eHealth pharmaceutical services: linking patients, pharmacists and physicians - Current strategies and lessons learned from ePharmacare/FCT project

Full text

policy paper
eHealth pharmaceutical services: linking patients,
pharmacists and physicians - Current strategies
and lessons learned from ePharmacare/FCT project
João Gregório e Luís Velez Lapão
junho 2016
eHealth: A NEW HOPE FOR HEALTH SYSTEM
SUSTAINABILITY
Innovation with information systems and technologies
(IST) has been central to the transitions observed in global
health.[1] The utilization of IST for the provision of health-
care and health services - eHealth - is a trend in health
systems and disease management, which may have a sig-
nicant impact on health outcomes in the near future.[2,3]
Governments across the world are promoting IST in their
healthcare systems with the intention of transforming servi-
ce organisation and delivery, especially in terms of resource
utilisation, clinical decision making, patient satisfaction and
service productivity and quality.[4] IST potential will allow to
redesign traditional healthcare services, as they are able to
oer the foundation for the transition between traditional
institution-centred applications to patient-centred appli-
cations.[3] The perspective of a patient-centred approach
to the development of a healthcare service is important to
assure that the service is responsive to patient’s needs,
persuading them to have a more active role in disease ma-
nagement.[5]
The increasing prevalence of chronic diseases is lea-
ding to the necessity of health system reforms, with multi-
disciplinary teams as models of these movements, assig-
ning major roles for non-physicians such as nurses and
community pharmacists.[6] Essential to these collaborative
models is the communication between health professionals
and patients. Therefore, using IST emerges as a necessity
in the modern world that might have a signicant impact in
disease management. The use of IST will become a solu-
tion to improve healthcare eciency, either by becoming a
reliable source of information or by enabling new forms of
interaction with the healthcare system.[7,8]
PHARMACEUTICAL SERVICES: FROM MEDICINE
DISPENSING TO DISEASE MANAGEMENT
Pharmacists have experienced an expansion of their role
in the last three decades, developing the scope of services
oered.[9,10] This was largely the result of the work pro-
moted by Charles Hepler and Linda Strand,[11] who ini-
tially dened the concept of “pharmaceutical care”. This
concept involves a “process through which a pharmacist
cooperates with a patient and other professionals in desig-
ning, implementing and monitoring a therapeutic plan that
will produce specic therapeutic outcomes for the patient”,
establishing the foundations for pharmacists’ interventions
in disease management.[11] Driven by the initial work of
Hepler and Strand and the consequent emergence of new
roles, the pharmacy profession developed a wide variety of
pharmaceutical services (gure 2).
PHARMACEUTICAL SERVICES IN PORTUGAL
After the initial experience of pharmaceutical care
services,[10] the expansion of pharmacists’ roles in Por-
tugal has translated into a new regulatory framework.
[29] These regulatory changes expanded the provision
of services to be oered by pharmacies, such as home
care support, rst aid, medicines administration, im-
munization (particularly for inuenza u shots), clinical
analysis and therapeutic services. However, the disse-
mination of new services and forms of practice has
been slow. The reasons for this often mirror the same
reasons found elsewhere. Among these reasons, high
workload, lack of service’s demand, lack of com-
munication between health professionals and of team
work abilities, have been frequently reported.[25,30]
Figure 1. Pharmaceutical Services Maturity Framework
HEALTHCARE SERVICES BASED ON PATIENT’S
SPECIFIC DIAGNOSIS AND USE OF MEDICINES
DISTRIBUTION AND
PRODUCT-LINKED SERVICES
Level 1: Medicine
dispensing (e.g. including
counselling, generic
substitution, and handling
medicine waste)
Level 2: Health education and
information services (e.g. education
about specific medicines to patients
and healthcare personnel, therapy
compliance support)
Level 3: Advanced Services
(e.g. screening, monitoring,
and counselling on therapy
management, Medication
Review services)
Level 4: Enhanced Services
(e.g Disease management,
Pharmaceutical care,
Anticoagulant monitoring,
Needle and Syringe exchange,
Smoking cessation services)

policy paper
eHealth pharmaceutical services linking patients, pharmacists and Physicians - current
strategies and lessons learned from ePharmacare/FCT project
2
Pharmaceutical services have been considered ex-
tremely valuable for health systems, due to a greater e-
ciency, improvement in health services quality and in pa-
tient health-related outcomes.[12,13] However, community
pharmacies kept a static service concept that has deeply
contrasted with the developing of community pharmacists’
new clinical role and of a new service-centred paradigm in
customer relations.
With the necessity of frequent connections between pa-
tients, physicians, pharmacists and other care givers that
arises from the process of collaborative disease manage-
ment, the development of pharmaceutical services focu-
sing on collaborative disease management will undoubte-
dly require the use of IST.
DEVELOPING THE RIGHT STRATEGY TO IMPLEMENT
eHEALTH PHARMACEUTICAL SERVICES
The evolution of IST is having an important impact on the
denition of new roles for the community pharmacist.
[14,15] The use of properly deployed technological solutions
in the medicine dispensing process will relief pharmacist’s
workload, leaving more free time to assume other functions
while enhancing the patient-professional interaction.[8] IST
applications will be indispensable tools in pharma-
ceutical service provision; Therefore, a professional
strategy for community pharmacy implementation of these
applications is necessary.[16]
Calabretto and Swatman,[17] studied the socio-techno-
logical implications for information technology related inter-
ventions in community pharmacy. These authors found that
community pharmacies are still in the “infancy” of using IST
for service provision. Pharmacists are accustomed to use
IST based dispensing systems for many years, but there is
a very limited use of technology-based communication to-
ols (e.g. email or Web-based tools) to assist in patient care
and disease management. The underuse of the current
systems has been described as partially resulting from a
lack of IST skills, applications inadequacy for community
pharmacists’ needs, insucient patient-oriented atti-
tude, privacy protection concerns, and time constraints.
[16,18]
There seems to exist a dearth of research on the issue of
IST utilization in community pharmacy. Overall, researchers
have mainly investigated the eects of electronic transfer of
prescriptions on the work of community pharmacists,[4,19]
or the implementation of an internet based medication re-
cord cabinet.[17] Also, it seems the technology’s potential
to disrupt health professionals and users’ roles represents
a potential threat to the successful implementation, par-
ticularly in healthcare services.[4,15] These diculties in
implementation seem to be mostly due to managerial
and behavioural factors.[4]
In the majority of countries, IST support for professional
pharmaceutical services provision is used only locally, for
record keeping, patient management and customer rela-
tions. Nevertheless, IST seems particularly indispensable
in facilitating access to information needed in patient care,
such as clinical patient data, guidelines, and evidence-
-based information. As e‐prescribing, electronic medical
records, and other technological advances are implemen-
ted and integrated, patients will have increased access to
primary healthcare providers for diagnosis, monitoring, and
triage. Sta shortages, especially in pharmacies loca-
ted in rural or suburban areas can also be mitigated
with the use of IST.[20]
ePHARMACARE PROJECT  DESIGN AND DEVELOPMENT
The ePharmacare project (FCT reference: PTDC/CCI-
-CIN/122690/2010) was designed to explore the develop-
ment of online pharmaceutical services. This project aimed
to develop a prototype of a web-based patient mana-
gement service model, establishing its acceptability, fea-
sibility, sustainability, and adaptability to future changes.[21]
Firstly, the project’s team developed a conceptual model
allowing the analysis of the dierent stakeholders’ positions
towards the use of such technological solution and the
possible outcomes (gure 2).
Figure 2. Conceptual model for the use of IST and eHealth in
the community pharmacy setting [ePharmacare Project (FCT
reference: PTDC/CCI-CIN/122690/2010)]
Enhanced health results, including:
Improved therapeutic adhesion
Improved monitoring of chronic conditions
Less utilization of health services
Improved patient satisfaction
Recording of parameters for chronic disease monitoring
Support for communication with patients and other
stakeholders (health professionals, social assistants)
Disease management, therapeutic management,
patient management
Physicians
and other
health
professionals
Patients
PROCESSES
Supported by Information
Technologies (ITs)
Community
pharmacist
teamwork
cooperation
+

This model highlights the necessity to involve the end
users in the development of IST applications. A user
centred approach may be more useful to be certain that
the system will be satisfying to the users’ needs, and that
they will be enthusiastic with its use perceiving the system
as useful,[5,22] Considering this, the research team choose
Design Science Research Methodologies (DSRM) as
the methodology to drive the design of platform to support
pharmaceutical services.[23] The goal of DSRM is to create
and study artifacts that dene ideas, practices or products
through which information systems can be analysed, de-
signed and implemented.
The ultimate purpose of technology and innovation in
healthcare is to improve quality of life. However, it is fre-
quent that the introduction of new tools is decided by po-
licymakers and experts without involving future users.[24]
Therefore, the need to use a methodology that allows the
design of an innovation with the end user’s input is evident.
3
policy paper
eHealth pharmaceutical services linking patients, pharmacists and Physicians - current
strategies and lessons learned from ePharmacare/FCT project
KEY MESSAGES
• There is a need for IST support, in developing an ex-
tended role for community pharmacists to include the
valuable interaction with patients and better unders-
tand their needs.
• Community pharmacies have the potential to provide
remote disease management services assisted by IST.
These are low cost services, which translates to high
value to the patient, pharmacists and health systems.
However, there is a need to improve pharmacy mana-
gement, with clearer roles for the dierent professionals.
• Electronic communication between GPs and commu-
nity pharmacists has shown better results than paper
based communication. Telepharmacy services were
established in rural areas and have demonstrated suc-
cess in improving the delivery of pharmaceutical care.
• Home telemonitoring of chronic diseases seems to be
a promising patient management approach that produ-
ces accurate and reliable data, empowers patients, in-
uences their attitudes and behaviours, and potentially
improves their medical conditions
• Studies show that the use of IST by healthcare pro-
fessionals may be a burden when the systems are not
developed considering the needs of professionals in
practice settings, hence the necessity of using highly
iterative methodologies such as Design Science.
• There is the potential to use a web-platform to pro-
vide education and capacitation to practicing profes-
sionals, with game-based learning or practicing cases
from daily activities.
LESSONS LEARNED: THE EXPERIENCE OF
ePHARMACARE/FCT PROJECT
ePharmacare’s eorts focused on the correct problem
denition and on studying an IST solution that will bring
benets to eHealth pharmaceutical services:
- A survey on the use of IST in Portuguese pharmacies
found that pharmacies’ IT system is mainly used for dis-
pensing medicines and administrative tasks, as expected.
Moreover, 38% of pharmacies already reported a social
network presence (e.g. Facebook®) and 15% of pharma-
cies reported using email to answer patients’ queries no
more than 5 times per month. All the survey respondents
claim that no nancial incentive for the implementation
of eHealth solutions and insucient support and gui-
dance from professional organizations are the most impor-
tant barriers to the implementation of eHealth solutions in
Community Pharmacy.
- An observational study was designed to assess the
feasibility of eHealth pharmaceutical service provision, by
studying pharmacists’ workload and current patterns of
pharmaceutical service provision.[25] Although some free
time was also found, it seems that the re-organization
of pharmacy work, with clear roles assigned to dierent
professionals, and the possibility of using IST to improve
pharmacy and patient management will be critical steps in
the way to eHealth pharmaceutical service implemen-
tation across the pharmacy market.
- A costing study was developed to assess the potential
value of new services compared to the traditional ones.[26]
In this study, validation and dispensing of the prescription,
together with managing of inventory and other records,
were found to be the highest-cost activities. These n-
dings suggest that managers could resort to automation
of some part of the processes, applying IST to lower the
time spent in some activities, leading to the re-organization
of processes and the internal functioning of the pharmacy.
- The main focus of the platform was therapeutic ma-
nagement and monitoring of several biochemical and
physiological parameters (gure 3). Patients using the pla-
tform would register these parameters (e.g. blood pressu-
re; fasting glycaemia; etc.) on a daily basis, allowing for the
close monitoring of medicines’ eects by the pharmacist.
The frequent communication between patient and
professional allowed the early identication of possible
adverse reactions and showed some signs of possible im-
pact on health outcomes that need to be further explored.

policy paper
eHealth pharmaceutical services linking patients, pharmacists and Physicians - current
strategies and lessons learned from ePharmacare/FCT project
4
Figure 3. Web-platform screenshot of a patient’s fasting blood
glucose graph
- Overall, the use of the platform by pharmacists has
shown no signs of possible impact on their workload.
Moreover, the management and social abilities that these
professionals do have may be used as complementary
tools to better interact with patients in a new web-based
service. However, whether these professionals do have the
necessary education regarding the provision of pharma-
ceutical care services, is an aspect that needs to be consi-
dered [27]. Capacitation of practising pharmacists will
be crucial for the diusion of new ways of pharmacy prac-
tice, and IST will also have an important role in providing
education.
HEALTH INFORMATION SYSTEMS INTEGRATION: A
MODEL OF DIMENSIONS TO ASSESS
With the development of the work done in ePharmacare,
the need to integrate several health information systems
from the dierent healthcare providers became evident.
Figure 4 intends to depict a possible scenario for Health
Information systems integration. With the integration,
data sharing portals such as the online platform developed
in ePharmacare will receive data validated by the prima-
ry healthcare professionals that are useful to pharmacists’
provided disease management in the community. In a reci-
procal way, data gathered by patients and caregivers in the
same portal, will be validated by community pharmacists
before entering it in the electronic health record managed
by primary care professionals. An integrated information
system that provides the stakeholders of disease mana-
gement with mechanisms that assure accountability, cre-
dibility, acceptability among other dimensions, would have
the potential to impact on several factors.[28] On the pro-
fessionals’ side, the dimensions of trust, communication,
role denition and professional recognition and certication
will surely benet of such a system. On patients and care-
givers’ side, an integrated system may improve professio-
nals’ needs assessment, while providing tailored informa-
tion through more frequent communication on a low cost
service, yielding a high value disease management.
Future research that focus on the impact of information
systems on these dimensions will greatly contribute to the
advancement of knowledge in the eld of health information
systems, eHealth, and pharmaceutical services provision.
Information Systems Integration
Electronic
Health
records
ePharmacare
online
system
Community Pharmacist
Improved Health Outcomes
GP & OTHER PRIMARY
HEALTHCARE PROFESSIONALS
Impact on
PATIENTS & CAREGIVERS
INFORMATION SYSTEMS INTEGRATION
• Trust
• Communication
• “Knowing each other”
• Professional roles/Role definition
•
Professional credentials/certification
• Accountability
• Co-responsibility
• Credibility
• Adaptability
• Needs assessment
• Tailored information
• Frequent communication
• Low cost/High value disease
management
• Acceptability
• Feasibility
• Sustainability
Impact on
Provides
Figure 4. Conceptual model for the Integration of Health Information Systems

7
policy paper
eHealth pharmaceutical services linking patients, pharmacists and Physicians - current
strategies and lessons learned from ePharmacare/FCT project
REFERÊNCIAS
1. Gardner CA, Acharya T, Yach D. Technological and social innovation: A
unifying new paradigm for global health. Health A. 2007. p. 1052–61.
2. Neuhauser L, Kreps GL. eHealth communication and behavior change:
promise and performance. Soc. Semiot. 2010;20:9–27.
3. Kuhn KA, Giuse DA, Lapão L, Wurst SHR. Expanding the scope of
health information systems: From hospitals to regional networks, to national
infrastructures, and beyond. Methods Inf. Med. 2007. p. 500–2.
4. Petrakaki D, Barber N, Waring J. The possibilities of technology in shaping
healthcare professionals: (Re/De-)Professionalisation of pharmacists in
England. Soc. Sci. Med. 2012;75:429–37.
5. Armstrong N, Powell J. Preliminary test of an Internet-based diabetes self-
management tool. J. Telemed. Telecare. 2008;14:114–6.
6. Kennie-Kaulbach N, Farrell B, Ward N, Johnston S, Gubbels A, Eguale T,
et al. Pharmacist provision of primary health care: a modied Delphi validation
of pharmacists’ competencies. BMC Fam. Pract. 2012. p. 27.
7. Santana S. Tendências na utilização da internet: Para questões de saúde e
doença em Portugal 2005-2007. Acta Med. Port. 2009;22:5–14.
8. Kreps GL, Neuhauser L. New directions in eHealth communication:
Opportunities and challenges. Patient Educ. Couns. 2010;78:329–36.
9. Anderson S. The state of the world’s pharmacy: a portrait of the pharmacy
profession. J. Interprof. Care. 2002;16:391–404.
10. Costa S, Santos C, Silveira J. Community pharmacy services in Portugal.
Ann. Pharmacother. 2006;40:2228–34.
11. Hepler CD, Strand LM. Opportunities and responsibilities in
pharmaceutical care. Am. J. Hosp. Pharm. 1990. p. 533–43.
12. Nkansah N, Mostovetsky O, Yu C, Chheng T, Beney J, Cm B, et al.
Eect of outpatient pharmacists non-dispensing roles on patient outcomes
and prescribing patterns ( Review ) Eect of outpatient pharmacists ’ non-
dispensing roles on patient outcomes and prescribing patterns. 2011;1–3.
13. Berenguer B, La Casa C, de la Matta MJ, Martín-Calero MJ. Pharmaceutical
care: past, present and future. Curr. Pharm. Des. 2004;10:3931–46.
14. Fox N, Ward K, O’Rourke A. The birth of the e-clinic. Continuity or
transformation in the UK governance of pharmaceutical consumption? Soc.
Sci. Med. 2005. p. 1474–84.
15. Katz SJ, Moyer CA. The Emerging Role of Online Communication
Between Patients and Their Providers. J Gen Intern Med. 2004;19:978–83.
16. Westerling AM, Haikala V, Airaksinen M. The role of information technology
in the development of community pharmacy services: visions and strategic
views of international experts. Res. Soc. Adm. Pharm. 2011;430–7.
17. Calabretto J, Swatman PMC. Sociotechnical implications for Information
Technology related interventions in community medication management – a
case study. 2010;5:1–12.
18. Velez Lapão L. Survey on the status of the hospital information systems
in Portugal. Methods Inf. Med. 2007. p. 493–9.
19. Astrand B, Montelius E, Petersson G, Ekedahl A. Assessment of
ePrescription quality: an observational study at three mail-order pharmacies.
BMC Med. Inform. Decis. Mak. 2009;9:8.
20. Collins B, Borders TF, Tebrink K, Xu KT. Utilization of prescription
medications and ancillary pharmacy services among rural elders in west
Texas: distance barriers and implications for telepharmacy. J. Health Hum.
Serv. Adm. 2007;30:75–97.
21. Gregorio J, Pizarro A, Cavaco A, Wipi R, Lovis C, Mira da Silva M, et
al. Online Pharmaceutical Care Provision: Full-Implementation of an eHealth
Service Using Design Science Research. Stud. Health Technol. Inform.
2015;210:261–5.
22. Demiris G, Afrin LB, Speedie S, Courtney KL, Sondhi M, Vimarlund V, et
al. Patient-centered Applications: Use of Information Technology to Promote
Disease Management and Wellness. A White Paper by the AMIA Knowledge
in Motion Working Group. J. Am. Med. Informatics Assoc. 2008;15:8–13.
23. Hevner AR von, March S, Park J, Ram S. Design science in information
systems research. MIS Q. 2004;
24. Fried LP, Piot P, Spencer HC, Parker R. The changing landscape of global
public health. Glob. Public Health. 2012;7 Suppl 1:S1–4.
25. Gregório J, Cavaco AM, Lapão LV. How to Best Manage Time Interaction
with Patients? Community Pharmacist Workload and Service Provision
Analysis. Res. Soc. Adm. Pharm. 2016;In press.
26. Gregório J, Russo G, Lapão LV. Pharmaceutical services cost analysis
using time-driven activity-based costing: A contribution to improve community
pharmacies’ management. Res. Soc. Adm. Pharm. 2016;12:475–85.
27. Gregorio J, Cavaco A, Lapao L V. A scenario-planning approach to
human resources for health: the case of community pharmacists in Portugal.
Hum. Resour. Health. 2014;12:13.
28. Bradley F, Ashcroft DM, Noyce PR. Integration and dierentiation:
A conceptual model ofgeneral practitioner and community pharmacist
collaboration. Res. Soc. Adm. Pharm. 2012;8:36–46.
29. Martins L, Queirós S. Competition among pharmacies and the typology
of services delivered: The Portuguese case. Health Policy (New. York). 2014;
30. Gastelurrutia MA, Benrimoj SIC, Castrillon CC, De Amezua MJC,
Fernandez-Llimos F, Faus MJ. Facilitators for practice change in Spanish
community pharmacy. Pharm. World Sci. 2009;31:32–9.