Journal of Community Medicine & Health Education
Open Access

The situation

One normal day at the Local’s Pharmacy, where Mildred worked as an intern, she saw one of the pharmacy’s regular customers coming through the door. The customer is Mr. Smith, a 75 year old man with numerous medical conditions. After greeting him with a smile, Mildred asked him how he was doing and asked what she could do for him that day. He was dropping off a prescription for Lisinopril that was prescribed by his cardiologist to treat his hypertension [1-4].

Lisinopril is an ACE (Angiotensin converting enzyme) inhibitor. ACE inhibitors work by lowering aldosterone levels in the body to lower the patient’s blood pressure. Also, Lisinopril can cause potassium retention in the body. According to Mr. Smith’s medication profile at the pharmacy, the Lisinopril was appropriate to fill. After dispensing the medication and counseling Mr. Smith on it, Mildred saw him leave the pharmacy.

A few days later, Mildred received a phone call from the local emergency room. The nurse on the line requested Mr. Smith’s medication fill history from their pharmacy. After speaking to the nurse and reviewing with the pharmacist in charge the various medications that Mr. Smith had filled at the pharmacy, they discovered there was a medication that was not on file. The nurse informed Mildred that Mr. Smith was also taking Spironolactone, which is a potassium sparing diuretic. The Spironolactone was prescribed by his primary care physician to treat edema in his legs, which is the swelling caused from the buildup of fluid. Mildred re-consulted with her supervising pharmacist in charge and verified that the Spironolactone was not filled at their pharmacy.

After the emergency room nurse followed up with Mildred and her pharmacist, she informed them that Mr. Smith picked up the Spironolactone from a different pharmacy. Mr. Smith originally went to the emergency room for signs of fatigue, nausea, and muscle weakness. By taking these two medications together, it caused Mr. Smith to develop hyperkalemia. Hyperkalemia is when the potassium levels in the blood are too high. Thankfully, Mr. Smith was able to recover from this situation. Had this been a severe case of hyperkalemia, his high potassium levels could have caused cardiac arrest and even death. Mildred and the pharmacist were both very concerned with this drug interaction. The Local’s Pharmacy has a computer system very similar to other chain and independent pharmacies in the country. The only downfall with the system is that the pharmacy staff cannot view other prescriptions that are filled at different locations for a specific patient. In Mildred’s situation, she was only able to see the prescriptions that Mr. Smith gets filled at The Local’s Pharmacy.

The pharmacy was opened over fifty years ago and offered the same services throughout its years of operation, just without the technology introduced over the last decades. But like the community it serves; the Local’s Pharmacy grew to meet the community’s needs. The pharmacy adopted a technology system that is in close relation to the systems utilized by most pharmacy chains across the country. The system is separate to that doctor’s offices and hospitals use to document, monitor, and evaluate a patient’s medical and prescription history.

In the healthcare system today, patients depend on many healthcare professionals to deliver their care [5]. The professionals consist of general physicians, specialized physicians, nurses, lab tab technicians, imagery technicians, physical therapists, pharmacists, etc. In the current health system, these professionals many times have no direct way to communicate with each other [6]. Sometimes the actions of one professional have adverse consequences to the actions of other professionals. The adverse consequences can cause harmful health effects to the patient and possibly even death [7,8].

Healthcare professionals should act like a high performing team to deliver high quality healthcare to the patient [9]. The team should practice the five disciplines of high performing teams: small size, capable and complementary members, shared purpose and performance objectives, productive norms and a working approach to effectively manage conflict, and mutual accountability [10]. Most of these conditions are meet with the specialized training the professionals receive, but none of these disciplines (except maybe small size) can be accomplished without communication between the members. Each team member must be aware of the actions and recommendations of the other members to be able to function as a high performing team. Barriers exist to effective communications between the professionals. Barriers such as time and distance constraints, availability of technology and the willingness to use the technology, and the traditional culture of the different medical professional disciplines [6].

Possible solutions to the problem

Communication can be accomplished between the team members is serval ways. The team members can have face to face meetings to discuss each patient, or they could use video conferencing if they are not located in the same facility. The team members could use paper notes or some form of technology based note and record system that is accessible and usable by all the team members. Also, the traditional culture of healthcare practitioners acting on their own can be altered with proper training [9].

Evaluation of the solutions

Patients can be harmed if medical professionals do not collaborate with each other to care for the patient [8]. The example of Mr. Smith shows how serious the consequences can be. Mr. Smith’s physician could have held a phone, email, or face to face consultation with Mr. Smith’s pharmacist, but this is unlikely to happen because of time contracts. With the many patients a physician and a pharmacist sees, an individual consultation with each patient’s other medical providers is not practical. Even if the patient is in a hospital and all the attending medical professionals are in the same location, again time constraints probably restrain the ability to meet with all the professionals regularly.

Technology can assist with the communication between the members of the patient’s health professional team. Since their introduction to the healthcare field, Electronic Health Records (EHRs) have always played a main role in various core measures such as medication reconciliation, computerized physician order entry (CPOE), e-prescribing, clinical decision support, and immunizations. However, since pharmacists have not been recognized by the Centers for Medicare and Medicaid Services (CMS) as eligible providers, the access a pharmacist has to patient medical history and EHRs are limited [2].

Pharmacists in charge are required to keep their own record of patient prescriptions filled within their store. Because the CMS has not recognized pharmacists as eligible providers, pharmacists cannot access, change, add, or take away information to a patient’s Electronic Health Record without the patient’s prior consent. However, in some countries, pharmacists within the community are allowed access to national Electronic Health Record data to monitor patient therapy [2].

Clinical pharmacists within hospital organizations can access parts of EHR for medication therapy management. Pharmacists working within an inpatient setting can examine the EHRs to evaluate patients, identify potential for medication problems, review medication regimens, check for drug related interactions or diseases, etc. This luxury is not provided for other pharmacies outside of the hospital setting, and approximately half the hospitals do not allow pharmacist documentation within the EHR. Consequently, pharmacists outside of the inpatient setting and some inside the inpatient setting are left out of the information loop [2].

Computerized physician order entry (CPOE) is effective in keeping all a patient’s medical providers informed about the patient. The use of CPOE has shown to decrease medical errors, but fewer than ten percent of US hospitals have implemented its use [11]. The attending physician is responsible for entering the information, and this is one reason the system has not been widely used. Physicians do not have time for additional tasks between patients. Another problem with the CPOE is that the physician is the only one who can access the records to add remarks to them [11]. Other health professionals like pharmacists need to be able to access the records and make notes on the records.

Patient medical care can be thought of as group work, a collaboration of all the medical professionals that a patient sees. The use of accurate medical records accessible by all health professionals is necessary. Often the physicians themselves are not aware of all the medications a patient is taking. A review showed twenty five percent of the people were taking additional drugs unbeknown to their referring general practitioner and that suspected adverse drug reactions had occurred in about fifty five percent of the people [12]. As a hospital executive observed: “Other industries would never allow the fragmentation to occur that occurs in health care. The automotive industry, the finance, I mean, they just, it is all about consolidation and dis-intermediating all that crap from happening, right? We have allowed intermediations and hand offs to happen, and quite frankly, when you think about it, that is why health care doesn’t deliver at the level that it can. Every hand off is an opportunity for failure” [2].

Physicians do not work in a vacuum. They have nurses, physician assistants (PAs), transcribers, etc. to help them in the office and this does not include the specialist physicians that patients are referred to, the imaging and lab specialists who conduct the tests for the physician, and the pharmacist who fills the prescriptions the physician prescribes to the patient. All of these professionals must know what the other is doing for the patient to be given the best care and cause the least harm to the patient. The CPOE can be used to keep all of these professionals informed about the patient and align each one to provide the highest quality care to the patient.

A barrier to collaboration in healthcare is also caused by the traditional culture of the participants, especially the physician [11]. Traditionally the physician made all the decisions, and the nurses had no voice in the care of the patient. The nurse was just there to carry out the physician’s orders [1]. This is changing as nurses become more educated and as the knowledge base a physician is required to know to be proficient as a physician is becoming more than one person can hold in his head. The physician is becoming more reliant on specialists to advise him. The physician must work as part of a team to provide the best health care to the patient. The physician may be the team leader, but he is now more reliant on input from members of the patient’s healthcare team [13]. Also, other healthcare specialists have the traditional view that they make their own decisions and do not want to be dependent on others [5]. This culture must change as modern healthcare is becoming more of a team approach than an individual approach [1].

Medical professionals should be trained collaboratively with other healthcare workers to provide the best care [13]. For example, at Francis Marion University, the School of Health Sciences is training nurses, physician assistants, and, in collaboration with the University of South Carolina Medical School, physicians. All of these professionals are trained with the same staff and cross training is encouraged. Physicians need assistance with their workload and trained nurses and physician assistants provide the physician with a trained, knowledgeable inter professional team. Also at the University since many medical professionals may practice independently, a course of business practices and procedures is taught. An example of this is the offering of the Master of Business Administration in Healthcare Executive Management. This degree is offered in collaboration between the School of Health Sciences and the School of Business. Each school collaborates with the other to provide a high quality education in both disciplines [14]. Physicians and other healthcare workers trained in business practices become very familiar with the concepts of teamwork and optimal team performance disciplines (Table 1).

Table 1: Barriers to effective healthcare team communications and solutions.

Dr. Parisa Aslani has conducted much research on collaboration between medical professionals especially research related to the collaboration between pharmacists and physicians. Her findings showed that there was a much more likelihood of adverse drug interactions when there was no collaboration between pharmacists and physicians. In cases where there was collaboration either face to face or using technology such as CPOE, the likelihood of adverse drug interactions decreased significantly.

Collaboration among all the healthcare providers who attend to a patient is critical to the wellbeing of the patient. The providers should be viewed as a team with the goal of providing the best healthcare possible to the patient. Healthcare providers trained in business concepts of teamwork have the knowledge to be more productive team members and leaders, and the traditional medical culture of physicians to work independently has to be overcome. Technology can fill the needs to share information amongst all the providers, but the technology must be utilized and it must be accessible to all providers. If Mr. Smith’s providers had used this existing technology, he probably would not have had to visit the emergency room.

No funding was received for this research

The author declares that she has no conflicts of interest or competing interests.

All research and writing were done by the author.

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