潇湘渌水 @ 2010-09-12 19:24
Separation of prescribing from dispensing
Unlike the prevailing practice in other, particularly Western countries, the duties of the pharmacist and physician are not entirely separated. Chinese doctors are allowed to dispense drugs themselves and the practice of pharmacy is sometimes integrated with that of the physician, particularly in traditional Chinese medicine. The idea of separating the two professions has been debated as the trend for specialization has increased in the health sciences. Other countries such as South Korea, Japan and Taiwan have successfully separated the jurisidications to legally separate the practice of prescribing from the practice of dispensing. That legislation has also specified that only pharmacists may supply scheduled pharmaceuticals to the public, and that pharmacists cannot form business partnerships with physicians or give them "kickback" payments. Possible reform for this area is being considered by the Chinese regulatory authorities.
Pharmacist role
Since the economic reform period of the 1980s, the development of the Chinese pharmaceutical industry has led to the introduction of new and effective drug substances. It also changed the role of the pharmacist. The scope for extemporaneous compounding of medicines was much diminished and with it the need for the manipulative skills that were previously applied by the pharmacist to the preparation of bougies, cachets, pills, plasters, and liquids. Pharmacists continue, however, to fulfill the prescriber's intentions by providing advice and information; by formulating, storing, and providing correct dosage forms; and by assuring the efficacy and quality of the dispensed or supplied medicinal product.
In the future, pharmacists are expected to become more integral within the health care system. Rather than only dispensing medication and other routine duties, pharmacists are to be involved more in patient care with their particular knowledge and skills. ------Source: Sep, 2010. Wikipedia.-Pharmacy in China
-------------------
Separation of prescribing from dispensing
In most jurisdictions (such as the United States), pharmacists are regulated separately from physicians. These jurisdictions also usually specify that only pharmacists may supply scheduled pharmaceuticals to the public, and that pharmacists cannot form business partnerships with physicians or give them "kickback" payments. However, the American Medical Association (AMA) Code of Ethics provides that physicians may dispense drugs within their office practices as long as there is no patient exploitation and patients have the right to a written prescription that can be filled elsewhere. 7 to 10 percent of American physicians practices reportedly dispense drugs on their own.[16]
In some rural areas in the United Kingdom, there are dispensing doctors [17] who are allowed to both prescribe and dispense prescription-only medicines to their patients from within their practices. The law requires that the GP practice be located in a designated rural area and that there is also a specified, minimum distance (currently 1.6 kilometres) between a patient's home and the nearest retail pharmacy.
上两段可以看出，处方和配方权的分割是可分可合，视具体情况而定的。一般是分割、制衡，但在乡下或医生没有病人可看的情况下又可合二为一。同时即使美国也有7成医生会自己配药，但是前提是他们的医药分离形成了习惯和路径，这个路径会使医生不至于像中国的医生那样走TCM的路径形成不负责任、开大处方、滥用药的习惯。
In other jurisdictions (particularly in Asian countries such as China, Malaysia, and Singapore), doctors are allowed to dispense drugs themselves and the practice of pharmacy is sometimes integrated with that of the physician, particularly in traditional Chinese medicine.
In Canada it is common for a medical clinic and a pharmacy to be located together and for the ownership in both enterprises to be common, but licensed separately.
The reason for the majority rule is the high risk of a conflict of interest and/or the avoidance of absolute powers. Otherwise, the physician has a financial self-interest in "diagnosing" as many conditions as possible, and in exaggerating their seriousness, because he or she can then sell more medications to the patient. Such self-interest directly conflicts with the patient's interest in obtaining cost-effective medication and avoiding the unnecessary use of medication that may have side-effects. This system reflects much similarity to the checks and balances system of the U.S. and many other governments.
A campaign for separation has begun in many countries and has already been successful (like in Korea). As many of the remaining nations move towards separation, resistance and lobbying from dispensing doctors who have pecuniary interests may prove a major stumbling block (e.g. in Malaysia).--这个马来非常有意思，我还有一个他们的医生协会反击SPD做的一个PPT，非常生动，说自古以来医药就是这样，而且这样有很多好处--其他他们说的挺有道理，因为西方现在的一个趋势就是在SPD的基础上开展的，即联合用药管理CDTM，但是注意：是在SPD的基础上，没有过专业化的东方是一回事，在专业化和分工以后再开展联合又是另一回事，路径和习惯、制度制约的context是完全不一样的，专业化知识和水平也是完全不一样的。
The future of pharmacy
In the coming decades, pharmacists are expected to become more integral within the health care system. Rather than simply dispensing medication, pharmacists will be paid for their patient care skills.[18]
Medication Therapy Management (MTM)- A practice of pharmacy currently being taught at schools of pharmacy nationwide includes the clinical services that pharmacists can provide for their patients. Such services include the thorough analysis of all medication (prescription, non-prescription, and herbals) currently being taken by an individual. The result is a reconciliation of medication and patient education resulting in increased patient health outcomes and decreased costs to the health care system.[19]
This shift has already commenced in some countries; for instance, pharmacists in Australia receive remuneration from the Australian Government for conducting comprehensive Home Medicines Reviews. In Canada, pharmacists in certain provinces have limited prescribing rights (as in Alberta and British Columbia) or are remunerated by their provincial government for expanded services such as medications reviews (Medschecks in Ontario). In the United Kingdom, pharmacists who undertake additional training are obtaining prescribing rights. They are also being paid for by the government for medicine use reviews. In the United States, pharmaceutical care or clinical pharmacy has had an evolving influence on the practice of pharmacy.[12] Moreover, the Doctor of Pharmacy (Pharm. D.) degree is now required before entering practice and some pharmacists now complete one or two years of residency or fellowship training following graduation. In addition, consultant pharmacists, who traditionally operated primarily in nursing homes are now expanding into direct consultation with patients, under the banner of "senior care pharmacy."[20] ------Source: Sep, 2010. Wikipedia.-Pharmacy
------------------------
在北美那边的药物使用已经发展到又考虑联合的程度了
Unlike the prevailing practice in other, particularly Western countries, the duties of the pharmacist and physician are not entirely separated. Chinese doctors are allowed to dispense drugs themselves and the practice of pharmacy is sometimes integrated with that of the physician, particularly in traditional Chinese medicine. The idea of separating the two professions has been debated as the trend for specialization has increased in the health sciences. Other countries such as South Korea, Japan and Taiwan have successfully separated the jurisidications to legally separate the practice of prescribing from the practice of dispensing. That legislation has also specified that only pharmacists may supply scheduled pharmaceuticals to the public, and that pharmacists cannot form business partnerships with physicians or give them "kickback" payments. Possible reform for this area is being considered by the Chinese regulatory authorities.
Pharmacist role
Since the economic reform period of the 1980s, the development of the Chinese pharmaceutical industry has led to the introduction of new and effective drug substances. It also changed the role of the pharmacist. The scope for extemporaneous compounding of medicines was much diminished and with it the need for the manipulative skills that were previously applied by the pharmacist to the preparation of bougies, cachets, pills, plasters, and liquids. Pharmacists continue, however, to fulfill the prescriber's intentions by providing advice and information; by formulating, storing, and providing correct dosage forms; and by assuring the efficacy and quality of the dispensed or supplied medicinal product.
In the future, pharmacists are expected to become more integral within the health care system. Rather than only dispensing medication and other routine duties, pharmacists are to be involved more in patient care with their particular knowledge and skills. ------Source: Sep, 2010. Wikipedia.-Pharmacy in China
-------------------
Separation of prescribing from dispensing
In most jurisdictions (such as the United States), pharmacists are regulated separately from physicians. These jurisdictions also usually specify that only pharmacists may supply scheduled pharmaceuticals to the public, and that pharmacists cannot form business partnerships with physicians or give them "kickback" payments. However, the American Medical Association (AMA) Code of Ethics provides that physicians may dispense drugs within their office practices as long as there is no patient exploitation and patients have the right to a written prescription that can be filled elsewhere. 7 to 10 percent of American physicians practices reportedly dispense drugs on their own.[16]
In some rural areas in the United Kingdom, there are dispensing doctors [17] who are allowed to both prescribe and dispense prescription-only medicines to their patients from within their practices. The law requires that the GP practice be located in a designated rural area and that there is also a specified, minimum distance (currently 1.6 kilometres) between a patient's home and the nearest retail pharmacy.
上两段可以看出，处方和配方权的分割是可分可合，视具体情况而定的。一般是分割、制衡，但在乡下或医生没有病人可看的情况下又可合二为一。同时即使美国也有7成医生会自己配药，但是前提是他们的医药分离形成了习惯和路径，这个路径会使医生不至于像中国的医生那样走TCM的路径形成不负责任、开大处方、滥用药的习惯。
In other jurisdictions (particularly in Asian countries such as China, Malaysia, and Singapore), doctors are allowed to dispense drugs themselves and the practice of pharmacy is sometimes integrated with that of the physician, particularly in traditional Chinese medicine.
In Canada it is common for a medical clinic and a pharmacy to be located together and for the ownership in both enterprises to be common, but licensed separately.
The reason for the majority rule is the high risk of a conflict of interest and/or the avoidance of absolute powers. Otherwise, the physician has a financial self-interest in "diagnosing" as many conditions as possible, and in exaggerating their seriousness, because he or she can then sell more medications to the patient. Such self-interest directly conflicts with the patient's interest in obtaining cost-effective medication and avoiding the unnecessary use of medication that may have side-effects. This system reflects much similarity to the checks and balances system of the U.S. and many other governments.
A campaign for separation has begun in many countries and has already been successful (like in Korea). As many of the remaining nations move towards separation, resistance and lobbying from dispensing doctors who have pecuniary interests may prove a major stumbling block (e.g. in Malaysia).--这个马来非常有意思，我还有一个他们的医生协会反击SPD做的一个PPT，非常生动，说自古以来医药就是这样，而且这样有很多好处--其他他们说的挺有道理，因为西方现在的一个趋势就是在SPD的基础上开展的，即联合用药管理CDTM，但是注意：是在SPD的基础上，没有过专业化的东方是一回事，在专业化和分工以后再开展联合又是另一回事，路径和习惯、制度制约的context是完全不一样的，专业化知识和水平也是完全不一样的。
The future of pharmacy
In the coming decades, pharmacists are expected to become more integral within the health care system. Rather than simply dispensing medication, pharmacists will be paid for their patient care skills.[18]
Medication Therapy Management (MTM)- A practice of pharmacy currently being taught at schools of pharmacy nationwide includes the clinical services that pharmacists can provide for their patients. Such services include the thorough analysis of all medication (prescription, non-prescription, and herbals) currently being taken by an individual. The result is a reconciliation of medication and patient education resulting in increased patient health outcomes and decreased costs to the health care system.[19]
This shift has already commenced in some countries; for instance, pharmacists in Australia receive remuneration from the Australian Government for conducting comprehensive Home Medicines Reviews. In Canada, pharmacists in certain provinces have limited prescribing rights (as in Alberta and British Columbia) or are remunerated by their provincial government for expanded services such as medications reviews (Medschecks in Ontario). In the United Kingdom, pharmacists who undertake additional training are obtaining prescribing rights. They are also being paid for by the government for medicine use reviews. In the United States, pharmaceutical care or clinical pharmacy has had an evolving influence on the practice of pharmacy.[12] Moreover, the Doctor of Pharmacy (Pharm. D.) degree is now required before entering practice and some pharmacists now complete one or two years of residency or fellowship training following graduation. In addition, consultant pharmacists, who traditionally operated primarily in nursing homes are now expanding into direct consultation with patients, under the banner of "senior care pharmacy."[20] ------Source: Sep, 2010. Wikipedia.-Pharmacy
------------------------
在北美那边的药物使用已经发展到又考虑联合的程度了
MTM Services: Opportunities for Collaborative Practice Relationships
Dana Singla, PharmD
Published Online: February 1, 2005 - 12:00:00
After years of debate and compromise, President
George W. Bush signed the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 into law in December 2003.1 (A
complete discussion of Medicare reform is beyond the scope of this
article.) In addition, however, to providing a prescription drug
benefit, this legislation requires plans offering Medicare Part D to
develop medication therapy management services and to compensate
pharmacists for providing those services. Patients eligible to receive
those services include patients taking multiple medications or suffering
from selected chronic disease states (diabetes, asthma, hypertension,
hyperlipidemia, congestive heart failure). Congress has finally
recognized the valuable contributions pharmacists can make to patient
care.
George W. Bush signed the Medicare Prescription Drug, Improvement and
Modernization Act of 2003 into law in December 2003.1 (A
complete discussion of Medicare reform is beyond the scope of this
article.) In addition, however, to providing a prescription drug
benefit, this legislation requires plans offering Medicare Part D to
develop medication therapy management services and to compensate
pharmacists for providing those services. Patients eligible to receive
those services include patients taking multiple medications or suffering
from selected chronic disease states (diabetes, asthma, hypertension,
hyperlipidemia, congestive heart failure). Congress has finally
recognized the valuable contributions pharmacists can make to patient
care.
The medication therapy management program introduced
in Medicare Part D is not a new concept. It is typically referred to as collaborative
drug therapy management (CDTM). The American College of
Clinical Pharmacy defines CDTM by pharmacists as follows: a
collaborative practice agreement between physicians and qualified
pharmacists whereby pharmacists work within the context of a defined
protocol, permitting them to assume professional responsibility for
performing patient assessments; ordering drug therapy-related laboratory
tests; administering drugs; and selecting, initiating, monitoring,
continuing, and adjusting drug regimens.2 In this role,
pharmacists are acting as physician enhancers, applying their specific
drug therapy knowledge to accompany that of the collaborating
professionals.
in Medicare Part D is not a new concept. It is typically referred to as collaborative
drug therapy management (CDTM). The American College of
Clinical Pharmacy defines CDTM by pharmacists as follows: a
collaborative practice agreement between physicians and qualified
pharmacists whereby pharmacists work within the context of a defined
protocol, permitting them to assume professional responsibility for
performing patient assessments; ordering drug therapy-related laboratory
tests; administering drugs; and selecting, initiating, monitoring,
continuing, and adjusting drug regimens.2 In this role,
pharmacists are acting as physician enhancers, applying their specific
drug therapy knowledge to accompany that of the collaborating
professionals.
History of CDTM
Less than 100 years ago, pharmacists were able to
prescribe drugs legally. The passage of the Federal Food, Drug and
Cosmetic Act of 1938 and the Durham-Humphrey Amendment of 1951 resulted
in the legal separation of prescribing and dispensing. Over the years,
the 2 activities have been merging together again in the form of CDTM.
In the 1960s, pharmacists in the Indian Health Service began assuming an
active role in drug therapy management. In 1973, the Pharmacist
Practitioner Program was developed, and it remains in existence today.3In 1974, the Department of Health, Education and Welfare enacted a
drug regimen review regulation for nursing homes. In 1995, the Veterans
Health Administration began allowing pharmacists with advanced training
to participate in CDTM. These programs?as well as the success of early
CDTM programs in California, Washington, and Florida?have all
contributed to the expansion of CDTM.
prescribe drugs legally. The passage of the Federal Food, Drug and
Cosmetic Act of 1938 and the Durham-Humphrey Amendment of 1951 resulted
in the legal separation of prescribing and dispensing. Over the years,
the 2 activities have been merging together again in the form of CDTM.
In the 1960s, pharmacists in the Indian Health Service began assuming an
active role in drug therapy management. In 1973, the Pharmacist
Practitioner Program was developed, and it remains in existence today.3In 1974, the Department of Health, Education and Welfare enacted a
drug regimen review regulation for nursing homes. In 1995, the Veterans
Health Administration began allowing pharmacists with advanced training
to participate in CDTM. These programs?as well as the success of early
CDTM programs in California, Washington, and Florida?have all
contributed to the expansion of CDTM.
Federal legislation defers authority for determining
pharmacist scope of practice to the individual state pharmacy practice
acts. Therefore, collaborative agreements vary significantly, based on
state legislation, practice environment, and pharmacist training and
education requirements. At the end of 2002, 39 states allowed various
types of CDTM within their pharmacist scope of practice.
pharmacist scope of practice to the individual state pharmacy practice
acts. Therefore, collaborative agreements vary significantly, based on
state legislation, practice environment, and pharmacist training and
education requirements. At the end of 2002, 39 states allowed various
types of CDTM within their pharmacist scope of practice.
Obstacles and Requirements for Establishing
CDTM
CDTM
Many pharmacists, even those in states that have
legislative approval, do not currently engage in CDTM because of various
obstacles. These obstacles include the following:
legislative approval, do not currently engage in CDTM because of various
obstacles. These obstacles include the following:
- Difficulty obtaining physician acceptance
- Lack of support from administration
- Slow process for getting credentialing status
- Inadequate knowledge of billing and clinical skills
- Indifferent attitude of pharmacy practitioners
- Lack of cohesive vision for practice models
- Insufficient space to perform services
- Outcomes failing to meet expectations4
The American College of Clinical Pharmacy has
identified some key elements for pharmacists to successfully participate
in CDTM (Table). These elements are discussed below.2
identified some key elements for pharmacists to successfully participate
in CDTM (Table). These elements are discussed below.2
Collaborative Relationship
One of the most important elements for a successful
CDTM service is a collaborative relationship with physicians. Physicians
are responsible for referring patients to the service, assisting with
protocol development and review, drafting the CDTM agreement, and
providing patient data, if not readily available, as well as promoting
the service to other physicians.
CDTM service is a collaborative relationship with physicians. Physicians
are responsible for referring patients to the service, assisting with
protocol development and review, drafting the CDTM agreement, and
providing patient data, if not readily available, as well as promoting
the service to other physicians.
Physicians may not be aware of the role pharmacists
can play in drug therapy management. Educating physicians about the
pharmacist's role, in addition to acting as a resource and being willing
to assist when called on, can help change this view of what is expected
from a pharmacist. Several national pharmacy organizations such as the
American Society of Health-System Pharmacists and the American
Pharmacists Association (APhA), along with national primary care
physician groups, support cognitive services being provided by
pharmacists.
can play in drug therapy management. Educating physicians about the
pharmacist's role, in addition to acting as a resource and being willing
to assist when called on, can help change this view of what is expected
from a pharmacist. Several national pharmacy organizations such as the
American Society of Health-System Pharmacists and the American
Pharmacists Association (APhA), along with national primary care
physician groups, support cognitive services being provided by
pharmacists.
Access to Medical Records
Access to patient medical records is probably one of
the most challenging steps for pharmacists located in the community
pharmacy setting. With good knowledge of basic physical assessment
skills and with the availability of many point-of care devices, however,
much of the physical assessment and laboratory data can be gathered
within the pharmacy. Maintaining a good working relationship with the
referring provider and office staff will be helpful in obtaining missing
patient information.
the most challenging steps for pharmacists located in the community
pharmacy setting. With good knowledge of basic physical assessment
skills and with the availability of many point-of care devices, however,
much of the physical assessment and laboratory data can be gathered
within the pharmacy. Maintaining a good working relationship with the
referring provider and office staff will be helpful in obtaining missing
patient information.
Educational Requirements
A pharmacist's educational requirements and training
to participate in CDTM may vary with state legislation requirements or
with the requirements of the collaborating practitioners. Some may
require a Doctor of Pharmacy degree, residency training, or, at a
minimum, credentialing in the disease state being managed. National and
state pharmacy associations may offer these specialized credentialing
programs. For example, the APhA has established an Advanced Practice
Institute to train pharmacists to participate in collaborative
practices.5
to participate in CDTM may vary with state legislation requirements or
with the requirements of the collaborating practitioners. Some may
require a Doctor of Pharmacy degree, residency training, or, at a
minimum, credentialing in the disease state being managed. National and
state pharmacy associations may offer these specialized credentialing
programs. For example, the APhA has established an Advanced Practice
Institute to train pharmacists to participate in collaborative
practices.5
Documentation
Appropriate documentation of the patient visit is
crucial. A clinic encounter form can be created to provide direct
documentation of the patient visit that can be easily communicated to
the provider, have all the appropriate elements for billing, and adhere
to legal requirements. Policies and procedures should be in place
defining the pharmacist and physician roles within the CDTM service, how
information will be shared, ensuring patient privacy and
confidentiality, and how patient outcomes will be measured.
crucial. A clinic encounter form can be created to provide direct
documentation of the patient visit that can be easily communicated to
the provider, have all the appropriate elements for billing, and adhere
to legal requirements. Policies and procedures should be in place
defining the pharmacist and physician roles within the CDTM service, how
information will be shared, ensuring patient privacy and
confidentiality, and how patient outcomes will be measured.
Payment
Passage of the new Medicare legislation is not
insignificant when it comes to reimbursement for pharmacists' services.
Third-party payers and others usually follow the lead of Medicare when
determining reimbursement rates. Until these parameters are more clearly
defined, however, pharmacists must educate themselves regarding billing
for services in order to ensure appropriate reimbursement rates.
Consulting with institutional billing departments or with the
collaborating physician's billing department may be a good place to
start.
insignificant when it comes to reimbursement for pharmacists' services.
Third-party payers and others usually follow the lead of Medicare when
determining reimbursement rates. Until these parameters are more clearly
defined, however, pharmacists must educate themselves regarding billing
for services in order to ensure appropriate reimbursement rates.
Consulting with institutional billing departments or with the
collaborating physician's billing department may be a good place to
start.
Summary
Establishing CDTM services provides many obstacles
and challenges. On the other hand, the rewards of improving patient
health outcomes, building a close working relationship with physicians
in the community, and the satisfaction of providing pharmaceutical care
services are well worth the effort. The need for pharmacist involvement
in such services will only continue to grow as the number of patients
taking multiple medications for chronic disease states continues to
increase. Medicare reform has opened the door for increased
reimbursement for these services, and national and state pharmacy
organizations are working hard to ensure appropriate reimbursement.
CDTM当然有障碍和挑战，但是这中更高发展层面的障碍和挑战又怎是低级社会能知晓的，社会制度不是一日建成的，很多时候社会之间根本就是不能比的，尤其是在深处，比两个GDP数字不过是骗骗人而已。and challenges. On the other hand, the rewards of improving patient
health outcomes, building a close working relationship with physicians
in the community, and the satisfaction of providing pharmaceutical care
services are well worth the effort. The need for pharmacist involvement
in such services will only continue to grow as the number of patients
taking multiple medications for chronic disease states continues to
increase. Medicare reform has opened the door for increased
reimbursement for these services, and national and state pharmacy
organizations are working hard to ensure appropriate reimbursement.
