Mister, not Robot

Staying Relevant as a Pharmacist in the Age of Digital Disruption

Safe, Secure and Comfortable

Pharmacy has changed a lot since I started as a first year Pharmacy student in 1999. I was drawn to pharmacy because I was pretty good at maths and chemistry, you were likely to get a job at the end of it, you could work part time in if you had children, and you could help people without touching them. It was safe, secure and comfortable. There have been a lot of changes to Pharmacy practice over those 20 years.

When I was a pre-registrant pharmacist at the Royal Adelaide Hospital, the early career trajectory went something like this. Accept that the first few years would be dominated by being a dispensary workhorse where you would learn your trade and get to know people in the department. Once you worked the required period as a registered pharmacist in Australia, go to the UK. Be overpaid to work as a locum pharmacist to fund your travels. Return to Australia and await the opportunity when a vacancy arises and you're able to work as a clinical pharmacist on the wards. In the meantime, do whatever comes up to keep yourself busy and as professionally satisfied as possible.

By around 2008 that type of career path became extinct in South Australia. There was no longer a reciprocal agreement between the Australian and UK Pharmacy Board, making it more difficult to gain registration as a Pharmacist in the UK. You could still get work, but the pay was much less inviting. Along with introducing the PBS to hospitals, the Pharmaceutical Reforms Agreement dramatically shifted the pharmacy workforce balance and initiated an era of standardised processes and KPI targets. This systematised approach to pharmacy service delivery is now deeply embedded.

Primary care pharmacy has also evolved significantly, primarily in the areas of non-dispensing services. Medication management services were first included in the third Community Pharmacy Agreement (2000 to 2005), with the Home Medicine Review program introduced to the Medicare benefits schedule in 2001. The current sixth Community Pharmacy Agreement (2015 to 2020) now lists a host of community pharmacy programs. And it doesn't stop there. Community pharmacies now offer vaccinations, blood pressure checks, baby clinics, pain management, weight management consultations, to name but a few. And there's more on the horizon. Pharmacists embedded in aged care facilities and GP practices, pharmacist prescribing, hospital referrals for HMRs, all of these are thought to be imminent innovations to pharmacy practice, touted as being essential to meeting the medication-related needs of society according to the recent PSA report Pharmacists in 2023.

Of course, all this professional evolution has occurred within the broader context of the patient safety movement. The 1999 Institute of Medicine Report, To Err is Human, highlighted the very real impact of preventable errors in healthcare. Medications make an important contribution to this harm. In Australia 2 to 3% of all hospital admissions are medication-related, costing around $1.2 billion p.a. (Roughead, 2016). Within the hospital, patients can expect to encounter at least one error during their admission, with errors occurring in around 9% of overall medication administrations (Roughead, 2016). More than 90% of patients have at least one medication-related problem once they are discharged from hospital (PSA Connecting the Dots). In the community setting, more than half of RACF residents are exposed to at least one potentially inappropriate medicine, and one in five people are experiencing an adverse medication reaction at the time of an HMR.

This data creates the sense of urgency required to garner political attention. Indeed, it created the political environment required to turn pharmaceutical care for a philosophy of practice into international models of care like the HMR program. There is something wrong that needs to be fixed. There are people that need to be rescued, a healthcare system in crisis. Pharmacists must lead the changes required. Pharmacists are the custodians of medication safety, responsible for implementing the principles of quality use of medicines outlined in Australia's National Medicine Policy (Pharm in 2023). Rhetoric like this is strong in all facets of pharmacy, and it can be useful to a point. But a time comes when you will be called upon to walk the talk and be judged on your outcomes.

Outcomes That Matter

Some may claim there is plenty of evidence of outcomes. Pharmacy practice researchers have produced many publications demonstrating activity, cost benefit, and superiority over processes overseen by other professional groups. It almost seems the profession is so comfortable that they don't even care if they fracture their relationship with medical colleagues by putting them down or pursuing expanded practice. But are these the outcomes that matter?

According to the Pharmacists in 2023 report, More than 70% of Australians aged over 45 years regularly use medicines, but only around half of them use their medicines as prescribed. What the report doesn’t mention is that up to two thirds of this non-adherence relates to individuals making intentional decisions to deviate from the prescribed treatment (WHO 2003). Of equal note, is that this intentional non-adherence is not a contemporary phenomenon. These statistics have been consistently reported since at least the 1980s in studies of older adults and people taking antihypertensive agents. Yet we still know so little about it. Why people make those decisions. How we could positively influence them.

At an individual level, non-adherence may lead to sub-optimal health outcomes (e.g. non-adherence to appropriate pharmacotherapy). It could also be a demonstration of a self-initiated risk mitigation strategy (e.g. non-adherence to a medication that is causing an ADR). At a societal level, non-adherence is an important contributor to medication waste which has both economic and environmental impact.

Australia's Return Unwanted Medicines Project facilitates safe disposal of medicines. A 2016 audit of that program found 60% of returned items were PBS medicines. Six of the most commonly returned PBS medicines were used for chronic conditions, three of which (atorvastatin, simvastatin and metformin) were also in the top 20 most prescribed PBS medicines. Approximately 10% of the returned PBS medicines were expired and around 10% were unopened. They conservatively estimated the cost of wasted PBS medicines to be around $11.6 million per year. This is an obvious underestimate of the actual cost, not accounting for the medicines that are unsafely disposed of. These low levels of adherence and high wastage of medicines is not money well spent. This is the sort of data that is of paramount importance.

Social Need For Change

Australia's healthcare expenditure, as with most developed nations, is growing at an unsustainable rate. Unlike some other areas of health (e.g. dental, allied health), the majority of expenditure of medicines is from the Australian Government (AIHW). The Australian Government expenditure on benefit-paid pharmaceuticals has increased from $4 billion in 2000 to nearly than $11 billion in 2016 (AIHW). The value of the PBS has been on the Governments radar for some time, they just haven't had much of an alternative

This situation makes being a tightly regulated industry both a blessing and a curse, depending on your perspective. The health industry has benefited greatly from government protections. Legislation and strong professional organisations have ensured there is strong resistance to disruption from outsiders, creating a secure closed system. The flipside of this is that health hasn’t had the same pressures to evolve, innovate and grow in productivity. This slow growth coupled with ever increasing expenditure is not good for our economy. This is not good for anybody. Not only is the health system unaffordable, it ties up money and resources that could be used to create more productivity and grow the economy. This is the leverage point for technology companies. This is the reason why digital disruption is inevitable in healthcare.

Advances in automation, robotics and machine learning will force paradigm shifts across all of society, including health. And for good reason. People should be able to get their medicines at the lowest cost possible, delivered in a way that is responsive to their needs. The Government should be getting value for their healthcare spend. The question is, can Pharmacy recognise this change and evolve the profession to be in a position where this change can be considered the saving grace, rather than the death knell?

Eek, the Robots are Coming!

We are at the beginning of what some are calling the Fourth Industrial Revolution, an age of digital disruption. These types of disruptions involve convergence of different technologies to create a paradigm shift in the industry and culture in which it exists.

Let’s illustrate this with the well-known example of Amazon. When Amazon first came on the scene, it offered an alternative method of retail shopping. For our household, this meant we started to get more regular notices to pick up parcels at the post office because it enabled my Dad’s enthusiasm for buying books more readily than waiting for an opportunity to browse at the major bookstore in town. Good for the postal industry who were delivering more parcels. Challenging for the bookstores who were serving the mass market but presented new opportunities for those able to find a niche.

When the kindle was introduced it built on that original technical platform creating an alternative to traditional books. Not so well liked by those who enjoy the physical token of a book on their shelf, but great for people who wanted something more portable and less clutter in their lives. Good for the writers because it paved the way for self-publication. Challenging for the publishers because they had to redefine themselves and their industry.

Where is Amazon now? Everywhere. In the US, you can have a fridge that can use sensors, talk to other IT systems and have a litre of milk delivered to your door before you even realise you should have added it to your grocery list. The internet of things, automation, artificial intelligence, cloud computing all converging to create an approach to household groceries that most people would never have envisaged when they had their first experience of buying a book online in the late 1990s.

Last year Amazon entered the Pharmacy market in the US when they acquired PillPack. PillPack is a dose administration aid service launched in 2014 that delivers medications each month with a monthly medication list and clear dosing instructions. They offer 24/7 Pharmacy phone support and can supply urgent medications immediately upon request. The only cost to the customer is the co-payment. Shipping is free. It is easy to see the appeal of this model of care.

While it may only have a small slice of the $424 billion US prescription market so far, the very announcement of the acquisition was enough to start disrupting the industry. But it has not without resistance. Some of this resistance has resulted in benefits for consumers, pushing other Pharmacy chains to innovate their services. Others have unfairly put the consumer in the middle, with reports that CVS and Walgreens, the two largest Pharmacy chains in the US, are actively blocking customers from transferring their Pharmacy services to Amazon. Yet Amazon persists despite this conflict. This willingness to clash with the powerful and tightly regulated industry should be viewed as a caution sign to Australian Pharmacy.

Consumer Experience

In their 2018 article Amazon Enters Pharmacy Market in the AJP, CEO of MedAdvisor Robert Read suggested that Australian pharmacies are at risk of losing up to 20% of their business when Amazon almost inevitably bring their supply chain model here. He makes the key point that the leverage for this type of industry disruption is the focus on consumer experience, and notes that pharmacy have not been progressing fast enough in this area.

One of the key distinguishing features between the way the technical industries approach pharmacy, compared with within the pharmacy profession, is that enhancing the consumer experience is the central objective of the business model, not a desirable afterthought. In an article in Wired magazine Pharmacies Are Awful – But These Startups Could Fix Them, one CEO describes their approach as “[taking] note of what is really annoying about the current pharmacy experience, and taken a little bit of frustration out”.

I don’t know how you can argue against pursuing a commercial model that has the potential to reduce errors and enhance consumer experience at a lower cost. If the Pharmacy Profession resists automation and disruption of industry, they risk being perceived as being more interested in protecting the interest of Pharmacists than serving their community.

The End is (Not?) Nigh

It’s easy to think about automation only in terms of medication supply, but don’t get too comfortable with that. What is most likely is that the supply chain represents the simplest entry point, the low hanging fruit. On the website for PharmacyOS, the software platform that underpins PillPack, is the following quote from Co-Founder and CTO Elliott Cohen “PharmacyOS is more than a rethinking of a pharmacy system. It truly represents the early stages of a platform that over time will create a radical shift in chronic care management”. Supply is just the beginning.

Some commentators believe that health is likely to be one of the last areas to be impacted by this type of technology. That it’s too complex, too nuanced, too personal. When listening to these opinions, it’s important to keep two things in mind. Firstly, much of this commentary is considered through the lens of medicine and nursing. Pharmacy is quite different. Secondly, as discussed earlier, the primary approach to reducing medication errors in healthcare, particularly hospital environments, has been through systems and processes. IT people would call these algorithms. Algorithms that can be programmed into and implemented using technological solutions.

In their recent report, Connecting the Dots: Digitally Empowered Pharmacists, the PSA outline their vision for how medicine use will improve by 2023 through digital health transformation.  They provide examples of how improved integration of information systems will connect healthcare providers and empower pharmacists to act as medication experts. An alternative albeit cynical view of this report is that it provides a road map to healthcare funders for the abundance of pharmacist roles that could be automated once the technology allows.

Get Familiar with Automation

In terms of robots replacing systems, we need to talk about the main types of automation that are in play. The first is automation that occurs behind the scenes. Automation of tasks that are repetitive with little variation. This robotic process automation is the type described in the PSA report. The electronic medical record, electronic medication management system and pharmacist shared medicines list all talking to one another behind the scenes to improve integration. This is essential groundwork for any other progress to take place. It’s also the kind of experience that provides clinicians with a false sense of assurance that automation will never happen in healthcare; because those systems usually suck. You don’t feel empowered by them, you feel like a slave to them. But transition periods are always difficult, and a time will come where you forgot what it was like to be working in a hospital and having to call the community pharmacy to check a dispensing history.

Other types of automation which are likely to impact health but are currently more speculative are cognitive automation and robotics. Cognitive automation utilises machine learning to recognise patterns and understand language. This type of automation will potentially replace roles that are built upon rules and procedures, which broadens the threat to pharmacy practice beyond the supply chain, particularly in the hospital environment.

One of the things that make hospitals such a breeding ground for clinical pharmacists is that they are kind learning environments. Pharmacists are regularly exposed to a high volume of scenarios where they can practice identifying and resolving drug related problems using a set of general processes and frameworks. They get well versed in being able to identify and resolve problems because they start to recognise patterns and link current problems to past encounters that share similar features. Best possible medication histories. Responding to medicines information queries. Of vital importance to this learning is the timely feedback that they receive. They can see the outcomes of their recommendations, track the clinical changes that occur, hear the resistance in the tone of voice of the doctor, get notified by the dispensary staff that something they signed off on is incorrect. Machine based learning is like this on steroids. It’s like being able to capture the learning experiences from all the pharmacists working within the system, along with additional inputs from information systems, through sensors and the internet of things.

Pharmacists who have worked with a dispensing robot may have a tainted view of the prospect of robotics in healthcare, but the progress in these industries is rapid. Deep learning is artificial intelligence that allows machines to learn and evolve, to figure things out. It has enabled computer vision to progress rapidly from basic object recognition, to complex visual perception where AI is able to closely mimic the interpretations and inferences that a human would make if faced with the same image. This breakthrough, along with development of other types of perceptions, has opened the doors for the multitude of possible applications for social robots which can move safely around people and interact with them. Autonomous mobile robots that have sensory perception are being used for things like stock control and logistics. Chatbots are being to developed that can provide tailored counselling. Robot reporters are being used to write written narratives for major publications like the Washington Post.

Armageddon Outta Here

You can see that there are some serious implications for all aspects of Pharmacy Practice. For all aspects of society. Roles and responsibilities will change. Some roles will disappear. People will be displaced and feel insecure. The potential impact on society is massive. So massive that it can be overwhelming. But we can’t afford to be overwhelmed. As a society we must be informed so that we can be intentional with our adoption of technology and regulate it appropriately.

We have control over which tasks should be replaced by automation and which ones can be augmented by it, it is not inevitable. But we must be informed, and we must engage with the change before us.

If you take the position that automation will be the death knell of Pharmacy, it is likely because you have some level of attachment to the way the profession is currently positioned. But I want you to reflect on that for a moment. Firstly, do you think there is scope for the profession to do better?

Systems and processes are essential to contemporary healthcare environments. As Atul Gawande puts it, hospitals need pit crews, not cowboys. And for good reason. The number of lives that are impacted or lost due to preventable mistakes is unacceptable. But there is limited professional satisfaction in being a cog in the healthcare machine that is a hospital. So yes, automation may reduce the need for pharmacists undertaking repetitive work in hospitals, but is that so bad?

Professional identity is based upon core values, moral principles, self-awareness and self-regulation. In their recent paper, Gregory and Austin found that there is a lack of professional identity amongst community pharmacists which may explain some of the difficulties that pharmacists have being confident in their value and reluctance to take responsibility. In his related editorial Ross Tsuyuki challenges individuals, stating “ultimately, pharmacists need to choose how we want our culture and our profession-hood to be”. He goes on to say, “in an age when dispensing of drugs and drug information can be Amazon’d and Google’d, our face-to-face contact and our relationships with patients are our future”. I couldn’t agree more. I believe this will only be achieved through activation of individuals, not through our professional organisations.

At this point I risk losing you as a reader. I am going to ask you to shift your focus from “how can we fix this?” to “what can I do to continue to add value”. This may go against the grain to those of you who feel responsible for the greater good. So, I’m going challenge that, and we can argue about it later.

I suggest one of the reasons we lack professional identity is because we are currently built on a paradigm that is focused on baseline competency rather than quality. It is pragmatically built this way because that is what we can assess and regulate. But automation will lower the value of professionals who are performing at baseline level competency. Regardless of the industry, if you are incapable of offering value beyond a robot you will not be considered a professional, you will be a technician.

Now there is nothing wrong with being a technician. Pharmacy practice relies upon them heavily. And perhaps this will help to establish a career structure which enables them to systematically assume responsibility over processes like supply chain management. But that is not a profession.

This highlights some of the issues that will need to be considered regarding education and professional regulation. Can we deliver flexible programs of education that can be tailored to an individual’s practice profile? Is it going to be suitable to have a singular category of registration or will there need to be different types of pharmacist, as with nursing and psychology? Do all Pharmacists need to undertake registration? They’re all important questions, but they’re not worth addressing unless there are enough individual pharmacists out there willing to push for a focus on quality over baseline competence. This might make you uncomfortable because it means you are putting yourself above others, which may be perceived as being arrogant and selfishly motivated. I used to think that way. That the only way we could make progress was to systematically increase the lowest common denominator. That this could only be achieved through strengthening our organisations. I don’t think that anymore.

I do acknowledge that professional organisations play an essential role in advocating for the profession and supporting the development of the knowledge and skills of their members within pharmacy-specific domains, but they exist to represent their members, not society. They may desire to advance practice and raise quality standards but, assuming a normal distribution pattern, more members are interested in following prescribed career paths than they are in forging their own. This creates a sense of comfort and security, but it does not drive innovation. It creates an insular monoculture, an environment of mutual gratification where members no longer feel the need to demonstrate their value because it is assumed.

The result is organisations who are always pushing their agenda, which is to embed the profession in society and protect their members. The problem with this is, they start to believe their own propaganda. They buy into the professional motivators and they forget the social contract.

If you consider yourself a healthcare professional, you must put the social need ahead of your professional drivers. Before the desire to deliver the biggest profit margin. Before your ego and desire to be recognised as an expert and an esteemed member of the community. This is the basis of the moral principles that form professional identity. You must make improving the outcomes of medicines use your individual priority. You must take action as an individual, not wait to be told what to do.

Remain Relevant

If you want to remain relevant as a pharmacist throughout the era of digital disruption, you must be clear on your professional identity because that is what shapes your strategic goals. If, like me, you base your practice on the Pharmaceutical Care philosophy of practice then this should be a straightforward exercise. If you are unsure, then you should acquaint yourself with the original writings on the topic, before the term got diluted and confused.

Once you are confident in your strategic goals you can develop your value proposition. Set out your aspirations. Don’t pursue opportunities because that’s what the defined career path tells you to do. Pursue opportunities to develop enabling skills and knowledge that will allow you to contribute your value. Make sure you do the important work well and set about defining your unique competitive edge.

Do the important work well

As there is now, there are some core knowledge domains and enabling skills that will continue to be foundational in all areas of pharmacy practice and it’s important that you do this work well. I believe the focus will shift from being experts in medicines to being experts in how medicines are used. This may appear a matter of superficial semantics, but to me it indicates a shift from a professional called upon to impart knowledge, to one driven to achieve improvements in outcomes. Supply of medicines is an integral part of this.

This may seem contradictory. Afterall, I have suggested that maximising automation in the supply process is the best way forward. That minimising involvement of pharmacists by increasing the capability of pharmacy technicians to oversee supply chain management is an exciting prospect. But this does not mean supply of medicines should be divorced from the pharmacy profession, it just changes the relationship.

If you ask most people walking down the street what they want from pharmacy, it will likely relate to timely, accurate, and affordable supply of medicines. Supply is our trojan horse. It’s our opportunity to initiate a consultation with someone that opens them up to be receptive to other medication management services that they may not recognise they need. By embracing automation, we can use pharmacists in the parts of the process that leverage the most value. Not the clinical checking for drug interactions and doses. Not the visual check for accuracy. Yes, maybe in the interim, but eventually robots will do this better, so let them. No, in the talking to patient bit. Triaging the receipt of prescriptions and OTC queries. Talking with them about how to use their medicines effectively and safely. Getting good at that stuff. Even if robots can do this, our humanity and capacity to connect will mean we will likely do this better. This might not happen in the same face to face way we are used to now. The method doesn’t matter, the connection does.

And maybe we also need to start thinking about how our relationships with each other influence this supply process. Reflect on how well we collaborate with colleagues in other practice settings. How we value their contribution. How we recognise the work that they do. If this is the core role of pharmacy, then we should pay attention to all aspects of the system. Again, you have the power to initiate this change. You do not need to be told what to do.

The other important work that we must not neglect is maintaining our knowledge base. Yes, computers may take over medicines information and clinical decision support, but there will still be a requirement for advanced domain-specific knowledge. If you are talking to a patient, you need to be able to read between the lines and recognise that they the convoluted story they are telling is about an adverse drug reaction.

Find your edge

We can’t predict how digital disruption will impact the pharmacy workforce, but we can position ourselves to be resilient to change. This starts with being confident that the value you contribute isn’t attached to the title of Registered Pharmacist. It isn’t about being recognised as an expert in medicines. It is about your capacity to utilise your unique combination of knowledge and enabling skills to contribute to meaningful outcomes. That is your competitive edge.

Soft skills like communication and emotional intelligence are probably the most obvious enabling skills that all pharmacists should pay great attention to. This is nothing new, I know, but up until now people have been able to get away without developing those skills to an advanced level. Refine these skills. Work on your patient communication skills by actively paying attention to the details. Get better at asking questions by starting a podcast. Sharpen your interprofessional communication through better preparation and seeking out feedback. Improve your writing skills by starting a blog or write essays to share your realtime learning and insights. Don’t abandon the traditional methods of publication and presentation, expand your repertoire.

ICT skills and basic coding are also obvious targets for skills development. ICT skills will enable you to be confident in using technology platforms to their full capacity. Coding may enable you to shape the development of those platforms, to teach and maintain the machines. There are a whole host of health technologies under development which could introduce an entirely new service area. In their recent article, Baines and colleagues suggest pharmacy could play an important role in emerging technologies such as data analytics and health technology. If that sort of stuff interests you then get involved. Find out about it.

If you want to provide direct patient care, then you might want to broaden your knowledge base beyond biomedical science. Equip yourself by learning about social determinants of health and behavioural change models. Learn about cultural awareness, learn the language of a community that is currently underserved.

If pharmacy management systems are more your thing, think about other skills. By management systems, I mean those ‘behind the scenes’ roles of pharmacists like drug formulary management, QUM activities, antimicrobial stewardship, chemotherapy validation, drug use evaluation etc. Go deep in your knowledge of clinical governance and ethics. Develop skills in working with big data and managing AI systems.

Learn how to conduct robust research. Meaningful research. Research that helps us to better understand real problems that we encounter in our practice. Not because you must to advance your career or get your post grad. Research because you’re curious and you want to make things better. Develop the research that can be used to train the AI. Build partnerships that cross sectors and industries. Find a venture capitalist and get them to fund you.

Develop skills outside of pharmacy altogether. Entrepreneurial skills, leadership skills, business skills. Chase the rabbit holes and see what you find. By doing so you won’t just enhance the value of your individual contribution, you will enrich your colleagues by broadening their outlook.

Do it alone, together

We can’t rely on professional organisations to change the culture of pharmacy.  To prioritise the social need. To demand quality, not baseline competence. We need individuals to challenge the status quo. To take action and put themselves out there.

We don’t need permission to do this. But we do need courage to share our ideas and experiences with a generous spirit. Take this essay as an example. The idea of letting anybody read my thoughts on this topic scares me to death. I can think of all sorts of criticisms and judgements and reasons not to do it. But my feeling that this is something that is important to talk about makes me share it anyway. The feeling that there are likely other people out there who care even more than I do. That we might be able to connect and start building a culture that fosters creative thinking and innovation from the bottom up.