Abstract
Introduction:Navarra´s healthcare model is based on coordination between healthcare levels and the integration of diverse healthcare professionals across them.
The objectives of this study were describe the design, implementation, and evaluation a communication channel between Primary Care (PC) teams and Community Pharmacies (CP) within each Basic Health Zone in Navarra, integrated into the electronic prescription system.
Materials and Methods: A channel was designed to enable interaction between CP and PC professionals through the electronic prescription. A procedure was developed, outlining responsibilities, notification protocols and the distinction between urgent and non-urgent incidents. For the evaluation, a satisfaction survey was distributed to all participants.
Results: The system was progressively expanded since 2021, reaching 95% of PC teams and 100% of CPs in 2024. Satisfaction surveys revealed a high appraisal of the channel, particularly among CPs, highlighting its utility, improvements in work organization and optimization of resolution times.
Conclusion: The implementation of an appropriate communication channel between PC teams and CPs is essential for enhancing patient care. This channel has improved the quality of interprofessional collaboration, acting as a catalyst for alignment and trust between HC and CP professionals.
Keywords: Interprofessional Relations, Community Pharmacy Services, Primary Health Care
Abstract
Resumen
Introducción: El modelo sanitario de Navarra se apoya en la coordinación entre niveles asistenciales y la integración de los diferentes profesionales sanitarios en los distintos niveles.
Los objetivos del trabajo fueron describir el diseño, implementación y evaluación de un canal de comunicación entre los equipos de AP y las farmacias comunitarias (FC) de cada zona básica de salud (ZBS) de Navarra a través de la receta electrónica.
Material y métodos: Se diseñó un canal de comunicación que, a través de la receta electrónica, lograba la comunicación entre los farmacéuticos comunitarios y los profesionales de los CS.
Se elaboró un procedimiento normalizado de trabajo en el que se indicaban las responsabilidades, cómo realizar las notificaciones y la diferencia entre incidencias urgentes y no urgentes.
Para la evaluación, se envió una encuesta de satisfacción a todos los profesionales implicados.
Resultados: El sistema se extendió progresivamente hasta alcanzar en 2024 al 95 % de los equipos de AP y al 100 % de las FC de Navarra.
Las encuestas de satisfacción mostraron una elevada valoración del canal, especialmente por parte de los profesionales de las FC, destacando su utilidad, la mejora en la organización del trabajo y la optimización del tiempo de resolución.
Conclusiones: La puesta en marcha de un canal de comunicación adecuado entre los equipos de AP y las FC es fundamental y permite mejorar la atención a nuestros pacientes. Este canal de comunicación ha permitido mejorar la calidad de la colaboración interprofesional, siendo un punto de acercamiento y confianza entre los profesionales del CS y de la FC.
Palabras clave: Relaciones interprofesionales, servicios de farmacia comunitaria, atención primaria de salud
INTRODUCTION
In Spain, Primary Care (PC) constitutes the backbone of the National Health System. This model enables comprehensive, continuous, and patient-centred care for individuals, families, and communities over time, reaching the entire population regardless of socioeconomic status [1].
In Navarre, the healthcare system is based on an organisational model aimed at facilitating comprehensive, patient-centred care, with PC functioning as the core of the healthcare system. The region is organised into 58 primary healthcare zones (PHZs), serving a population of 670,459 inhabitants, and includes 585 community pharmacies. The importance of integration among the different levels of care became even more evident during the SARS-CoV-2 pandemic, which highlighted the need to address health problems through a comprehensive approach [2]. However, integration of healthcare services should not be limited to organisational coordination among institutions; genuine clinical integration is also essential, involving effective and practical coordination of healthcare activities beyond administrative or organisational agreements.
Comprehensive and coordinated pharmaceutical care across different healthcare settings requires pharmacists to be integrated into multidisciplinary healthcare teams in order to improve population health outcomes. The knowledge and skills of community pharmacists make them healthcare professionals capable of contributing to the comprehensive management of pharmacotherapy in coordination with other healthcare professionals. In 2020, the Council of Europe adopted Resolution CM/Res(2020) [3] on the implementation of pharmaceutical care within healthcare systems, aimed at promoting the appropriate and safe use of medicines through activities such as the identification of pharmacotherapy-related problems. Pharmaceutical intervention in this context requires the establishment of an appropriate framework for interprofessional collaboration [4].
Numerous studies have demonstrated the benefits of collaboration and integration of pharmacists, both from primary care pharmacy services and community pharmacies, within multidisciplinary healthcare teams [5,6]. However, several barriers hinder interdisciplinary collaboration, including limited access to shared electronic health records, lack of communication channels, absence of common protocols, and time constraints, among others. These barriers should therefore be considered when implementing clinical integration models aimed at coordinating healthcare services and ensuring continuity of care for patients.
At present, structured collaboration between community pharmacists and healthcare teams remains an unresolved issue, as this practice is generally not established between primary care teams and community pharmacies. In this context, technological advances represent valuable tools for the development and improvement of healthcare practice.
Errors of omission or delay in medication administration are defined as the failure to administer a necessary medication to a patient because the treatment has not been prescribed, transcribed, dispensed, or administered. These errors ranked first among the medication errors most frequently reported in 2022 and may lead to adverse events. To prevent them, the establishment of a list of critical medications has been recommended. Although the development of such a list does not itself prevent omission errors, it acts as a decision-support tool that enables prioritisation and the implementation of safety barriers for medications in which time is a determining factor for patient prognosis [7,8].
Community pharmacies are frequently the setting in which medication-related incidents are detected, such as medicine shortages, prescriptions not renewed in the electronic prescribing system, or pharmaceutical dosage forms inappropriate for the patient’s clinical situation, all of which may lead to delays in medication dispensing. To address these issues, the implementation of a well-defined communication channel has been one of the most frequently requested improvement measures by pharmacists [6]. Accordingly, in our region, a system has been implemented within the electronic prescribing software that enables community pharmacists to intervene professionally when detecting a medication-related incident, documenting and notifying the responsible healthcare professional at the health centre (HC). This system allows most incidents to be resolved, thereby avoiding patient inconvenience and increasing satisfaction with the healthcare system.
The main objective of this project was to describe the design and implementation of a communication channel between primary care teams and community pharmacies within each primary healthcare zone (PHZ) in Navarre through the electronic prescribing system. The secondary objective was to describe the evaluation of the channel’s performance and its acceptance among primary care teams and community pharmacies. This article aims to describe all the processes involved in the implementation of this communication channel.
MATERIALS AND METHODS
Description of the initiative
The project was promoted by a multidisciplinary group coordinated by primary care pharmacists (PCPs), which also included community pharmacists and physicians from the Primary Care Management Department.
With the support of an information technology team, a communication channel was designed within the electronic prescribing application to enable communication between community pharmacists and healthcare professionals at health centres (HCs).
A standard operating procedure (SOP) was developed to pilot this communication channel in three primary healthcare zones (PHZs) in Navarre: one urban and two rural. one urban and two rural. The SOP is presented in Appendix 1. These areas were selected because they represented different healthcare realities within the region: one urban area located in a highly populated district of Pamplona with a high workload; one rural area in the Pyrenees, characterised by low population density and geographical dispersion; and another rural area with a larger population and frequent staffing shortages.
In each PHZ, a meeting was held involving healthcare professionals from the HC and the managers of the community pharmacies in the area. These meetings were coordinated by the PCP responsible for the PHZ and included professionals from the Primary Care Management Department and representatives from the Official College of Pharmacists of Navarre. The communication channel and its implementation process were explained in detail during these meetings. Following the pilot phase, the communication channel was extended to all PHZs in the region.
Scope
The incidents or communications included within this communication channel may be classified into two categories: urgent incidents and non-urgent communications.
Urgent incidents were defined as those which, if not addressed within a short period of time, could have clinically relevant consequences for the patient. This category included:
Medication that could not be dispensed because the prescription had exceeded its validity period in the electronic prescribing system, the dosage regimen was not updated and the patient was taking the medication more frequently than prescribed, package loss or damage, medicine shortages, or any other circumstance in which treatment interruption could have clinical consequences for the patient.
Inappropriate pharmaceutical dosage forms in patients with dysphagia.
Adverse drug reactions or other clinically relevant medication-related problems.
Non-urgent communications included those considered clinically relevant and requiring intervention by the primary care team, although not requiring immediate action. These included:
Adherence problems or medication misuse detected in the community pharmacy.
Adverse drug reactions, medication-related problems, or disease-related problems identified in the community pharmacy that required review by the primary care team.
The assessment and classification of the type of incident were carried out by the community pharmacist, with decisions individualised for each specific case. This aspect was considered critical and was therefore emphasised during the training sessions delivered to professionals from HCs and community pharmacies before implementation of the communication channel.
Responsibilities
Community pharmacy professionals were responsible for communicating urgent incidents and non-urgent communications included in the SOP approved and agreed upon by the professionals involved in each PHZ.
Primary care teams were responsible for responding to urgent incidents from community pharmacies within one working day of receipt and for managing non-urgent communications within the timeframe agreed upon in each PHZ, ranging from five to ten working days. The primary care team management established the generic email address to which incidents should be sent and designated the personnel responsible for receiving and managing these messages.
Primary care pharmacists were responsible for collaborating in the development and updating of the SOP, facilitating coordination between primary care teams and community pharmacies, and coordinating the evaluation committees.
Development
Collaboration was established with the Health Technology Service of the Government of Navarre to develop the digital tool required to implement the communication channel. During the pilot phase, this tool was incorporated into the Navarre electronic prescribing system (LAMIA), enabling community pharmacies to notify urgent incidents and non-urgent communications to HC professionals.
During the design process, the communication channel was developed to fulfil several key characteristics considered essential:
Traceability
Ease of use
Flexibility to adapt to local characteristics
Broad access for all HCs using the channel
Patient-linked notifications
Possibility of consulting message history
Bidirectional communication
Priority was given to the creation of a user-friendly channel, avoiding coding systems for problems or notifications that might complicate reporting. Therefore, an unrestricted free-text field was enabled to describe the incident.
The communication workflow between community pharmacies and primary care teams was established as follows:
During patient care or medication dispensing, the community pharmacist detects one of the incidents included in the SOP. If not already completed, the pharmacist scans the patient’s individual healthcare card using the magnetic stripe reader to access the electronic prescribing system (LAMIA). Once inside the system, the pharmacist accesses the communication tool labelled “HC messages”. The tool allows selection, via a dropdown menu, of the HC to which the notification is addressed and whether the notification corresponds to an urgent incident or a non-urgent communication. A free-text section is available to describe the notification, while the patient’s name and identification code and the originating community pharmacy are automatically displayed by default.
Once the notification has been sent, it is received in the generic email account of the primary care team with the subject line “Urgent pharmacy incident” or “Non-urgent pharmacy communication”. The administrative staff responsible for managing this email forwards the message to the patient’s reference healthcare professional or, in their absence, to the professional designated according to the organisation of the HC. In addition, an internal consultation without patient appointment is generated for that same professional indicating whether it concerns an “Urgent pharmacy incident” or a “Non-urgent pharmacy communication”. This process ensures that the notification is addressed by an HC professional even if the patient’s physician and/or nurse are unavailable at that time.
If the response to an urgent incident does not result in an update of the electronic prescription and requires additional intervention by the HC healthcare professional, the community pharmacy is contacted, preferably through the electronic prescribing system, or alternatively by telephone or email.
Additionally, a list of medications potentially associated with urgent incidents was developed. The following general criteria were considered when defining medications for which abrupt interruption of treatment may have clinical consequences for the patient:
Medications associated with the occurrence of a “withdrawal or rebound syndrome”, understood as the reappearance of symptoms related to the condition for which the drug was prescribed, occurring between the first and third day after treatment discontinuation.
Medications whose withdrawal may cause a “withdrawal syndrome”, defined as a set of symptoms opposite to the therapeutic effects, which the patient may not previously have experienced and whose intensity depends on treatment dose and duration.
“High-risk medications” for chronic patients, involved in medication errors causing patient harm either through omission or delayed administration, as well as severe adverse reactions due to interactions or other causes, because of their narrow therapeutic index.
This list was developed taking as one of its references the MARC list (High-Risk Medications in Chronic Patients) (9), although it has been continuously updated during operation of the communication channel by consensus and at the request of both community pharmacies and primary care teams. The updated list as of November 2025 is provided in Appendix 2.
Process monitoring
Evaluation of the impact of the communication channel on workflow, the resolution of treatment-related incidents, and acceptance of the channel was conducted through the establishment of an evaluation committee in each PHZ. Each committee included one representative from each of the involved parties: the HC director or delegate, the PCP responsible for the area, and one community pharmacist. This structure allowed all participants to discuss issues related to the communication channel with their representative, who would then raise them within the evaluation committee in order to implement the necessary decisions for process monitoring. In addition, a satisfaction survey (Appendix 3) was distributed to healthcare professionals from both health centres and community pharmacies.
RESULTS
From February to November 2021, a pilot implementation of the communication channel was carried out in three primary healthcare zones (PHZs), one urban and two rural, involving one health centre in each zone and a total of ten associated local healthcare practices. The urban zone served a population of 16,726 individuals entitled to public healthcare and included 16 community pharmacists (CPs). One of the rural zones served a population of 4,486 individuals entitled to public healthcare and included six CPs, while the other rural zone served 906 individuals and included two CPs.
In 2021, implementation meetings were held in February (urban zone and rural zone 1) and May (rural zone 2). During these meetings, members of the evaluation committee responsible for monitoring the process were appointed. Three evaluation meetings were conducted in each PHZ. These meetings assessed whether the reported incidents met the clinical relevance criteria established in the SOP. Following analysis of the initial data, the evaluation committees from all three zones agreed on the need to develop a guidance list of medicines likely to generate urgent incidents in order to facilitate incident classification.
From February to June 2021, notifications were submitted by email to a primary care pharmacist (PCP) responsible for managing them. From June 2021 onwards, an electronic tool was made available, allowing CPs to report incidents through the electronic prescribing system (LAMIA).
Between February and November 2021, a total of 588 incidents were reported (144 urgent and 444 non-urgent), with an average of 26 incidents managed per month by each health centre. Of these, 224 were reported in rural zone 1, 37 in rural zone 2, and 188 in the urban zone. Ninety-nine per cent were resolved within the established one-working-day timeframe. Only 24% met the SOP criteria for urgent incidents, while the remainder corresponded to non-urgent communications.
Following completion of the pilot phase in the three PHZs, satisfaction surveys were conducted among the professionals involved. Seventeen questionnaires were analysed. Eighty-two per cent of respondents considered effective communication between CPs and health centres to be essential. The usefulness of the communication channel received a mean score of 4.6 out of 5, with respondents highlighting improvements in work organisation and optimisation of the time required to resolve incidents.
The results of this pilot project supported the subsequent expansion of the communication channel to the remaining PHZs in Navarre, with the final zone joining in October 2024 (Figure 1).
Figure 1. Evolution of the percentage of primary healthcare zones in which the communication channel was implemented.
Since October 2024, the communication channel has been fully operational in primary care teams covering 95% of PHZs in Navarre and in 100% of community pharmacies. The three health centres not participating have opted not to do so. Up to November 2025, a total of 197,292 incidents had been communicated, 47% classified as urgent and 53% as non-urgent communications.
The satisfaction survey was relaunched in April 2024 as part of the evaluation of the communication channel across different PHZs, with the aim of assessing user satisfaction.
A total of 204 questionnaires were completed (Figure 2). Sixty-three per cent of responses came from health centre/local practice staff, compared with 37% from community pharmacists.
All CP respondents considered effective communication between community pharmacies and health centres essential for improving patient care, compared with 62% of health centre professionals. Among the latter, 32% considered it desirable but not essential, while 4% considered it unnecessary.
Regarding the usefulness of the communication channel, 93% of health centre professionals and 52% of CPs rated it 4 or 5 out of 5 (Figure 2.1).
Figure 2.1. How useful do you find this communication channel? (not at all useful; 5 = very useful) .
When asked about the impact of the communication channel on work organisation, health centre professionals gave a mean score of 2.9, compared with 3.9 among CPs (Figure 2.2).
Figure 2.2. Regarding incident resolution, how much do you think work organization has improved using this communication channel?
Similar results were observed regarding improvements in incident resolution times: 2.9 points among health centre staff versus 3.8 points among CPs (Figure 2.3).
Figure 2.3. Regarding incident resolution, how do you think the time spent on them has improved using this communication channel?
Overall, 64% of health centre professionals and 81% of CPs considered that the communication channel had improved communication between both settings (Figure 2.4).
Figure 2.4. Do you think the relationship and communication with community pharmacies/primar y care centers has improved?
DISCUSSION
The implementation of this communication channel is facilitating the resolution of medication-related incidents identified in community pharmacies, enabling patients to have these issues resolved without the need to attend their health centre. Furthermore, the fact that such incidents are reported by healthcare professionals adds value to patient care.
Efforts were made to implement the communication channel individually within each PHZ, adapting it to the specific characteristics and needs of each area. Each PHZ determined the response times for non-urgent communications and identified whether incidents originating from community pharmacies would be referred to medical or nursing professionals. The process of launching the communication channel in each PHZ, involving all participating professionals, became an opportunity to improve mutual understanding of professional practice and internal organisational structures. Reaching consensus on aspects such as response times for non-urgent communications and promoting shared decision-making among all professionals involved were considered key factors for the successful operation of the channel in resolving incidents, ultimately contributing to patient satisfaction.
During the pilot phase, the average number of monthly incidents was higher in rural than in urban areas. This may reflect variability between PHZs, including differences in patient populations and healthcare staff turnover, highlighting the importance of adapting the communication channel, whenever possible, to local characteristics and needs. Nevertheless, communications are not restricted to professionals within the same PHZ. Community pharmacists can submit incidents to any health centre where the communication channel has been implemented. This avoids unnecessary patient visits to their designated health centre and allows incidents to be resolved from any location within the region. Other factors, such as pharmacists’ engagement and training, may also contribute to these differences.
The availability of a list of medicines likely to generate urgent incidents has enabled community pharmacists to report urgent incidents more confidently and effectively. This contributes to reducing pressure on the healthcare system by optimising the time invested by healthcare professionals. It also facilitates the identification of medication errors before they reach patients, for example by updating prescriptions that cannot be dispensed because they involve high-risk medicines, thereby preventing non-adherence or identifying potential medication errors before the patient takes the prescribed treatment.
As demonstrated by the satisfaction survey results, CPs were more satisfied with the operation of the communication channel. This may be because, as reflected in the survey findings, CPs perceived a greater need for communication with health centres and consequently placed greater value on the channel’s usefulness and its contribution to improving work organisation. One limitation of this study is the absence of patient satisfaction surveys, which should be considered in future research.
An outstanding challenge remains the implementation of bidirectional communication through the same channel, a demand expressed by professionals in both settings and currently under development. Suggestions for improvement arising from the pilot evaluation, implementation meetings, and discussions within the evaluation committees indicate the need for continued enhancement of both the communication process and the technological platform, with the aim of reducing interprofessional barriers. Continuous evaluation by local committees and central coordination by primary care pharmacists facilitate the implementation of improvements at both regional and local levels. Future studies should also attempt to quantify the time invested by healthcare professionals in resolving incidents and the time saved by patients.
Previous studies have highlighted the importance of involving community pharmacists in patients’ pharmacotherapy to improve medication safety. In 2021, Piquer-Martinez et al. concluded that integrating community pharmacy into the healthcare system may improve patients’ access to primary care services, enhance cost-effectiveness, and promote healthcare system sustainability [10]. Similarly, White et al., in a study conducted in 2022, emphasised the importance of involving community pharmacists in this role, while acknowledging barriers such as limited awareness of pharmacists’ responsibilities, restricted access to clinical information, and variability among pharmacies [11].
One of the key steps towards maximising healthcare system efficiency is to promote and facilitate collaborative working among healthcare professionals. Establishing an effective communication channel between primary care teams and community pharmacies is therefore essential and contributes to improving patient care. This communication channel has enhanced the quality of interprofessional collaboration, serving as a mechanism for building trust and strengthening relationships between health centre and community pharmacy professionals.
APPENDIX.
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