practices in medicine. Pharmacists who provide patient-specific information with a goal of improving patient outcomes use the medical literature to support their choices. 23,24 Pharmacists involved in patient-care areas (e.g., hospitals, clinics, long-term care, home health care) now frequently answer drug information questions, participate in evaluating patients' drug therapy, and conduct medication usage evaluation activities. In one survey of more than 500 hospitals, approximately 95% have staff pharmacists routinely answer drug information questions. 16 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 diabetic patients or a group of nurses in the practice facility. In either case, the pharmacist educates those who are the 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 3 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... 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 pharmacists as providers 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. 25 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 problemsolving skills are required to fully assess the situation, develop a search strategy, evaluate the information, 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. Table 1–2. Medication Information Skills a. Assess available information and gather situational data needed to characterize question or issue b. Formulate appropriate question(s) c. Use a systematic approach to find needed information d. Evaluate information critically for validity and applicability e. Develop, organize, and summarize response for question or issue f. Communicate clearly when speaking or writing, at an appropriate level of understanding g. 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, and participate in helping patients manage chronic diseases. Opportunities for pharmacists are also available in the area of veterinary pharmacy. Both the animal owner and the veterinarian need information. 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. Factors Influencing the Evolution of the Pharmacist's Role as a Medication Information Provider In addition to the changing philosophy of practice, several other factors are influential in the evolution of the pharmacist's role as a medication information provider. These include the emphasis on medication safety, integration of new information technology, changes in the health care environment with focus on evidence-based medicine and evaluation of outcomes, the sophistication of medication therapy, and the self-care movement. ADVERSE DRUG EVENTS (ADES) The 1999 Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health Care System,26 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 4 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... generated a great deal of discussion in the medical community and legislature because of the impact of ADEs on patient health and well-being, and because of economic implications. Despite efforts to decrease the frequency of medical errors after this report, many consumers are still dissatisfied with the quality of health care in the United States. In a recent survey, 27 40% of respondents believed that the quality of health care has gotten worse in the past 5 years, while only 17% said that it has improved. Thirty-four percent of respondents said that they or a family member had experienced a medical error at some point in their life. Efforts are ongoing to lobby for additional funding for initiatives to decrease the risk of medical errors in the United States. Because of the pharmacist's role in helping to identify and prevent ADEs in patients, this could have future implications. 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. 2 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. Patient safety may be improved by quickly identifying potential problems and communicating them to health care professionals. The training and expertise of drug information specialists qualifies them to play a major role in this process. INTEGRATION OF NEW HEALTH INFORMATION TECHNOLOGIES Computer technology has changed drastically, but positively, the ability to store and access information. Even though the amount of literature is much larger today than previously, it is more manageable. The World Wide Web (WWW) allows the user to easily access the scientific literature, government publications, items in the news, and many other items, frequently without cost to the clinician or the consumer. Handheld devices (e.g., smartphones) allow practitioners to have a full range of applications (decision-support tools, medical references) that can be available at the point of care. 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 checking; to provide medication profiles and set appointments; and as a time-management tool and to search drug information databases (e.g., general drug information texts, 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, family, and friends. The use of Twitter, Facebook, e-mail, Web forums, and blogs has simplified the way in which peers can exchange news and share opinions. Several professional organizations (e.g., 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 pharmacist's computer desktop through Webinars. A pharmacist working in a community pharmacy can obtain information 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 5 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... about a foreign medication found only in a resource obtained from another country as easily as he or she can communicate with health care professionals locally. In one recent survey, an estimated 98% of pharmacists responded that they had access to the Internet at their practice site. 16 Although the Internet has been used to transfer information instantaneously to clinicians and researchers, its value as a patient-care resource and professional education tool is only starting to be tested. One of the concerns in using the Internet for transfer of patient information is confidentiality. 28-30 There is an increasing need by health professionals, as well as the consumer, 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 e-journals and e-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 site freemedicaljournals.com (http://www.freemedicaljournals.com) provides a comprehensive list of medical journals that are also 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 U.S. Food and Drug Administration (FDA) through enrollment in a clinical trial. In addition to health professionals, patients are also accessing information on 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.31 Information that is either incomplete or inaccurate may result in harmful behavior, such as discontinuing medication or increasing the doses.32 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). Drug information centers have created their own Web sites to post information about their center and services, provide links to related sites considered to be of acceptable quality, to accept adverse drug reaction reports, and as a convenient means of receiving and answering drug information questions and providing information regarding formulary changes, institution-specific therapeutic guidelines, and drug policy initiatives. 33 The advantage of having a request form for answering drug 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. 34 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, and therefore the center can provide easy access to their primary patrons without receiving extraneous questions from outside their defined clientele. 35-37 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 6 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... There is a massive effort nationally to modernize health care by making all medical records standardized and electronic. 38 This is considered to be the cornerstone for improvements in quality of care, patient safety, and efficiencies, all leading to an economic benefit. For example, the use of technology-based interventions may help reduce the risk of recurrent exposure to medications to which patients have a known allergy, especially with a real-time clinical decision-support system. 39 Overall, 41% of hospitals had one or more components of the medical record (e.g., medication administration record [MAR], clinical documentation, vital signs, CPOE, laboratory or radiology results, progress notes) in electronic form. 16 However, only 9.2% of hospitals with components of an electronic medical record (EMR) had a complete EMR system and did not use patient charts. Overall, 84.6% of hospitals provided pharmacists access to medication-relevant portions of the EMR for the purpose of managing medication therapy. The actual physician order was sent to the pharmacy by a variety of methods. Digital image capture was used by 32.7% of hospitals, followed by fax (23.7%) and electronic receipt through CPOE (5.1%). Although in another recent study of 1125 hospitals, a total of 220 (19.6%) had CPOE systems.40 This discrepancy between the two surveys is probably secondary to the types of hospitals that were assessed. 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. 41 This offers opportunities for pharmacists, and in particular medication information specialists, to take a leadership role in planning and implementing computerized intervention programs that automatically educate at the point of prescribing. The use of computer-based clinical support systems that provide patient information with recommendations based on the best evidence have proven to be valuable in the patient-care setting, including a reported decrease in length of hospital stay. 42,43 In one study that examined the value of using a decision-support program to assist physicians in using antiinfective 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 was compared against a group of patients who were admitted to the unit 2 years before the intervention program. The length of hospital stay was statistically different with an average of 10 days, 16.7 days, and 12.9 days, respectively. 40 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. It is important not only that pharmacists keep up with medication use concepts, but that they also stay abreast of developments in the area of 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 a recent IOM report. 7 FOCUS ON EVIDENCE-BASED MEDICINE AND DRUG POLICY DEVELOPMENT Pharmacists' 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 $275 billion on prescription drugs in 2006.44 Growth in prescription expenditures in 2007 was strongly influenced by several factors including the Medicare Part D benefit and increased spending on biologics. The Center for Medicare and Medicaid Services (CMS) estimates that total outpatient prescription drug costs was expected to increase by 8% in 2009. 44 Likewise, the IOM recently completed a 3-year study of the uninsured with a recommendation that universal health insurance coverage be available in the United States by 2010, 45 which at least is partially addressed by laws passed in 2010. In 2001, uninsured Americans received $35 billion in uncompensated medical care; $30 billion was 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 7 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... ultimately paid for with tax dollars. 45 Although a list of insurance benefits has not been defined, it will be created based on evidence of improved patient care. 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. 46 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 is an approach to practice and teaching that integrates current clinical research evidence with pathophysiologic rationale, professional expertise, and patient preferences to make decisions for a population. 47 This has strengthened the need for pharmacists to have a solid understanding of medication information concepts and skills. Pharmacists need to be able to evaluate the medication use issues for a group of patients; 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. 48 All of these situations require pharmacists to use medication 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 an MCO. Outcomes research can be used to identify the effectiveness of pharmaceutical products and services in achieving desired health outcomes and, especially in light of the integration of the electronic medical record, will likely prove valuable in detecting problems and benefits. 49 Likewise, the branch of outcomes research, pharmacoeconomics, provides tools to assess cost, consequences, and efficiency (see Chapter 8). 50 Evidence-based medicine should include rigorously designed observational studies that include a full range of health outcomes (e.g., quality of life, patient functionality, and patient preferences). This will be discussed more fully in Chapter 8. SOPHISTICATION OF MEDICATION THERAPY The sophisticated level of medication therapy that occurs today provides pharmacists much more opportunity to lend their expertise in assessing the 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 physicians and other 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 2000 compounds are in various stages of drug development. 51 A record 633 are new biotechnology medicines. 52 Several of the drugs in the different stages of development could have a substantial impact on clinical practice and drug expenditures once they are 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 8 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... commercially available. For instance, it is anticipated that at least 750 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. 51,52 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. 52,53 There is also a trend toward individualization of health care using pharmacogenomic profiling to determine potential drug effectiveness. 54 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 become more productive sooner. 55 THE SELF-CARE MOVEMENT Finally, consumers have a continually growing desire for information about their medications. 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, and radio reports. The potential negative impact of this information is the increased use of advertised drugs when alternatives may be more appropriate, resulting in increases in drug spending and utilization.56 E-marketing (marketing through digital media such as Web, e-mail, and wireless media) also continues to grow. More consumers are going on the Internet for health information. A 200857 Harris poll found that 81% (150 million consumers) of Internet users search for health information on the Web, compared to 1998 when the number of consumers was reported to be only 54 million. Today, 66% of all adults and 81% of those who are online use the Internet for health information. Likewise, 25% of respondents claimed that they searched for health information frequently (an average of 4.8 times per month) and believe that they were both successful in their search (89%) and found reliable information (86%). Just under half (47%) have discussed the information they obtained online with their physicians, and approximately half (49%) of those have gone back online to look for information as a result of that discussion. Because a single individual is able to serve as author, editor, and publisher of a Web site, there is no safeguard on the quality of information available on the Internet. The end result may be a highly informed or perhaps misinformed consumer. 58-60 When patients find information about medications that they are either considering to start taking or are currently taking, from either the Internet, through the lay press, or by DTCA, a pharmacist can help them critically assess the medication information that they find and add to the information based on specific patient-related needs. 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 using some form of CAM. 61 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 2005.62,63 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 data from well-designed clinical trials. Consumers are increasingly interested in finding reliable information regarding these products; pharmacists are in an excellent position to 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 9 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... help provide such information. One drug information center describes its experience with a devoted telephone line to provide information regarding herbal supplements. 64 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. It also described the challenges and limitations of finding reliable information on herbal products. Several resources are available that have information on herbal products. 65 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. Groups like the National Council on Patient Information and Education (NCPIE) encourage patients to seek information when they have questions. The experience with some medication information hotlines that have been established for public access has indicated the public desire and need for information.66 Such hotlines, often established by pharmacists, are intended to enhance the relationships between pharmacists, physicians, 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 advent of consumerism require that all pharmacists have a strong foundation in medication information concepts. Educating for the Need 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 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. 67 Twenty-three educators and practitioners participated in the conference. Several key concepts were developed including that (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 lifelong learner and problem solver. Based on 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.68,69 The CAPE outcomes, which are guidelines used for pharmacy education, continue to include medication information skills for all pharmacy students. 25 In a recent survey, all pharmacy schools offered didactic drug information education to first-professional-year students either as a stand-alone course (70%) or integrated throughout the professional curriculum. 70 Fifty-one of the 60 colleges offered an advanced pharmacy practice experience in drug information, and 62% of these had it as an elective. However, 58% of respondents felt that 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. Medication information and policy development are integrated throughout the three goal areas addressed in the pharmacy practice residency standards. Currently, there are 15 ASHP-accredited specialty practice (PGY-2) residencies in medication information with a total of 19 available positions (http://accred.ashp.org/aps/pages/directory /residencyProgramSearch.aspx). Many other advanced training opportunities exist in the pharmaceutical industry. Copyright © McGraw-Hill Global Education Holdings, LLC. All rights reserved. Privacy Notice. Any use is subject to the Terms of Use and Notice. 29/07/2013 09:53 AccessPharmacy | Print: The Evolution 10 de 10 http://www.accesspharmacy.com.ezproxy2.library.usyd.edu.au/popup.a... 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