Saving Health – and Pharmacy if you can find it

I don’t know whether this is unique just to me or because I have a long and clear memory of pharmaceutical events since my entry to the profession in 1956.
But I get very angry when I see a national TV program supposedly involving all of “health” where none of the participants are pharmacists!
Nada! Zilch! Not one!
Where are our pharmacy leaders?
They are failing the profession of pharmacy miserably!

A recent SBS program pulled together patients, carers, nurses, health professionals, and economists, to discuss the challenges in reforming healthcare.
Pharmacy leaders should be vocally beating down the door to access this type of SBS program to spread the message of what pharmacists are capable of.
Pharmacy is the third largest health profession and I don’t think that it serves anyone, patient or health professional, to suppress the voice and the utility of pharmacists strategically located around Australia.

The program had all the usual suspects present as “talking heads”, contributing to a conversation that certainly displayed all their prejudices.
Moderated by Jenny Brockie, it included Professor John Dwyer (Professor of Medicine), Charlotte Hespe (GP), Stephen Duckett (economist at Grattan Institute), Terry Barnes (Public policy consultant and former adviser to two federal health ministers)
For most “insiders” there was nothing new to note – just more of the same old, same old.

The stars of the show were two articulate mothers who were active carers for some very sick children.
Even though other panel members were more vocal and authoritative, these mothers shone through.

They were:
* Carly Stewart whose seven-year-old son Lachlan has cerebral palsy, requiring treatment from up to eight different hospital departments. She says the biggest hurdle for her family is poor communication between doctors across these departments.

* Katherine Clay’s two-year-old James Robins has cystic fibrosis, and requires consistent medical care.
His mother prefers to use Hospital in the Home (HITH) wherever possible, because it gives James a sense of normality in his daily routine, and reduces his chances of contracting further infections.
“I can certainly tell you that I’m tech savvy so I’ve gone on and made sure my on-line E-Health Registry for our family is up-to-date but when I opened James’ E-Health record I expected that possibly it would have his x-ray scan, admissions, drugs, anything like that, the fact that he has cystic fibrosis. I thought that perhaps, you know, if there was a car accident I’ve stupidly assumed that maybe people could go onto the computer and see this person has this condition or this concern but there was nothing in there at all. So I’ve updated his, like daily medication, but I’ve recently looked again and it’s not updated at all. Not once.”

Also present was an individual adult patient (Candice Kriewalt) who was asked:
What’s your experience of the system with all the people you have to see?”
Her comments follow:

* Candice Kriewalt, a rheumatoid arthritis sufferer for 16 years.
“I find that I have to really navigate it myself. So none of my health practitioners are in the same place, they’re all over the place really and I find that I’m trying to interpret their information, remember it, keep a record of it, have a printed record, and then when I go to the next practitioner, you know, recall it to them accurately. Between the GP and the specialist there’s contact, I’m not sure how frequent, yeah, but between all the other professionals, yeah, information that I’ve, you know, they’ve printed for me which is not every appointment I get things printed, results, I’ve sort of got a haphazard record that I sort of try and piece together and take it with me.”

Very early in this interview it became completely obvious that record keeping by medical practitioners was at an appalling level and that for patients to cope they had to take the initiative to manage their own records if they were lucky enough to get a glimpse of what doctor notes had been taken.
There was a culture, by doctors, of not sharing information with patients in a consistent and chronological format.
Says Carly Stewart:
“I have very clear memories of hiding in the toilet with my son’s file because they (doctors) didn’t like you to look at it.”

The $’s multi-million that have been spent on electronic health records has resulted in a “non system”.
There may be an electronic health record infrastructure somewhere, but nobody is using it.
The first problem to rectify is to make it a mandatory “opt out” system

I’ll deviate from the SBS program for a moment:
In 2005, frustrated with hospital policies in transmission of information to health practitioners and patients, I resigned from my post as Director of Pharmacy at a public hospital and decided to develop a document exchange suitable for transmission and storage of health documents.
It took two years, but a practical program was created.
It was piloted in the hospital I was previously a part of and that was when some amazing events took place that I still shake my head in disbelief:

(I) The oversight committee for the pilot included the local Division of General Practice representatives from their IT committee.
(ii) On day one of the pilot, the Division CEO rang the Director of Nursing and stated:”Don’t use this software. Our techs have hacked it and it leaks like a sieve.”
(iii) I contacted the IT people in the Division who I knew personally. They stated that they liked my system, they had not hacked it, and they were looking forward to working with it.
They also disclosed that the Division had suddenly come up with a version of encrypted email that they were going to quietly pilot simultaneously with my software. And they believed it was “buggy” and not suited for hospital use.
(iv) The Division CEO was contacted by the Director of Nursing and given the facts of my response. He immediately apologised and the pilot went ahead.
(v) The representatives of the Division on the oversight committee then resigned.
This left a hole in the eventual report in respect of community GP opinion.
(vi) The pilot began. The original pilot was designed to cover the transmission of discharge summaries from the hospital to GP’s in the community.
This was suddenly changed without notice, to the transport of a summary document that was used in the Women’s Care Unit charting the history of a pregnant woman through to childbirth completion. We later discovered that discharge summaries were to go via the GP email system.
(vii) To add further to the confusion, the document was a hard copy version – not an expected electronic document.
(viii) Two weeks of frenzied programming and we came up with an electronic version of the paper document. Then the first transmissions occurred to specialists.
(ix) We were then told subsequently that the document had to go to six different locations with each location having its own separate format storage (ascii,pdf,html, XML etc).
(x) Seven days more frenzied programming activity and a successful pilot ensued to all six locations.
(xi) A university with a business/computer science faculty was retained (at my expense) to observe the entire pilot study and report on its processes and outcomes.
It was a very complimentary report, and it obviated the need for a report from the hospital oversight committee.
At all times local GP behaviour was appalling and legal action was considered.
(xii) During this entire process a communication was kept with the IT Department of NSW Health with the view to expanding the pilot study to a state-wide trial.
(xiii) The first question I was asked was how would I be able to register a security key to access the system for 9000 people state-wide and how long would it take.
(xiv) We had already designed a “key signing” process that could be undertaken over the Internet that took approximately two minutes to complete per person.
Staff details were conveyed to us via the hospital IT department through our system and we generated a key and sent it back via the same secure system.
(xv) A time allocation estimate per person was extended to 5 minutes which meant that working 40 hours per week (spread among three part-time people) we could do a complete job in a period just in excess of two weeks. So in round figures we gave an estimate of three weeks.
(xvi) Evidently previous government systems had fallen down from the usual vendors in this aspect. Having proved our point, negotiations began for a proposed trial.
(xvii) At this stage negotiations began to get haphazard with appointments not being kept and people asked to attend confidential meetings who belonged to competing companies and should not have been there.
(xviii) We were told that we had to subordinate our software to a major hospital vendor.
The software was standalone and did not need such an overlay. This vendor’s software collapsed regularly over a normal day’s activity and we wanted nothing to do with it.
(xviv) Later, we were told by the head of an area IT department that if my system went ahead, it would mean that he would not need up to 50% of his staff.
On that basis, he said he could not support it.

At that stage I lost my patience with the entire process.
But what was lost was a substantial private investment on my part for a system that answered the requirement for Australian health documents to be able to be transmitted privately and securely.
It still addresses the problem but languishes in electronic storage gathering dust.
It was also accessible by a patient and could grow incrementally.
The cost was significantly lower than what followed on after that nationally.

But the real blocks to good record keeping and information sharing are the doctors themselves.
When the moderator of the SBS program asked who used the current PCEHR, only two people in the studio put up their hand.
In other words, translated across the entire health profession, nobody is using the system which still has a budget of $140 million to spend.
GP’s have the gatekeeping role and they are not doing their job!
Access to this revealing online version of this SBS program can be found at this link:

It is well worth viewing the entire program to refresh your perspective on how confused the medical profession is and how it is fast becoming unsustainable.

Read the patient comments carefully and analyse them for your setting.
These people are articulate and sensible. And they will respond positively to any improvement to their current treatment, if you can find a way to communicate with them and offer a practical alternative.

Consider the frequency that most pharmacists see patients at their convenient shop locations.
What does it take for government health decision-makers to see that if patients need their health records adjusted or someone to become an advocate for them, then there are all these highly trained pharmacists with the ability and the utility to sort out this health mess, because they can and have the will to do so.
But don’t pay “peanuts” if you decide to solve your problems using pharmacists.
Provide decent reimbursement for services on offer and get out of the rut of only seeing pharmacists as drug dispensers.

The doctors in the SBS audience and on the panel displayed an attitude that they wanted to design and own a health system that suits them – not necessarily suit the patient.
When asked why the health system did not work they actually admitted that it was the culture of medicine that caused all the problems.
Well I would say to our federal government that unless you get agreement to cultural change and have some consumer input to it, the health system will never change.

Even Terry Barnes, who is not always the best health analyst (he was the adviser for the recent GP co-payments) made the comment that GP gatekeeper roles should be watered down.
After making patient records an opt-out system, the above advice was probably the only other positive for the program.
The existing health jungle is inefficient and has insufficient attention paid to patient needs.
The patients are wearing out their shoes being directed from one specialist to the other.
All specialists are only interested in the isolated “bits” that fall into their specialty and nobody is advocating for the patient and tying all the ends up in usable information.
When we talk about health costs being unsustainable and we see sectors of health being suppressed (such as pharmacy – it has become invisible) then it is time for action.
The call for patient-centred “homes” on the surface, looks like a solution, but culture will intervene.
Medical culture will prevent it from being successful and it will remain expensive.
It is necessary to have competing models led by different health professionals, if success is to occur.
Already, the worst health system in the world (the US) is starting to show signs of renewal, because they have discovered pharmacists save payers (insurance companies) in the form of lower rebates and that medication reviews are a really sound patient investment.
Hospital rebound rates (the most expensive of all patients in any system) are already down by a third due to pharmacist input.
Pharmacy-based clinics dealing in primary health are exploding because of the care provided at an economical cost.
That they are almost totally staffed by nurses is not a very smart presentation by the profession.

Pharmacy is allowed to work very well in other countries.
Australia could remove the impediments to their pharmacists, by providing funding and encouragement to the development of clinical pharmacists across a range of settings.

One of the asides by Charlotte Hespe (GP) one of the panel commentators in the SBS program, was that she and the AMA were not in favour of incorporating pharmacists into primary care.
This was the only mention of pharmacy and the comment was not explored.
But there was an exchange for Clinical Nurse Practitioners as follows:

JENNY BROCKIE: Okay, you mentioned nurse practitioners. Let’s talk about nurse practitioners, you’re one of them Chris, what exactly is a nurse practitioner?

CHRIS HELMS, NURSE PRACTITIONER:  Right, so a nurse practitioner is a Registered Nurse who has advanced clinical education and training in the assessment, diagnosis and management of chronic conditions which have traditionally been treated by medical professionals here in Australia.

JENNY BROCKIE: What sort of things?

CHRIS HELMS: Well for example for my own practice I treat anything from coughs and colds, sinus infections, et cetera, to things like diabetes, hypertension, high cholesterol, heart failure, et cetera.

JENNY BROCKIE  You sound a bit like a GP?

CHRIS HELMS: And in fact I’ve heard that before.

JENNY BROCKIE: What is the difference?

CHRIS HELMS  Yeah, the qualitative difference is first of all I tend to spend a great deal of time, a longer time with my clients than a typical GP consult for the same condition and that’s because probably 50 to 75 percent of my consultation time is spent on assessing, diagnosing and managing the actual condition that they’re presenting with. But the other 25 to maybe even 50 percent of the time you know some place between 25 and 50 percent of the time I’m actually provided education about the illness. I’m trying to talk to them about well, okay, you’ve come in with your complaint of high blood pressure and you’re still smoking and you’re very overweight so let’s talk about those conditions.

JENNY BROCKIE: And how can you afford the time to do that?

CHRIS HELMS: Well that’s actually a very interesting question because right now in Australia, nurse practitioners are struggling to actually…

JENNY BROCKIE: Who pays you?

CHRIS HELMS: Well depends. The nurse practitioners can work in the public sector or the private sector. I happen to work in the private sector and right now I recently did a report on the financial impact of hiring a nurse practitioner to work in collaboration with general practitioners in general practice and it showed that it’s, it’s extremely difficult to maintain financial viability because the reimbursement is not adequate. And so, you know…

JENNY BROCKIE  So do you claim through Medicare?

CHRIS HELMS: I claim through Medicare, yeah.

JENNY BROCKIE: So what can you, what can’t you do that a GP can do?

CHRIS HELMS: So what I can’t do is, for example, if somebody comes in and I evaluate that there’s probably a gland, a thyroid disorder for example, there’s a nodule on somebody’s neck and I perform some blood tests, those blood tests indicate that they have a problem with their thyroid, it’s under functioning but I can’t order the actual diagnostic test which is used to help supplement the diagnosis.

JENNY BROCKIE: How much training do you do by the way?

CHRIS HELMS: You have three years of your baccalaureate Registered Nursing program and then you have to have a minimum of five years Registered Nursing experience, then you need to get post graduate qualifications and then finally you can get into a Master’s degree in Nurse Practitioner program which in general lasts about two years and…

JENNY BROCKIE: So how many years all up?

CHRIS HELMS: About ten years.


CHRIS HELMS: The other problem with nurse practitioners however is that a lot of them actually work in these trans boundary models where they’re actually helping assist with the translation between the hospital and the home and keeping people in their homes. Unfortunately nurse practitioners here in Australia are only operating at about 40 percent efficiency because of national state based and local restrictions in their practice. So it’s actually quite frustrating.

JENNY BROCKIE: Okay, Saxon, what does the AMA think about nurse practitioners and them having an increasingly independent role in health care?

DR SAXON SMITH: Well we’re a strong advocate for practice nurses and have been. You may not be aware…

JENNY BROCKIE: But that’s different to nurse practitioners?

DR SAXON SMITH: I’m being very appropriate with the language because if you may remember about three months ago the government tried to cut the rebates around the ability to fund your practice nurse which provides the role that Chris is talking about, and it’s a very distinct entity.

JENNY BROCKIE: No, but ten years training is a bit of a different role I think, isn’t it, to…

CHRIS HELMS: Absolutely. I mean the kind of care that I’m providing is not as a role of a practice nurse. I’m a nurse practitioner working in primary health care and I work with practice nurses and we work as a team.

JENNY BROCKIE: I want to go back, this is really important because these sort of things become, you know, issues around what we support and what we don’t support and I just want to clarify that with you Saxon, do you or do you not support the idea of nurse practitioners writing scripts, doing the kind of things that doctors, that GPs would do?

DR SAXON SMITH: The AMA’s position is that we do not support of role of an independent nurse practitioner. We support the role that they can have in that practice nurse setting, where they can have extended role, they can provide all the education that Chris is talking about but as part of that team.

JENNY BROCKIE: But why don’t you support them having a more independent role? What’s the basis of your objection to the idea of them having more of an independent role?

DR SAXON SMITH: Well the question is why are they existing? And they’re existing because you have a model of health care which means that an interaction for a GP is limited by time because that’s how you’re funded.

CHRIS HELMS I guess I feel that, you know – it’s unfortunate that the idea of, first of all, a medical home is being perpetuated. I feel that it should be a primary health care home because it implies that people are actually working together in concert with each other. That may be a nurse practitioner, that may be a physiotherapist or a dietitian.

And you will need to access the website transcript to see extensions of this conversation.
I was interested to draw comparisons with clinical nurse practitioners and clinical service pharmacists.
Both would overlap with each other and GP’s, but that is only because gaps are appearing in GP services.
Note that Chris Helms finds it difficult to make ends meet because his primary role is as an educator to the patient. He runs out of consultation time.
Exactly the area where clinical service pharmacists want to pitch their service direction, so will have similar problems.
GP’s are not providing education, only referrals.
It is fast becoming an empty and arid service.
GP’s are not providing “homes” for clinical nurse practitioners and so there is an opportunity to provide them a truly collaborative home within community pharmacy clinics – but not at the expense of clinical service pharmacist practitioners.
Pharmacists do have the ability to provide a primary health care home that could meet community expectations economically.

Meanwhile, the PGA has done to clinical service practitioners exactly what GP’s are doing to clinical nurse practitioners – denying them a true “home”.
I’ve left in the cynical comments by Dr Saxon-Smith (AMA president NSW) where he deliberately confuses “practice nurses” as being “clinical nurse practitioners” and then admitting they have no support for the latter.
This comment has been repeated by the AMA in respect of clinical service pharmacists in recent times, the argument being that these roles fragment health.
Yet listening to the patients in this program they are pleading for an advocate and a patient record.
And an educator, if you listen to the arguments of Chris Helms.
Picking up patients on discharge for a medication review and providing an update service for patients in community pharmacy and recording it electronically, would provide a needed service that would pay for itself if funded by government.
But again, that means adequate funding.
The Consumer Health Forum might even go “to bat” on that one for pharmacists as well.

While the doctors are in a mess, the same could be said of the pharmacists.
Pharmacy leaders are not doing their job, they are arguing internally and are not looking holistically at the profession.
They are not being “seen” by the community at large and pharmacy’s case is not being stated clearly.
An “Ask” advertising campaign is neither original or sufficient.
To reinforce that statement I add another excerpt from the commentary. In particular, I point you to the comments by the medical student. Can you find the word “pharmacist” in her statement and is this an appropriate method to promote leadership of doctors when they may not have an aptitude?
The comments flow from Terry Barnes’ comment on watering down the GP gatekeeper role:

JENNY BROCKIE:   But Terry’s talking about wanting an increased role for people other than doctors. 

PROFESSOR JOHN DWYER:  That’s what we’ve been talking about all night. 

DR SAXON SMITH: A coordinated team based patient centric. 

DR CHARLOTTE HESPE:  And we’ve got to be careful that we don’t fund the system that’s becomes more dislocated and I think that’s where Saxon is sort of saying where the AMA doesn’t support say pharmacists doing primary health care and doesn’t support practice nurses because you then have this siloing, continuously. 

JENNY BROCKIE:   Okay, but my question is does the culture have to change for that to actually work? Does the culture…

DR CHARLOTTE HESPE:  Well the culture can’t change while we don’t fund it.  We’ve got no ability to do it so at the moment everybody continues to do their little silos. 

JENNY BROCKIE:   Laura, what did you want to say, Laura? 

LAURA GRANT:   As a current medical student this model is what we are being taught in university right now. My university holds on-line forums that cover cohorts of nursing students, physiotherapists, occupational therapists, speech therapists and a medical student and we can all come in there and take the typical role that we could take.  So the medical student is the leader of the conversation but it’s about teaching us to actually understand each profession and what they bring. So it’s not just thinking, it’s not simple and it’s not siloed.

Indeed, pharmacy seems to be in its invisible silo, in a system that is embedded at source, and will require a significant culture shift before patients are “heard”.
Why would you fund a medical mess like that?

Leave a Reply

Your email address will not be published. Required fields are marked *