In India, pharmacists have often struggled to define their role in patients and other health care professionals. Nevertheless, the changing scenario in the health care delivery through pharmacist takes great strides in becoming recognized as the medication expert in the health care team. It is rather obvious that we pharmacists cannot expect more recognition in this field without accepting more responsibility in medication management.
Over the years, the concept of 'pharmaceutical care' has been evolved as the one of the integral part of service that pharmacist can offer. To be specific, pharmaceutical care is a patient-centered, outcomes oriented pharmacy practice that requires the pharmacist to work in concert with the patient and the patient's other health care providers to promote health, to prevent disease, and to assess, monitor, initiate, and modify medication use. One of the major objective is to optimize the patient's health-related quality of life and achieve positive clinical outcomes with realistic economic expenditures. The paradigm shift in perception of pharmacist from product-based to a service-based profession through pharmaceutical care has been driven by many factors. One of the most influential factors is the recognition of the impact of medication-related morbidity and mortality.
In any disease or clinical alteration, the management by specific drugs is a pri-mary intervention by practicing clinician. However, in clinical setting, there are various problems about the medications that are been prescribed to patients and these are termed as drug related problems (DRPs). The DRPs vary from patient to patient and also vary in patient types such as outpatients, ambulatory patients and in patients (hospitalized). Most commonly encountered DRPs to be checked are;
i. Whether proper drug is indicated for the current disease indication
ii. Whether the same drug is been dispensed
iii. Whether the drug prescribed has taken in to account the pregnancy status, age of patient, other contraindications
iv. Whether drug prescribed is given in proper dose (Adjustment for kidney, liver failure, age and body size)
v. Whether convenient or optimal dosing interval is been prescribed (especially in case of novel drug delivery systems)
vi Whether informed the patient about the adverse drug reactions (ADRs) such as side effects, allergic reactions, drug induced medical problems (e.g. coloration of urine and other biological fluids etc), drug induced clinical laboratory test value change etc.
vii. Whether drug-drug, drug-disease, drug-nutrient, drug - laboratory test interactions are anticipated and informed to patient.
viii. Whether informed patient the directions for missing dose etc.
In addition to DRPs many other factors such as lack of time, space, trained personnel, provider acceptance, pharmacist concerns regarding a lack of advanced practice skills, and fear of change has resulted in improper management of patient's medication problems. Due to these constraints and a continued lack of clinical knowledge, skills, or abilities, coupled with overburden of new responsibilities constitute improper implementation of pharmaceutical care in the community setting.
In a country like India, the patient has poor knowledge about the management of medications.Tracking medications is one of the most critical components of successful care-giving in health care delivery network. In most of the instances, community pharmacist is the only person who is eligible to help patients understand the basic objectives and management of disease medication.
Today, community pharmacy sector in India is unorganized for proper management of medication therapy. The physician or community pharmacist mostly relies on verbal communication for detailing the proper use of medications.
Medication Therapy Management (MTM) is a distinct service or group of services that optimize therapeutic outcomes for individual patients. MTM or alike conceptual management strategies have been developed in western countries particularly USA, so as to provide patient specific medication care. The model MTM services are designed to improve care, enhance communication among patients and providers, improve collaboration among providers, and optimize medication use for improved patient outcomes.
The role of pharmacist to provide and participate in MTM has got a legal status. (Medicare Modernization Act of 2003 (effective January 2006), USA represents a valuable opportunity for community pharmacists to enhance patient care and address the nationally recognized need to identify and resolve medication therapy problems.)
Basic structure and organization of MTM
To achieve the goal of pharmaceutical care, professional relationship must be established and maintained accomplished by the pharmacist. Pharmacist should collect, organize, record, and maintain patient-specific medical information. Patient-specific medical information must be evaluated and a drug therapy plan should be developed with mutual consent of patient. The pharmacist should review, monitor, and modify the therapeutic plan as necessary and appropriate, in concert with the patient and healthcare team. Concept of the MTM is based on long-term relationship between the patient, community pharmacy and community pharmacist. With independent right to practice MTM, the pharmacist can initiate MTM services when complex medication therapy problems are recognized through the dispensing process.
In this model, the patient visits the pharmacist on a regular basis so as to address ongoing medication monitoring issues and need / event-based medication therapy problems. The number of visits required to productively manage a patient's therapy will largely depend on complexity of the patient's medication therapy problems. MTM is viewed on a annual medication review basis i.e. the patient is monitored yearly and all the medication related problems occurred during the year are addressed by pharmacist. This particular step of MTM is important especially for those patients who are suffering through chronic illness like diabetes, hypertension, asthma, arthritis, etc.
MTM in community pharmacy includes five core components;
*Medication therapy review
*A personal medication record
*A medication action plan
*Intervention and referral
*Documentation and follow-up
Medication therapy review is conducted between the patient or caregiver and the pharmacist, preferably in person and one to one basis. The one to one interaction enhances the pharmacist-patient relationship. This step improves the ability of pharmacist to observe clinically significant signs of patient's health problems, such as adverse reactions to medications, lethargy, alopecia, extrapyramidal symptoms, jaundice, disorientation etc. The pharmacist's observations can result in early detection of MRPs and thus can reduce emergency situations, hospitalizations, and medication misuse.
The information obtained in the review should be documented in a specially formatted personal medication record. At the end of a comprehensive medication therapy review, the patient should receive this record, which contains detailed information about his or her medications (prescription and nonprescription medications, herbal products, and other dietary supplements). The patient can voluntarily share the record form with all the health care providers to enhance continuum of the care. The patient is instructed to produce this record to health care providers in different clinical settings at all appointments to help ensure that each and every practitioner is aware of the patient's current medication regimen. Patients are also advised to take the record with them if they have to be admitted to a hospital or other institution or if they seek emergency care.
Medication action plan is a patient-centered document, which is devised, based on medication therapy review and other components of the disease. The plan is devised collaboratively by the patient, pharmacist, physician, and other health care providers as appropriate and contains information the patient can use to improve medication self-management.
During the entire tenure of MTM visits, medication therapy problems are identified and pharmacist intervenes on the patient's behalf. Interventions are intended to address specific medication problems or collaborating with physicians or other health care providers to resolve existing or potential medication-related problems. Pharmacist can discussed the various issues regarding DRPs and other issues with patient's physician. Pharmacist if required, can also refer the patient to most appropriate health care provider such as specialists or super specialists in the related field (orthopedics, neurologist etc). This encourages the patient to fully utilize available health care services to prevent future adverse events, whether clinical, humanistic, or economic.
Documentation is the most essential component of patient and pharmaceutical care. The pharmacist who is providing MTM service is responsible for the detailed documentation of the patient. Documentation is important in evaluating patient progress and also in billing purposes.
Documentation of MTM services should include the patient demographics, known allergies, diseases, or conditions, record of all medications, including prescription, nonprescription, herbal, and other dietary supplement products, assessment of medication therapy problems and plans for resolution, therapeutic monitoring performed, interventions or referrals made, education received, schedule and plan for follow-up appointment, amount of time spent with patient, feedback to providers or patients, etc.
Technology available for MTM
It is tedious task for a pharmacist to give attention and to remember each and individual visits, interventions etc. To aid the pharmacist in this process, various software-based technologies are available which precisely help patient, pharmacist and other health care providers to accomplish complete pharmaceutical care.
MTM in Indian perspective
With over five lakhs pharmacists across India, the MTM is an effective tool that can help pharmacist to get involved with individual patient and improve on patient's safety and effective clinical outcome.There is a wide scope for applicability of this type of service, which is novel in itself. There needs proper continued training and development of specialized programmes for the community pharmacist which can be the best alternative clinical manpower source, that one can utilize to improve the health care delivery in India.
To be effective there needs reorganization on government's part for taking such noble initiative. The basic infrastructure in the community pharmacy has to be changed. Continuing education programmes are essential to update improve quality of practice for practicing pharmacists. First and foremost the willingness in practicing community pharmacist has to be improved to more than just dispensing medications. The practicing pharmacist should reorient from product based to service based profession.Through this type of services, there will be upliftment to overall pharmacy practice profession in country and pharmacist would evolve as one of the most important integral part of the health care system.
authors are with pharmacy group, Birla Institute of Technology and Science, Pilani,Rajasthan)