The impact of genomics on health care resources would be influenced by a number of factors, including the effectiveness, number and costs of treatments employing genetic treatments, the speed of medical advance and the reaction of health care regulators, all of which were largely unknown at this stage.
The term “genetic testing” needed to be defined carefully and it comprised two strands – disease genetics, which involved testing for the genes causing or being associated with disease, and pharmacogenetics, which involved testing for the genes for drug metabolism and/or drug action and hence which drugs would produce a response. Benefits of genetic testing included new insights into disease and medicines, and the potential for optimal drug response. However, there were risks in terms of providing unsolicited information within a family and the associated legal, ethical and social implications.
In terms of disease genetics, the discovery of BRCA 1 and 2 (the genes associated with an increased risk of breast cancer) provided an option for surgery to minimise the risk of breast and ovarian cancer. Identification of the genes related to Alzheimer’s disease – and there were three common alleles, APO4, 3 and 2 – provided opportunities for new treatments, while a total genetic scan could give an indication of, for example, the probability of coronary heart disease or risk of dementia. Such knowledge could help individuals to prepare for the future and consider treatment options to minimise risk.
The overall cost impact of disease genetics was difficult to measure. New screening procedures, counselling services and preventive strategies would increase costs, but the avoidance or delay of disease or a decrease in disease severity would lead to reductions in medication, fewer visits to doctors and shorter hospital stays and hence could lead to lower costs. But whether health care systems could cope was unknown. Health care budgeting tended to be short term, but the benefits of disease genetics would only be realised in the longer term. The options were to restrict access, introduce co-payments, or be more flexible in moving funds across the health care system. In terms of pharmacogenetics, a link had been found between the response to treatment with pravastatin and polymorphism of the CETP gene. Patients with the CETP gene responded to the drug, whereas those without the gene did not. Clozapine was another example, and patients with certain alleles at the 5-HT2A receptor responded better to the drug than those without. Potential benefits of pharmacogenetics included reductions in adverse drug reactions and a lowering of the costs associated with drug-related morbidity and mortality. Treatment could be more effective because it was better targeted, and there could eventually be a reduction in unnecessary drug use and costs of diagnoses.
However, as was the case for disease genetics, the overall costs of pharmacogenetics were difficult to measure. While fewer adverse events, reductions in unnecessary drug use and improved outcomes could reduce costs, the advent of curative health care would increase demand and hence costs.
Issues and Concerns
Again, pharmacogenetics raised several issues. What would happen to those who had a disease for which there was no treatment? This had implications for counselling. The advent of new therapies would reduce resources in some parts of the health care budget, but increase them in others, and money would have to be moved around with more flexibility than was currently the case. How rapidly would new technology be introduced into health care? Would all countries be able to afford it? And how would the increasing requirements for information be managed? Who would develop the infrastructure? Pharmacists had to address these issues, Dr Schubert said.
Indeed, genetic technology could lead to an increasing role for pharmacy, in that doctors would diagnose and pharmacists could select treatments on the basis of pharmacogenetics. But to enable this to happen, there was a need for appropriate education and getting the information infrastructure right, he concluded
Making the Most of Systems
Pharmacists are already using IT systems to support their daily work and, when considering the IT requirements for emerging working practices, pharmacists should consider what functions could be provided by systems that they already use.
For example, all pharmacies use pharmacy management systems for medication records, dispensing, and labelling, ordering and stock control.
Pharmacists should also make the most of services that are available in their locality, for example, electronic prescription service release 2.
Adoption and use of EPS release 2 in areas where it is available has the potential to make dispensing and reimbursement processes more efficient for community pharmacists and the nomination process may help pharmacists to secure prescription business.
Access to patient record systems will assist pharmacists with professional decision-making in providing patient-centred services. For example, the summary care record is now available in many areas, and has been shown to be beneficial for hospital pharmacists for medicines reconciliation. In future, it may be used by community pharmacists.
The Power of Internet
The internet has been widely adopted for business and social communications. In future, as internet use becomes universal, there may be an increase in the number of internet pharmacies, and use of the internet to display and disseminate information on medicines and health from pharmacies.
Currently, secure web-based platforms are available from various providers to support enhanced pharmacy services and public health initiatives. The use of these will increase and also web platforms will be used as a communication portal to make information available to pharmacists from other care settings (eg, hospital discharge information).
Electronic Prescribing and Discharge
Electronic prescribing (EP) systems automate prescribing, supply and administration of medicines in hospitals, where they have been shown to reduce medication errors and have a major impact on patient safety. However, the effect on error reduction is dependent on system design and a poorly implemented system can actually increase error rates.
Recently, many hospitals have adopted electronic discharge systems (sometimes as a “quick-win” compared with a whole-hospital EP system). However, these systems may have inadequate decision support functions and data fields that are not in a standard format. Furthermore, they route the discharge information to GPs, not to community pharmacists. There are a number of local and national initiatives being developed to address these issues.
Barcode Medicine Identification
Barcode identification of medicines has been used with EP systems and has been shown to reduce medicine administration errors, as well as improve the completeness of the medication history. However, barcode medicine identification at the point of administration is an interruptive process and, for this reason, health professionals often develop “work arounds” to circumvent barcode scanning.
The Falsified Medicines Directive (FMD), due to be implemented in 2017, calls for unique identification of medicines at the point of dispensing, in order to combat counterfeiting. Although the exact UK system to support FMD has not yet been developed, this process is likely to involve barcode scanning of medicines and will therefore have a major impact on pharmacy workflow.
Robots have been used in logistics and distribution for many years, but only recently in pharmacy. Many UK hospitals installed dispensary robots. Pharmacy robots have been shown to reduce the incidence of dispensing errors, improve the speed and efficiency of the dispensing process, and optimise use of space in the pharmacy.
Robot use in community pharmacy in the UK is still relatively limited.
As newer, smaller and more efficient machines become available, robot use in all sectors of pharmacy is likely to increase. Similarly, automated methadone dispensing machines (eg, Methameasure, Methadose) offer accuracy and efficiency in the laborious methadone dispensing process and their use is likely to increase, too, especially in pharmacies with a high volume of methadone dispensing.
The use of electronic ward cabinets is the next level of automation in hospitals. These have been shown to provide benefits such as reduced number of medication errors, reduction in number of missed doses, supply delays and stock outages, and reduction of stock-holding and wastage.
However, installation of ward cabinets constitutes a considerable expense, a major implementation project and a significant change in working practice for both pharmacy and nursing staff. For these reasons, ward cabinets have not been installed in many UK hospitals to date.
The use of mobile telephones is widespread in society. Some pharmacies are using text alerts to remind patients that repeat prescriptions are ready or to offer services, but sophisticated apps have been developed for disease monitoring, for example, recording of peak flow readings in asthma, monitoring of blood glucose levels, medication adherence support and health education. These apps will have a greater impact on pharmacy practice in future.
Various technologies are now available to support approaches to adherence monitoring. A number of vendors have developed “smart” packaging, where a microchip-containing tablet blister pack is able to monitor when doses are popped out (not necessarily taken) and prompt the patient to record side-effect monitoring information for the medicine in question. These data can then be transmitted to a mobile telephone or tablet device.
A more invasive adherence monitoring technology is the “smart” pill, for example, the Life note system, piloted by Lloyd’s pharmacy. This consists of a sensor pill, ingested by the patient, which transmits data on doses taken, heart rate, and body posture to a mobile telephone or tablet device, via a receiver patch on the patient’s skin. At present, this is available only as a dummy pill, but eventually it will be incorporated into medicines.
Telecare involves the use of digital communications technology (audio and visual) to provide healthcare consultations and services to patients remotely at home. Telecare has various potential benefits. It puts patients at the centre of their care and supports personalised medicine; it improves access to healthcare by reducing the need for hospital attendance (for people with poor mobility, or those in remote areas); and it can reduce the travelling times and costs of healthcare professionals.
In pharmacy, use of remote consultations, together with EPS release 2 and an internet pharmacy supply service, could transform the way that pharmacy services are provided. However, adoption of telecare in pharmacy would be dependent on the availability of reliable communications and integration architectures, the willingness of pharmacy operators to invest in these and also a critical mass of domestic use of digital technologies in all patient demographics. A range of systems and technologies is available to support the medicines supply and use processes. However, pharmacists will need to ensure that they harness technologies in a way that will support their professional aspirations and that they are not bypassed in the IT initiatives of the new NHS.
Write : Manik Charak