SEARCH

SEARCH BY CITATION

In a world where the population is ageing and in which there are increased pressures to treat patients in the primary care setting, new approaches are required to manage chronic disease. Since medicines are usually central to disease management, community pharmacists have endeavoured to embrace the practice of pharmaceutical care and medicines management. When we look across Europe, however, contemporary community pharmacy provision falls far short of what could be considered best pharmaceutical care practice. Across the UK, there have been some improvements, including more consistency in advice provision to patients though the use of standard operating procedures in pharmacies and through better training of technicians and counter assistants. However, the patient often still remains a receptacle for the receipt of care with, in the main, having little involvement in their disease management. It is time therefore to explore new approaches to getting patients more involved in their care. Improving medication adherence, which still seems to be stuck at the very resistant 50% mark, is central, as is getting better warning systems in place for when a patient with a chronic illness is getting ‘out of control’ such that they can either modify their own treatment under guidance and/or seek or obtain help once certain triggers are flagged. Early intervention can often result in the prevention of expensive hospitalisations and therefore ease the pressure on an already stretched secondary care system.

The application of new monitoring and communication technology within healthcare is considered an innovative solution to the challenges facing the health service, particularly as the population ages and the management of chronic illness becomes increasingly important. This ‘Connected Health’ concept, often involves the patient engaging in monitoring markers of disease control in their own home, with the data generated being transmitted to a central triage centre. Healthcare staff (often trained nurses) at the triage centre, provide patients with feedback regarding the next steps to be taken by the patient if the measured parameters are outside the ‘normal’ limits. This type of approach has resulted in some notable success, particularly within the VA system in the USA. Work in this area to date has, however, largely ignored the potentially pivotal input of pharmacists and in particular community pharmacists who are the key healthcare professionals in helping chronically ill patients manage their medicines in their own home (including adhering to the complex regimens which are often prescribed). The lack of integration of the activities of the general practitioner and the community pharmacist within the primary care sector in the UK is still very evident and the pharmacist (or drug expert) often has little influence in disease management outside the secondary care sector. A technology supported ‘connected health’ approach involving the patient, the GP and the community pharmacist has the potential to lead to a much more integrated approach.

Too often, however, the manufacturers of the home monitoring devices and the associated connectivity infrastructure used in the ‘connected health’ approach, forget that the primary healthcare system in the UK is complex and fragmented into small populations grouped around GP practices and community pharmacies. For the new technology to be fully effective, it is my view that patients must be treated as individuals and receive care from the healthcare professionals that they know and trust, rather than from a remote triage centre. Technology should therefore be used to link the three partners (patient, pharmacist, GP), with each having different responsibilities. In such an approach the patient will be responsible for managing their medicines according to an agreed schedule, carrying out the home monitoring and providing feedback on symptom control through the connected health equipment. The results of this engagement will then be relayed (wirelessly or via landline linkage) to a central (web-based) data platform, which will automatically send back a positive, supportive message to the patient if control is being achieved. When disease management markers become out of control, they will automatically trigger an alert message to be sent to the patient and also to the GP or pharmacist (or both) for appropriate action to be taken. Having reviewed the findings, the GP or pharmacist could then send a text message to the home base unit or telephone the patient to give advice.

This type of approach could also be delivered from a hospital base (hospital doctor and clinical pharmacist), for example, during the first month (highest risk period for readmission) after a patient has been hospitalised, before ‘discharging’ the patient to the primary care providers when the patient is deemed to be stabilised. This ‘ward in the community’ concept could be a useful approach to addressing high readmission rates. Continued support could be provided from the hospital pharmacy team if community pharmacists do not wish to become engaged.

There are some examples of pharmacist engagement in ‘connected health’ in published studies to date, however, these have been the exception. Although a recent study in the New England Journal of Medicine (evaluating a telemonitoring programme for heart failure patients) provided no evidence of benefit, further research is urgently required within this ‘space’ as monitoring equipment becomes more sophisticated and user friendly.

It is clear that not all patients will have the required self-efficacy to fully participate in this type of programme, or may have issues around privacy, and a test of suitability may need to be developed, in much the same way as a genomics test is used in personalised medicine. This would allow alternate approaches to care provision to be considered and help prevent unnecessary spend on equipment that will remain unused. It is clear that further rapid developments will be made in the connected health world in the near future. Pharmacists must become engaged or find themselves further excluded from the care of patients with chronic illness and pharmacy practice researchers must assist by providing the evidence base for this new paradigm in chronic disease management.

Selected bibliography

  1. Top of page
  2. Selected bibliography
  • Barr PJ, McElnay JC, Hughes CM. Connected health care: the future of health care and the role of the pharmacist. J Eval Clin Pract Doi: 10.1111/j.1356-2753.2010.01522.x.
  • Claudhry S et al. Telemonitoring in patients with heart failure. New Eng J Med 2010; 10.1056/NEJMoa1010029.
  • Darkins A et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed E-Health 2008; 14: 11181126.
  • Green BB et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomised controlled trial. JAMA 2008; 299: 28572867.