The Key Word is Strategy – and it Will Stimulate Clinical Service Design

With the pressure continuing to mount to design a range of clinical services for pharmacists, i2P advises that you need to design each type of service using a basic architecture and strategy.
This will unify your approach and make it easier to communicate your concept to other health professionals and potential patients.
This approach for strategy is a general management tool that can be applied generically and on a global basis limited to your practice, your total business or for industry and professional organisations seeking to provide backing and development for pharmacist/pharmacy strategic direction.

The basic architectural component is to recognise that pharmacy consumers divide into customers and patients.
Customers are those with general retail needs (non-clinical) and generally customers are shared/competed for against all other retail businesses.
Strategies to build an expanding customer pool must always be a priority for pharmacy owners, because the next step in the strategy process is to convert customers to patients.
Increasing customer numbers provide increased potential for expanding numbers of patients.

Conversion is generally an internal process and actually involves getting a customer to enter into a formal process of registration so that, where possible, the pharmacy is able to claim a level of “ownership” of that patient, and to design private strategies to be able to communicate “knowledge transfers” that are valued by patients, to the extent that they will pay for such a service.
Some of this communication may occur through the provision of electronic newsletters, not unlike i2P.

A Classical Strategy is based on achieving sustainable competitive advantage by positioning a pharmacy optimally in an attractive market (e.g. a shopping mall or a GP super clinic).
Since the basis of competitive advantage in these environments is known and non-malleable, advantage can be based on superior scale, differentiation (or, equivalently, scale within a narrower market segment), or superior capabilities.
This has been the traditional format that has focussed on retail strength rather that clinical service strength.
Dispensing has always been regarded as a clinical service and a segment of primary health care, but external forces have shaped and intervened in the form of a commoditised PBS, with the result it has become more retail-like.
As such, numbers of prescriptions and production line efficiencies have been built in to assist in competing with other pharmacies, but that process, in turn, has become less patient-friendly and the entire business model has become more attractive to the Colesworths.

An Adaptive Strategy is the format recommended by i2P.
Unlike the classical approach of sustainable competitive advantage, an adaptive approach to strategy rests on the idea of serial temporary advantage.
In unpredictable and non-malleable environments, the emphasis is on continuous experimentation and real-time adjustment, rather than on long-term analysis and planning.
Since advantage is temporary, the focus is on means, not ends.

The very thought of an expansion of traditional pharmacy services seems to have the Australian Medical Association (AMA) on a continual “war” footing.
At a recent National Press Club address, Professor Brian Owler (AMA president) said:

“the problems that we have with the latest CPA is really in relation to the roles of pharmacists and what they might be paid to do in the future”.

“I think we need to get back to recognising and respecting everyone’s roles within the health system, what their training, what their education actually is and what it actually prepares them to do”.

“The Pharmacy Guild are a strong lobby and good luck to them, they’ve negotiated strongly with the Government”.

“The only problem that we have in terms of the pharmacists is when we start talking about them taking a much more active role in doing some of the roles where it is really the GP’s role”.

I wish pharmacy could use that last argument in relation to competition with Woolworths and other major retailers.
Here, the AMA are definitely trying to shape whatever a future clinical service looks like, so let us adapt and respect the AMA fears.
Despite the fact that Professor Owler has been anything but respectful when he has mounted imagined and untrue public criticisms of pharmacy.
Perhaps he is softening his approach as he begins to realise that pharmacists would prefer to collaborate, but they are no longer prepared to put up with arrogance and posturing – an experience that I have been exposed to most of my professional life.
However, GP’s are likely to succeed in shaping pharmacy in a general sense, because it will suit both sides professionally and financially.

If pharmacists become strategically smart, the AMA are not likely to be aware of an upgrade of existing pharmacy activity if the service ends up increasing their patient number, while simultaneously reducing their investigative and diagnostic load.
And, of course, the above is collaboration under a different name.

The AMA current strategy for pharmacist collaboration is the practice pharmacist.
This may suit some pharmacists and it is simply another version of collaboration.
If it benefits both sides and focus becomes genuinely centred on the patient, then it becomes a valid form of collaboration.
If the capture of a pharmacist is really for demeaning purposes, then the relationship becomes invalid and not sustainable. Only time will tell.

An adaptive strategy approach works when the business environment is hard to predict and to shape, and when advantage may be short-lived.
Ongoing, substantial changes in technologies, customer needs, competitive offerings, or industry structure may all signal the need for an adaptive approach.
Business environments increasingly require this mind-set: today, roughly two-thirds of all industry sectors experience high volatility in demand, competitive rankings, and earnings, making long-term plans obsolete more quickly.

Strategizing in the adaptive context requires a process of watching and responding to changes in the environment by capturing change signals and managing a portfolio of experiments.
Adaptive pharmacies continuously vary the way they do business by trying many novel approaches and then scaling up and exploiting the most promising before repeating the cycle.
Successful adaptive firms outperform rivals by iterating more rapidly and effectively than their competitors.

So how would I start do I hear you say?

Well my advantage for the moment is that I have a number of unregistered patients and begin the process of formally registering them in the context of a patient profile embedded in a customer relations management software program.
To further market the service I would ensure that a reasonable budget be set aside for patient marketing and communication and software commissioned, unless good utility software already exists.

But first I would pick a single condition to commence my clinical service program and that would be the entry point of hypertension (and because I already conduct blood pressure checks).
I would not permanently provide a discounted or free service checking blood pressure, but I would allow “free windows” within that service to allow for some form of intervention platform.
The first “window” may be to establish a pattern for blood pressure and determine a rating value.
Patients that have a too high a blood pressure can then be referred back to their GP formally, in writing, and accompanied with their reading history.
Prior to that point, the patient will have been encouraged to purchase a BP monitor to home monitor and remove the problem of “white-coat” and “masked” hypertension.

The patient will also have been mentored in appropriate self-monitoring, with reference to the current guidelines (published by the High Blood Pressure Research Council of Australia), which are:

*  Measurements should be taken for seven days with a validated device.

*  Take measurements when seated, at around the same time in the morning and evening.

*  Don’t measure BP directly after vigorous exercise, smoking or caffeine ingestion.

*  Two BP readings should be taken each time, one minute apart while sitting quietly.

*  Hypertension is defined as an average home BP of at least 135/85mmHg.

The initial referral may also be accompanied with an electronic copy of the patient’s pharmacy profile as a definite means of collaboration (after discussion with all local GP’s as to their preference for an electronic format).

To this point I have only utilised elements of already existing systems to bring a new service to life.

The next step is an investment phase, and that could be in the order of around $15,000 for a retinal imaging camera.
If I was a contractor I would be willing to invest in this type of opportunity in my own right, but I would be willing to share the income in collaboration with a pharmacy who would give me access to their patient base.
That would minimise the cost of training to the pharmacy as well as the hardware and system on costs.
It would also allow me to provide service to more than one pharmacy ensuring that capacity for the service would be near full, creating economy all round.

Hypertension is an indicator for other illnesses and these illnesses (including early onset hypertension) can be detected through a simple digital retinal imaging program.
Two common brands of these types of cameras are Canon and DRS.
Retinal imaging is a fairly simple process but extra pharmacist training would be needed to interpret the images.

In addition to helping detect diseases early, retinal images provide a permanent and historical record of changes in a patient’s eye.
Images can be compared side-by-side, year after year, to discover even subtle changes and help monitor a patient’s health.

Retinal images also make it easier for a pharmacist to educate patients about their individual illness and wellness.
Both patient and pharmacist can review images together, and referrals or treatment options can be generated for any conditions revealed by the images.
The images can form part of any referral, and provide early data that may not be necessarily available to a local GP.
At this point pharmacist collaboration has been established in a meaningful way in that the GP has received a patient consultation through a pharmacist referral and the pharmacist has also provided imagery to help determine an early and more complete diagnosis.
A quality referral indeed!
The pharmacist has also generated a useful patient history that can also be shared with a GP or specialist.
Early adopters of this type of system would gain market advantage because competitor pharmacists will take longer to copy, adapt and network a similar service.

The following are some of the common diseases retinal imaging can help with and create early intervention through initial pharmacist intervention, treatment or referral.

The following conditions can be detected at an early stage

Age-related Macular Degeneration
Macular degeneration is usually signified by leaking of fluid or bleeding in the back of the eye. This causes central vision loss.
Pharmacist can initiate clinical nutrition treatment as well as GP referrals.
A dark spot at the back of the eye may signal a melanoma, which can grow unnoticed within the retina. If caught early, melanomas can be treated before they cause serious damage and travel to other areas of the body through the bloodstream.
Pharmacist could create an early referral.
Diabetic Retinopathy 
Diabetes can cause changes in the blood vessels of the retina, like swelling and leakage, or the creation of new blood vessels.
Blindness can result without early detection.
Here patient mentoring can begin plus patient referral.
Pharmacists can also begin the initiation of lifestyle changes with the patient.
Pressure against the optic nerve and compression of the eye’s blood vessels may indicate glaucoma.
This disease causes permanent and irreversible vision loss.
Pharmacist could initiate early referral.
Signs of high blood pressure often appear first in the eye. Indicators can include narrowing of the blood vessels, spots on the retina, or bleeding in the back of the eye.
Pharmacist could initiate a referral and patient mentoring for lifestyle changes.
Retinal Detachment 
Retinas can lift or pull away from the wall of the eye.
If not properly treated, this can cause permanent vision loss.
Pharmacist could initiate early detection and referral.

With the addition of a retinal image system building on a simple hypertension program, a range of opportunities have now occurred that can be individually leveraged.
Each opportunity can extend the range of a pharmacist clinical service and with appropriate design can generate a range of evidence based referrals that will impact positively with a GP’s own patient profile.
Electronic portable referral systems can extend the concept of collaboration without intruding in each other’s clinical space.
The pharmacy services offered take advantage of the traffic flow already existing within the pharmacy, and convert as much of that traffic as p;ossible, to become registered patients.
This is not intruding on GP turf, nor does it inhibit other pharmacists to compete, because collaborative systems are only inhibited through a lack of imagination and the ability to design an infrastructure around the envisaged concept.

So I think that the above system ticks all the boxes, even though I have not tried to implement the system in a client pharmacy as yet, nor have any evidence to substantiate its success.
In no way is it intended to replace the test performed by a skilled eye specialist, simply a screening test to detect a potential range of illnesses.

But I don’t think that it requires a lot of imagination to instinctively know that the above system would work.

Those of you who set out on the above journey, would you please share your successes with me?

Leave a Reply

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