Prescription for Digital Evolution: Transformative Recommendations for Pharmacy Practice in the Digital Age

Abstract

Increased administrative tasks, evolving expectations of care and advancement in practice scope have rapidly advanced digital health. Health policy has acknowledged the need for evaluation to determine the technological needs of clinicians, including pharmacists, to practice to full and top of scope. There is an emergent need for recommendations to address the technological transformation to enable community pharmacists’ practice. This study aimed to develop digital health recommendations, through expert consensus, for the government, pharmacy professional associations, pharmacy enterprises and software vendors, to facilitate community pharmacists’ practice. A modified Delphi survey was conducted online in February-March 2024. Pharmacists with digital health expertise were purposively recruited. Participants were asked to rate their level of agreement with the initial 24 research-derived statements in round 1. Consensus was defined a priori as ≥80% of participants strongly agreeing or agreeing with a statement and a standard deviation of ≤1.00. Review of participants’ free-text comments progressively reduced and refined the statements. All 22 participants completed the modified Delphi study in 3 survey rounds. Participants represented every Australian jurisdiction. Eighteen participants had more than 10 years of professional experience. Sixteen recommendations emerged: 6 for government, 2 for pharmacy professional associations, 4 for pharmacy enterprises and 4 for software vendors. The majority of recommendations require financial investment and harmonization of legislation across jurisdictions. Adoption of these recommendations, with significant investment across partners in the healthcare system and technology providers, will enable pharmacists to more effectively and safely practice utilizing technology solutions.

Introduction

Pharmacists play an integral role in the healthcare system, ensuring effective and safe medication management. ¹ Increased administrative tasks, changing patient expectations of care, and an evolving and growing scope of practice have resulted in the need for advanced technological solutions to support community pharmacists to optimize service delivery. ¹ There has been significant technological advancement in healthcare systems globally through the introduction of electronic prescribing, clinical decision support systems and electronic health ² ; however, there is limited research on its impact on community pharmacists. A recently published review of the implementation of Electronic Prescriptions, ³ My Health Record (Australia’s cloud-based opt-out shared patient electronic health record ⁴ ) and Real Time Prescription Monitoring ⁵ in Australia identified no programmatic evaluation of the technological needs of community pharmacists to enable practice. ⁶

Continued expansion of digitally enabled healthcare is the future of the Australian healthcare system, as evidenced by strategy documents such as the Digital Health Blueprint and Action Plan 2023-2033 ⁷ and National Digital Health Strategy and Delivery Roadmap 2023-2028. ⁸ An Unleashing the Potential of our Health Workforce - Scope of Practice Review is underway in Australia to determine the system barriers and enablers for all health professionals to practice to full and top of scope. ⁹ The Scope of Practice Review Issues Paper 1 identified technology as a “significant” factor in enabling health professionals to work to full and top of scope, contribute to health system sustainability and achieve improved patient outcomes. ¹⁰ Technology evaluation is critical in addressing enablers and barriers to adoption and ensuring technology is fit for purpose. ⁶

Government and policy stakeholders, such as consumers representatives and healthcare associations, will need to consider enablers ¹¹ (recommendations, guidelines) to support healthcare professionals such as community pharmacists to have timely access to patient data. Further to determining the technological needs of healthcare professionals is identifying digital transformation enablers to support their practice. Considerable effort, including the contribution of healthcare professionals and patients, will be required to create a sustainable whole-system approach for digitally enabled systems. ¹¹

Considering the pace of policy changes affecting pharmacists’ practice, it is timely to investigate and propose recommendations to stakeholders involved in digital transformation. This study aimed to produce digital health recommendations for the government, pharmacy professional associations, pharmacy enterprises and software vendors to support technology implementation for community pharmacists’ practice.

Methods

Modified Delphi Survey

This study was conducted in February-March 2024. Ethical approval was granted by the Curtin Human Research Ethics Committee, approval number HRE2022-0249-04.

The Delphi technique is a validated method to achieve “consensual agreement among expert panelists, through repeated iteration (usually by email) of anonymized opinions and of proposed statements from the group moderator.” ¹² Applications have included exploration of barriers and facilitators before system implementation, identification of key performance indicators for advanced practice, and definition of professional roles and practice standards for pharmacist prescribing. ¹² The current study utilized a modified Delphi approach, a validated method that develops the initial survey statements based on review of literature and prior qualitative interviews, ¹³ as opposed to proposed by the moderator.

The initial statements were informed by 4 research processes prior to review by the research team: qualitative interviews with community pharmacists identifying their technological needs to enable practice ¹⁴ ; a systematic scoping review of health informatics literature ¹⁵ ; and development ¹⁶ and application of a technology evaluation framework. ⁶ Twenty-four statements were derived pertaining to community pharmacists’ technological needs to facilitate clinical practice. Three pharmacy practice researchers reviewed the draft instrument for face and content validity. Minor changes were incorporated into the wording of several statements; all statements were retained.

Participant Recruitment

Participants were recruited using purposive sampling, ¹² to include pharmacists with specific expertise in digital health in Australia in a sector relevant to community pharmacy, including policy, advocacy and/or tertiary education. Purposive selection can yield valuable data for policy or management decision making. ¹⁷ “Snowballing” was also used in the initial recruitment, following participants’ suggestions of other experts who met the inclusion criteria. ¹²

Since the final recommendations from this study were intended for pharmacy stakeholders, it was imperative that pharmacists’ needs and perspectives were retained as the focus. “Expert advisor” criteria were adopted from the Australian Digital Health Agency. ¹⁸ To be considered an expert, the panelist was to: be a practicing healthcare or digital health provider with subject matter expertise in contributing to digital health and currency of practice, or experience in advocacy and engagement in digital health; or be engaged in training, education or research in digital health; or have membership of a digital health organization(s) or a qualification in digital health. ¹⁸

Pharmacists were recruited with consideration of demographic characteristics: area(s) of practice, number of years of experience and locality to ensure wide representation of opinions to inform the consensus. Experts were identified by the research team and invited via email.

This study aimed to recruit fifteen to twenty participants. Attrition of twenty to thirty percent was predicted ¹⁹ in order to receive ten to sixteen complete responses, sufficient for standard consensus statistics (explained below). Published Delphi studies report sample sizes from fifteen to several hundred participants. ¹² A systematic review identified a majority of Delphi studies had fewer than twenty-five participants. ²⁰

Participants were given 2 weeks to complete each survey round, with 1 week between each round. Reminder emails were sent to non-respondents 1 week after deployment of each round, and non-participation at 2 weeks was considered withdrawal from the study. Each participant was offered AU$180 as compensation for their professional time for completion of the study.

Data Collection

All survey rounds were distributed via an online survey platform, Qualtrics™, to facilitate remote participation and offer convenience. Consent to participate was sought electronically upon commencement of each survey. Each statement was accompanied by a five-point Likert scale, intentionally including a neutral response. ¹³ Participants were required to provide a response to all statements, and could save and return to their responses. In all survey rounds, participants were invited to explain their answers, suggest improvements to statement wording and suggest further statements to include in the subsequent round(s) to minimize the risk of limiting results. ¹² Participants were also sent, via email, a feedback report summarizing the consensus results from the previous round, to facilitate reflection on their previous ratings compared to responses from the whole group. ¹⁷ This was facilitated by inclusion of a prompt and free-text box following each statement. This study allowed for a third survey round to maximize the chance of reaching consensus. ¹²

Data Analysis

The Statistical Package for the Social Sciences^® (SPSS^®) version 29 was used to analyze data from all survey rounds. Descriptive statistics were utilized to report participants’ demographic characteristics and responses. Likert scale responses were coded numerically: strongly disagree = 1, somewhat disagree = 2, neither agree nor disagree = 3, somewhat agree = 4, and strongly agree = 5. The distribution of responses, median and standard deviation for each statement were calculated from the pooled data. Free-text comments offered against each statement were reviewed by the research team to aid refinement of statements. This assisted in identifying oversights and alternative perspectives to ensure the comprehensiveness and relevance of the final statements.

A dual-criteria definition of consensus was determined a priori as 80% of the panelists selecting ‘strongly agree’ or ‘agree’ to a statement (a conservative application of a definition derived from a systematic review (median 75% in agreement) ²⁰ ) and standard deviation $\le$ 1.00. ²¹ Stability of consensus was not calculated in this study, as statements in subsequent survey rounds (rounds 2 and 3) were progressively reduced. This approach has been adopted in other Delphi studies that have modified statements between survey rounds.^22,23 Following data analysis for each round, final consensus recommendations were progressively compiled.

Results

Twenty-two participants were recruited, all of whom completed all 3 survey rounds (Table 1). Eighteen participants were recruited via personalized email invitation, and 4 were recruited through snowballing. Participants represented every Australian jurisdiction, and eighteen participants had more than 10 years of experience within their practice area. Following the third Delphi round, the research team were confident that consensus had been reached, based on the consensus statistics for each statement and free-text comments from participants (Table 2).

Table 1.

Demographic Characteristics of Participants (N = 22).

Area(s) of Practice a	n (%)
Community pharmacy	16 (72.7)
Academia/Research	12 (54.5)
Professional organization	3 (13.6)
Software company or service	11 (50.0)
Other (free text response)	4 (18.2)
	• Consulting company
	• Private telehealth service
	• Regulation
	• Government
Number of Years of Experience
0-5 years	3 (13.6)
6-10 years	1 (4.5)
11-15 years	9 (40.9)
16-20 years	7 (31.8)
Over 20 years	2 (9.1)
Location
Queensland	1 (4.5)
Australian Capital Territory	1 (4.5)
New South Wales	7 (31.8)
Victoria	6 (27.3)
Tasmania	2 (9.1)
South Australia	1 (4.5)
Northern Territory	1 (4.5)
Western Australia	3 (13.6)

^aParticipants could select more than 1 practice area, indicating the number of years of experience in the longest practice area.

Table 2.

Results of all Three Survey Rounds.

Statement	Percentage of Participants in Agreement (Total participants = 22) (%)	Mean	Median	Standard Deviation	Number of Free Text Responses	Statement Outcome
Round 1
Government
1. The government should mandate the use of technology, in place of paper-based systems, to transfer patient information to and from pharmacies	77.3	3.86	4.00	1.082	8	Amend
2. There should be one national platform, operated by one provider, for secure messaging to enable health information transfer between health professionals	63.7	3.64	4.00	1.217	10	Amend
3. The government should be the sole funder for digital transformation in community pharmacies	40.9	2.95	2.50	1.397	10	Amend
4. The government should provide funding for digital transformation at transitions of care that involve community pharmacists	90.9	4.41	5.00	1.054	4	Include
5. Community pharmacies should be funded to upskill consumers in digital health	72.8	4.00	4.00	1.234	6	Amend
6. The government should be responsible for initiatives to improve the digital health literacy of consumers	90.9	4.27	4.00	0.767	4	Include
7. There should be national harmonization of legislation relating to health technologies used in pharmacies	86.3	4.50	5.00	1.012	5	Include
8. New technologies should only be adopted nationally if they are interoperable with existing platforms	68.2	3.68	4.00	1.427	8	Exclude
9. Community pharmacists should be able to access patient information, without consent, during the provision of a professional service	36.4	2.82	2.50	1.259	9	Exclude
Pharmacy Professional Associations
10. It is the responsibility of pharmacy associations to produce best-practice guidelines for use of technology in pharmacy	86.3	4.00	4.00	0.535	7	Include
11. It is the responsibility of pharmacy associations to train pharmacists in the use of new technologies	59.1	3.45	4.00	0.963	7	Exclude
12. Pharmacy associations should advocate for practice incentives for community pharmacies to expand their technological capacity	90.9	4.41	5.00	0.796	5	Include
13. Evidence of professional development in digital health should be mandated for annual Ahpra registration	40.9	3.36	3.00	1.177	7	Amend
Pharmacy Enterprises
14. It is the responsibility of pharmacy managers to ensure their employees are appropriately trained in new technologies	91	4.32	4.00	0.780	2	Include
15. When training of pharmacy staff is required for health technologies, it should occur in the pharmacy	50	3.23	3.50	1.110	6	Amend
16. Pharmacists should only engage in advanced roles or responsibilities not able to be automated	45.4	3.23	3.00	1.110	5	Exclude
17. All administrative tasks should be fully automated in community pharmacy	68.2	3.82	4.00	0.907	7	Amend
18. Artificial intelligence should be used to assess clinical information to support pharmacists’ clinical decision making	77.3	4.00	4.00	0.926	9	Amend
19. Cybersecurity training should be mandated for all pharmacy staff	90.9	4.55	5.00	0.800	4	Include
Software Vendors
20. Community pharmacists should be more involved in user testing of new technology	95.5	4.50	5.00	0.740	5	Amend
21. Software vendors should establish a system for health professionals to provide direct feedback about the software	100	4.86	5.00	0.351	7	Include
22. When new technologies are implemented, there should also be a process to independently evaluate its impact	95.4	4.59	5.00	0.590	5	Amend
23. Software vendors should passively collect data about how health professionals use their technology	90.9	4.23	4.00	0.752	8	Include
24. Software vendors should engage pharmacists to evaluate their technology throughout its lifecycle: Design, implementation and updates	100	4.73	5.00	0.456	3	Amend
Round 2
Government
1. Technological solutions should be the default in place of paper-based systems to transfer patient information	95.5	4.64	5.00	0.581	7	Include
2. Communication between health professionals involving patient data must occur through secure messaging platforms	90.9	4.73	5.00	0.631	7	Include
3. The government should invest in co-design with pharmacists to undertake digital transformation for pharmacies	100	4.86	5.00	0.351	6	Include
4. Community pharmacies should receive incentive payments for upskilling consumers in digital health	77.3	4.14	4.00	1.037	8	Amend
Pharmacy Professional Associations
5. Ahpra registered pharmacists engaging in digital health services must undertake relevant professional development	90.9	4.09	4.00	0.971	8	Amend
Pharmacy Enterprises
6. Pharmacy staff should receive onsite training for technology used in practice	77.3	4.05	4.00	1.090	10	Exclude
7. Automation should be introduced where feasible to improve productivity in pharmacies	90.9	4.50	5.00	0.802	8	Include
8. Pharmacists should embrace artificial intelligence in assessing clinical information	81.8	4.00	4.00	1.133	8	Amend
Software Vendors
9. Software vendors should consult community pharmacists in all stages of software development and implementation	86.4	4.18	4.00	1.053	11	Amend
10. The impact of technology in pharmacy practice should be evaluated by an independent body	63.6	3.59	4.00	1.221	8	Amend
Round 3
Government
1. Community pharmacies should receive a practice incentive payment to support consumer engagement in digital health	77.3	4.18	4.00	0.907	7	Exclude
Pharmacy Professional Associations
2. The annual mandatory professional development for Ahpra registered pharmacists must address digital competency	72.8	3.91	4.00	1.151	7	Exclude
Pharmacy Enterprises
3. Pharmacists should embrace artificial intelligence as a tool to assist with clinical decision making	81.8	4.00	4.00	0.926	9	Include
Software Vendors
4. Software vendors should invest in co-design with pharmacists in all stages of software development and implementation	86.4	4.41	5.00	1.098	7	Include
5. Independent evaluation on the impact of digital health initiatives must be in place to ensure continuous quality improvement	95.4	4.50	5.00	0.598	6	Include

Round 1

The first survey round consisted of twenty-four statements: 9 relating to government; 4 relating to pharmacy professional associations; 6 relating to pharmacy enterprises; and 5 relating to software vendors. Consensus was achieved for 9 out of twenty-four statements in round 1; these 9 statements were included verbatim in the final recommendations. Based on free-text comments, eleven statements were amended for inclusion in the second survey round, despite 4 having achieved consensus. Two of the eleven amended statements were combined, also on account of participants’ commentary. The remaining 4 statements were excluded due to perceived irrelevance or redundancy.

Round 2

The second survey round comprised ten statements (4 relating to government, 1 relating to pharmacy professional associations, 3 relating to pharmacy enterprises and 2 relating to software vendors). Consensus was achieved for 4 out of ten statements in round 2; these 4 were subsequently included in the final recommendations. Five statements were amended for inclusion in the following survey round, and 1 statement was excluded. While 3 of the 5 statements had reached consensus, participants’ comments informed amendments that warranted re-testing.

Round 3

The third survey round consisted of 5 statements (1 relating to government, 1 relating to pharmacy professional associations, 1 relating to pharmacy enterprises and 2 relating to software vendors). Three statements reached consensus and were included in the final recommendations without further refinement (Table 3). The remaining 2, despite their clarification, were perceived as redundant or unable to reach consensus.

Table 3.

Consolidated Recommendations.

Government

1. Government funding should be available to enable digital transformation at transitions of care that involve community pharmacists.

2. Initiatives to improve digital health literacy of consumers should be funded by the government.

3. There should be national harmonization of legislation relating to health technologies used in pharmacies.

4. Technological solutions should be the default in place of paper-based systems to transfer patient information.

5. Communication between health professionals involving patient data must occur through secure messaging platforms.

6. Digital transformation for pharmacies must be invested in by the government through co-design with pharmacists.

Pharmacy Professional Associations

7. Best-practice guidelines for use of technology in pharmacy are the responsibility of pharmacy associations.

8. Practice incentives for community pharmacies to expand their technological capacity should be advocated for by pharmacy associations.

Pharmacy Enterprises

9. Appropriate training for employees on new technologies is the responsibility of pharmacy managers.

10. Cybersecurity training should be mandated for all pharmacy staff.

11. Automation should be introduced where feasible to improve productivity in pharmacies.

12. Artificial intelligence should be embraced to assist with clinical decision making.

Software Vendors

13. Software vendors should establish a system for pharmacists to provide direct feedback about the software.

14. Passive data collection should occur on how pharmacists utilize vendor software.

15. Relevant stages of software development and implementation should occur through co-design with pharmacists.

16. There must be independent evaluation of digital technologies to inform ongoing improvement and future use.

Explanatory notes

Artificial intelligence (AI): “AI-enabled clinical decision support systems combine the knowledge reasoning techniques of AI and the functional models of clinical decision support systems.” 24

Automation: Pharmacy automation – automating major processes of pharmaceutical dispensing, including the use of robotics 25

Digital health literacy: “the ability to appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health-related problem.” 26

Digital transformation: “A process that aims to improve an entity by triggering significant changes to its properties through combinations of information, computing, communication and connectivity technologies.” 27

Practice incentives: Incentive payments aimed to support general practice, encouraging continuous improvement and better patient outcomes 28

Transitions of care: “When all, or part, of a person’s health care is transferred between care providers. 29

Review of Free-Text Responses

The following summary of free-text responses presents the participant feedback utilized in refining and reducing the statements (Table 4). For statements that progressed to the final recommendations, ie, had a high consensus and low standard deviation, there were no free-text comments requesting amendment.

Table 4.

Sample of Free-Text Responses.

Round 1

Perhaps it’s not about 1 platform, but the interoperability to ensure safe, secure and seamless transfer of information from all health professionals and other bodies to enable the best health outcomes for Australians and facilitate a more efficient and effective workflow for healthcare professionals. – P3

Technologies may help support pharmacists to engage in advanced roles/responsibilities. – P9

The Government is 1 stakeholder. There needs to be a co-design process with a number of key stakeholders driving and delivering this initiative. This would include peak bodies, consumers, subject matter experts, health care professionals, regulatory bodies etc. – P16

With the right governance, security measures and privacy, AI would be a powerful tool to support pharmacist clinical decision making. – P19

Round 2

Paper-based systems carry too many disadvantages in modern day society. Eg, things get lost/damaged, privacy risk, environmental cost, harder to open up access to multiple users at the same time. – P18

For best outcomes, it is critical for co-design and appropriate user testing with products in production and in live environments. The users can then provide feedback to ensure the software is optimal. Continuous cycle of improvement. Implementation also requires an understanding of the pharmacy landscape and integration into existing workflows. – P19

Round 3

Í believe that given digital health proficiency and competency is now so integral to practice, there should be some inclusion of enhancing digital skill-sets amongst pharmacists. This should be driven by strengthening the focus on digital competency within the competency standards (rather than mandating specific digital CPD). – P9

It would be useful to not only appreciate the benefits (fiscal savings, time efficiencies etc.) but also understand the challenges and gaps that may be created or exacerbated. Where do further solution enhancements or changes in practices need to occur to ensure continuous quality improvement (the answer may not always be digital). – P14

There is a balance between maximize AI and use in health and the risks, we need to educate pharmacists on how to use AI appropriately to achieve better health outcomes. – P16

Participants concurred that co-design of technologies with pharmacists as end users was necessary in relevant stages of the development and implementation of technology, but not necessarily during back-end coding. Through reports on how pharmacists as end users adopt technology as part of their workflow, software vendors could look to refine or expand on functionality that optimizes usage, prompting the related statement to be amended.

Amongst the statements considered for amendment, participants did not concur on a mandated single technological solution for patient information transfer. However, free-text responses indicated general agreement amongst participants that the transfer of patient information at transitions of care should be conducted through real-time secure messaging. Furthermore, participants called for widespread adoption of these technologies, once made available, by health professionals and consumers to replace paper-based information transfer. This sentiment was introduced into the relevant statement through amendment.

Participants agreed that pharmacy professional associations have a role in overseeing the development of best-practice guidelines; however, some comments suggested emphasizing the need for collaboration and co-design with all pharmacy associations, consumers, software vendors and other relevant stakeholders. The corresponding statement was amended accordingly. Participants also described agreement regarding direct user-feedback mechanisms to refine and develop technology, citing this as the norm. However, some recognized commercial constraints as a barrier in ensuring this occurred at all stages of technology development, prompting amendment of the related statement.

Free-text responses described optimism towards the potential role of artificial intelligence (AI) in augmenting clinical decision making, provided regulatory, data security and governance frameworks were developed and implemented. Participants called for flexibility in adopting AI-based clinical decision making, citing a lack of existing technology and the need for pharmacists to ensure they have the appropriate education and procedures to facilitate adoption. Participants described some agreement that automation could be introduced where feasible to improve pharmacy productivity, supporting pharmacists in undertaking more complex tasks. They emphasized feasibility as a potential barrier. Participants called for amendment of the statement relating to AI to acknowledge introduction of automation where feasible.

As indicated above, 8 statements were deleted on account of perceived redundancy or lack of consensus. While the participants collectively disagreed that incentive payments are needed for pharmacists to improve consumer digital health literacy, there was an acknowledgement that pharmacists could play a role in this area, and further work is needed to evaluate the purpose and outcome of this role. The statement relating to incentives was excluded from the final recommendations.

Consensus was not reached regarding the need for pharmacists to undergo continuing professional development in digital health technologies. Free-text responses described the “expectation” that every pharmacist should have “digital health competency.” Noting the rapid implementation of technology during the COVID-19 pandemic, participants described the use of technology in practice as becoming the “norm”, and as such, all pharmacists should have operational proficiency in these systems. On the contrary, some participants were in favor of mandatory continuing professional development relating to digital technologies, citing the need for pharmacists to demonstrate this as part of their annual professional registration. Furthermore, some participants described the need for national competency standards and pharmacy education to include digital health literacy as a core competency for pharmacy practice. On account of the diversity of opinions, the statement relating to mandatory continuing professional development was excluded.

Discussion

This is the first study to develop a suite of digital health recommendations relating to Australian pharmacy practice using a modified Delphi approach. This study derived sixteen digital health recommendations for the following stakeholders: 6 for government, including policy makers and funders; 2 for pharmacy professional associations involved in policy and advocacy; 4 for pharmacy enterprises, including pharmacy managers or employers involved in technology implementation; and 4 for software vendors. The adopted definition of consensus was appropriate, given the high percentage of participants in agreement and low standard deviation among the diverse expertise represented in the study. Participants’ free-text comments facilitated further refinement of statements, helping to ensure final recommendations were clear and succinct.

The overall findings concurred that Australia’s healthcare system would benefit from addressing fragmentation due to multiple funding and governance systems ³⁰ ; technology solutions for pharmacists are proposed to help reduce this fragmentation. Technology used during patient information transfer often operates in “information silos” ³¹ due to a lack of real-time information transfer. ³² This often results in poorer patient outcomes and further exacerbates fragmentation. ³² Evidently, practitioners engaged in our study had experienced this first-hand. Limited pharmacy stakeholder engagement, rapidly expedited implementation of new technology through the COVID-19 pandemic, and a lack of harmonization in jurisdictional legislation governing technological systems used in practice have previously been cited as factors that have negatively impacted technology implementation. ⁶ Numerous comments from participants acknowledged the complexity of rapid change across a country as geographically diverse as Australia. Resulting recommendations to harmonize legislation relating to health technologies and invest in technology codesign with pharmacists highlights this to stakeholders.

Enablers of digital transformation include funding to support the digital capacity and capability of community pharmacies and other health organizations, and harmonization in legislation to enable information transfer across jurisdictions. The need for government funding to facilitate digital health transformation was implied across the final sixteen recommendations. Digital capacity building should be conducted through co-design approaches, including pharmacists, patients and other stakeholders, to ensure this is fit for purpose. The government should invest in public health initiatives that support digital health literacy as an extension of health literacy to equip consumers with an understanding of how their information is used when accessing a healthcare service. This should be supported through government funding to enable digital transformation at transitions of care, as well as within pharmacies. Furthermore, consumers should be empowered and enabled to adopt these technologies.

Participants identified a need for transparent governance through best-practice standards and guidelines for technology use in practice. While the Australian Digital Health Agency is responsible for the strategic direction of digital health transformation in Australia, relevant stakeholders should be involved in the co-design and implementation of these directions. ⁶ Greater investment in evidence-based guidance for clinicians and patients has been described as an effective way to promote cost-effective and clinically safe healthcare practice. ³⁰ Additionally, previous work recommended establishing an expert panel of clinicians to “assess and endorse guidelines, and advise on dissemination, implementation and review of service delivery. ³⁰ The current study concurs with previous work recommending the need for prompt dissemination of best-practice guidelines and a “do-not-do” list to health professionals, updated in line with standards and evidence. ³⁰

Strategic direction from the Australian Digital Health Agency indicated that technology co-design would be imperative in ensuring digital transformation that facilitates patient-centered care. ⁷ This study calls for investment from government to engage pharmacists through co-design processes when considering digital transformation. The National Digital Health Strategy called for the implementation of improved conformance profiles to support software vendors in ensuring their technology is interoperable with other platforms as a set of guiding principles for technology design. ⁸

Technological capacity and capability funding rely on pharmacy enterprises investing in their own digital transformation. This presents 2 issues, the first being potentially poor adoption of new technology due to operational constraints, and the second, potential reliance on paper-based systems due to cost savings. These factors potentially exacerbate fragmentation in information transfer within community pharmacies. The recommendation for pharmacy professional associations to advocate for practice incentives or funding to allow community pharmacies to expand their technological capacity and capability was described as a necessary step in improving adoption. Furthermore, this funding should be allocated equitably, based on metrics including pharmacy size and location. While practice incentive payments are not novel, they have not been offered to pharmacies in Australia. Currently, Australia’s Practice Incentives Program eHealth Inventive provides funding for general practices to develop their digital capabilities, including secure messaging, electronic transfer of prescriptions and use of My Health Record among other technologies. ³³ Several studies have evaluated the impact of incentive payments on patient outcomes^34-36; however, there is limited evidence on their impact to technology adoption within general practice.

Researchers have cited the need for pharmacists and supporting staff to be supported with appropriate training and education to facilitate technology adoption.^6,37 The most commonly reported barrier to technology adoption has been a lack of resources, including workload and time constraints, and a lack of whole-team engagement in operationalizing workflow changes around newly implemented systems. ³⁷ The recommendation that there must be independent evaluation of digital technologies arising from this study recognizes that the current challenge of technological implementation in community pharmacy lies in balancing clinical and professional obligations alongside commercial responsibilities. ³⁷ It is the responsibility of those involved in technology implementation within community pharmacies to ensure employees have the capabilities to support its use, including cybersecurity awareness.

The rapid evolution of AI in healthcare, particularly in pharmacy practice, presents an array of potential AI applications, including implementation of therapeutic guidelines and prediction of patient adherence. ³⁸ This study includes 1 recommendation calling for pharmacists to embrace AI to assist with, as opposed to automate, clinical decision making. AI could improve efficiency through more connected multidisciplinary patient care, and enhance operational aspects of pharmacy practice, such as inventory management. ³⁸ Previous research to evaluate community pharmacists’ willingness to adopt AI-enabled technology in practice indicated that pharmacists perceived a lack of AI-related software and hardware, the need for human supervision of AI and potential costs as barriers to adoption. ³⁹ The recommendation that automation should be introduced where feasible to improve pharmacy productivity, and this echoes previous research calling for evaluation of the impact of automation and robotics systems in the medication management process. ³⁸ Additionally, automation of routine tasks could allow all staff to adopt more patient-focused tasks. ³⁸ If pharmacists are to embrace AI and automation in pharmacy practice, there must be processes to facilitate integration including the need to re-evaluate other factors influencing practice, such as professional indemnity cover and guidelines.

Furthermore, multi-stakeholder evaluation involving researchers, clinicians and the health technology sector has been described as the means to ensure continuous improvement and innovation. ⁸ Participants concurred that independent evaluation could inform ongoing improvement and future use of these technologies; however, they cited that this evaluation should remain independent and driven by clear purpose and outcomes. Participants described independent evaluation as costly and slow compared to the rapid implementation and iteration of technology in practice. Despite this, the value of evaluation was clearly recognized and acknowledged. This finding echoes research calling for the need of independent evaluation that reflects the fast-paced digital transformation in pharmacy. ¹⁵

Implications for Practice and Future Research

Recommendations from this study aim to inform stakeholders, at this critical time of evolution, regarding digital transformation enablers to support community pharmacists, among other health professionals. Future research could include presenting these statements to consumers to determine their viewpoints on these recommendations and, through triangulation, provide further recommendations for digital transformation. Health technology assessment in the context of pharmacy practice is commonly applied to pharmaceuticals, including diagnostic tests, medical devices and other public health interventions. ⁴⁰ Future research may consider the application of similar health technology assessment processes to digital technologies used in pharmacy. Considering the rapid pace of change, ongoing research is urged to address health system enablers and barriers to technology adoption, ensuring the inclusion of multiple stakeholders in the evaluation process.

Strengths and Limitations

The first round of this modified Delphi study was developed following review of health informatics literature, followed by face and content review by 3 expert pharmacists independent of the research team. As such, the initial statements were research informed, rather than proposed by the moderator. The provision (and inclusion) of a third survey round further strengthened the method to derive consensus statements.

This study involved participants from all Australian jurisdictions and with a range of expertise in digital health, and every participant completed all 3 rounds of the Delphi study. Most participants offered free-text comments of use in refining the statements. Consequently, we are confident of participants’ depth of engagement with the task and cross-sectionality of the study, despite the modest sample size.

Participants were not asked to review the final sixteen consensus statements presented together, and as such, there may be omissions in the concepts covered by the final statements.

Participants were asked to “self-describe” their level of digital health experience, which could have introduced bias in their perspectives. It is recognized that participants with a special interest in digital health may have brought to this research specific insights from their involvement in advisory groups or unique health roles. This level of detail about their backgrounds was not elicited and therefore not reported, as it may have identified the participants. Similarly, recruitment via snowballing may have over-represented particular perspectives. While methodological guidance indicated the sample size was sufficient, it is recognized that pharmacy practice uniquely differs by location or rurality, infrastructure and personal experience, therefore the perspective provided by participants may not be indicative of views expressed by the rest of the pharmacy profession. The majority of recommendations arising from this study imply the need for financial investment from the government. It was beyond the scope of this study to explore non-government avenues of funding and non-financial investment. However, a number of participants acknowledged a level of responsibility from pharmacy associations and enterprises to invest in their digital future. Additionally, participants were not asked to consider the level of government (Federal or state/territory) for this investment, or pharmacy practice outside of community pharmacy.

Conclusions

As community pharmacists’ practice evolves and expands, evaluation should determine barriers and enablers to practice and inform stakeholders involved in technology implementation to support these roles. This study presents sixteen recommendations for stakeholders – in government, pharmacy professional associations, pharmacy enterprises and software vendors – on digital health transformation strategies that may help address these needs. Significant investment, legislative alignment and co-design will ensure community pharmacists and other health professionals are supported by technological transformation to enable full and top of scope of practice.

Ethical Statement

Ethical Approval

Ethical approval was granted by the Curtin Human Research Ethics Office (approval number HRE2022-0249-04).

Consent to Participate

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. The participants provided their informed consent to participate in accordance with the ethical approval of this study.

ORCID iDs

Ayomide Ogundipe https://orcid.org/0000-0002-5000-7193

Tin Fei Sim https://orcid.org/0000-0003-0068-5006

Lynne Emmerton https://orcid.org/0000-0002-0806-6691