Ontario pharmacists’ perceptions of the Pharmaceutical Opinion Program

Introduction

In 2011, the Ontario government introduced the Pharmaceutical Opinion Program (POP),¹ through which pharmacists are compensated $15 for identifying a potential drug-related problem. This can occur during the course of dispensing a new or repeat prescription or when conducting a MedsCheck medication review. The pharmacist is expected to provide a clinical recommendation and rationale to the prescriber to address the problem. The end outcome of the consultation could be to dispense the prescription originally prescribed, to change the prescription (dose, duration, product, etc.) or to refuse to fill the prescription. The POP is currently only available to recipients of the Ontario Public Drug Programs.

Since the program was introduced in April 2011, pharmacists have provided more than 700,000 pharmaceutical opinions, the majority (68%) of which resulted in a changed prescription (Allan Malek, Ontario Pharmacists Association, personal communication, June 20, 2013).

Anecdotal reports suggest that pharmacist uptake of this program has been suboptimal, in part due to the misunderstanding of program requirements. Yet there has been no research to date about pharmacists’ experiences with and perceptions of the program. The goal of this research project was to ascertain the barriers and facilitators that community pharmacists have experienced while providing pharmaceutical opinions to their patients.

Methods

Design

This study used qualitative research methods. The data source was semistructured interviews (Appendix 1) with practising pharmacists in Ontario. A convenience sample of 20 community pharmacies was approached for participation. Eighteen of these pharmacies were located in Toronto, Ontario, and 2 pharmacies were located in Caledon, Ontario. The interviews were conducted by one of the investigators (M.M.) over a 3-week period in the summer of 2013.

Data analysis

Interviews were recorded and transcribed verbatim. The interview transcripts were coded independently by the 2 investigators (N.P. and M.M.), and their respective coding was compared; differences were reconciled through discussion.

Pilot testing

The interview guide was pilot tested in 3 pharmacies that were not part of the convenience sample. The interview guide was revised based on feedback received.

Results

Participants

Out of the 20 pharmacies contacted, 15 agreed to participate. The interviews lasted an average of 21 minutes.

Pharmacist and pharmacy characteristics

Ten owners, 3 managers and 2 staff pharmacists were interviewed; they had an average of 16 years of experience (Table 1). Five out of the 15 participating pharmacists were female. Participating pharmacies filled an average of 136 prescriptions per day (range = 30-400) and billed for an average of 5 pharmaceutical opinions per week (range = 1-21) (Table 2).

Table 1.

Demographic characteristics of the participants

Characteristic
Practice setting, n (%)
Independent	7 (47)
Banner	5 (33)
Chain	3 (20)
Position, n (%)
Owner	10 (67)
Manager	3 (20)
Staff pharmacist	2 (13)
Years in practice
Mean (SD)	16 (10)
Median	18
Range	1.5-32
Gender, n
Female	5
Male	10

Table 2.

Pharmacy demographic characteristics

	Mean (SD)	Median	Range
Prescriptions dispensed per day	136 (103)	95	30-400
Pharmaceutical opinions billed per week*	5 (5)	3.5	1-21
Percentage of pharmaceutical opinions resulting from a MedsCheck*	23% (19%)	20%	5-70%

^*If a pharmacist provided a range, the midpoint of the range was used for calculations.

Perceived barriers and facilitators

Participating pharmacists identified 6 key barriers and 3 key facilitators to providing pharmaceutical opinions; these were mainly related to the billing, and not the provision, of pharmaceutical opinions. All pharmacists indicated that as a standard of practice they contacted prescribers regarding prescriptions that had a drug therapy problem regardless of whether it was billed as a pharmaceutical opinion. Themes are presented below corresponding to the frequency of mention, from most prevalent to least prevalent.

Barriers

Workflow

Ten pharmacists reported experiencing challenges billing for pharmaceutical opinions because the service was not fully integrated into pharmacy workflow. They noted that pharmacists have been providing this service, addressing drug therapy problems, for years but were never compensated financially for it until very recently; hence, the workflow was not designed around this component. Nine of these pharmacists indicated that it was even more challenging to incorporate the service into pharmacy workflow because it was only available for patients covered by the Ontario Drug Benefit Plan (ODB). Because of this, these pharmacists recommended that the program should be expanded to include all Ontarians.

We see a [drug therapy] problem, we contact the doctor and we solve it. We have to get into the mindset that, oh, that is a PO opportunity, let’s bill it.

Physician resistance

Pharmacists felt that physicians were generally collaborative and accepting of their drug therapy recommendations. However, 8 pharmacists commented that some physicians did not respond to their suggestions in a timely manner and others were combative when they received recommendations from pharmacists. As a result of this experience, these pharmacists reported being more reluctant to contact physicians and make recommendations, unless it was required to address an imminent patient safety issue.

The challenge is really . . . that we want to collaborate with the physicians and have them accept the fact that this is the pharmacist’s responsibility and at least take a look at it [recommendation]. I mean, personally, the doctor doesn’t have to necessarily agree with all of our assessments, they should not, but at least a response would be nice.

It [delayed response from physician] affects the patients because they may go without medication for 3 days and that isn’t very helpful.

Staff resistance

Eight of the 10 pharmacy owners interviewed felt that their staff pharmacists and technicians did not consistently bill for pharmaceutical opinions despite providing them. This was attributed to the lack of motivation to complete the extra work involved in billing and documentation, in the absence of extra compensation for the staff.

A lot of times I will bill it . . . I don’t mind because I am the manager and the owner, but for other pharmacists . . . they might not. [Independent Owner]

Documentation

Six pharmacists believed that the amount of documentation acted as a barrier to billing for pharmaceutical opinions. A few pharmacists believed that the extra time spent on documentation was better spent filling prescriptions, as this decreased patient wait times and was more economical for the pharmacy. This was particularly noted as a problem when the pharmacy was busy and there was no pharmacist overlap.

The process is very tedious. In terms of the paperwork, the documentation can get to be too much; you can spend 10-15 minutes writing it up and you are still going to get paid the 15 dollars.

Unclear program criteria

When deciding whether their consultation with the prescriber qualified for a pharmaceutical opinion, pharmacists reported consulting the list of 8 eligible drug therapy problems indicated on the Ontario Ministry of Health’s website.¹ However, 5 pharmacists felt that the list and the associated explanation of these drug therapy problems were unclear and they therefore struggled to identify whether their clinical scenario and subsequent consultation qualified for reimbursement. Pharmacists also felt that the Ministry’s list was not comprehensive enough and did not capture a number of potential drug-related problems that they encountered in practice. These pharmacists reported having difficulty determining whether the drug therapy problem they encountered was related to a clinical issue (eligible for reimbursement) or an administrative/clerical issue (not eligible for reimbursement).

When you are looking at an obvious underdosage of a med. Doesn’t matter under or over—I can think of one instance where it was over, but it was glaringly obvious, by a factor of 10. . . . You would never dispense something like that to a patient. In that form it could do a lot of harm. So is that a therapeutic intervention or is that responding to a clerical error [made by a prescriber]?

Time

Five pharmacists expressed that the documentation and billing of the pharmaceutical opinions frequently took time from their other dispensing and counselling responsibilities. These pharmacists also reported that the time associated with this process led to a delay of all prescriptions currently in queue, which resulted in longer wait times for patients.

It is more the busy-ness [of the pharmacy]. Would you rather get $15 or cope with 5 angry patients because 5 prescriptions are delayed during this 5 or 6 minutes [while documenting the PO]?

Facilitators

Advanced training

Twelve pharmacists believed that further clinical training would allow them to provide more and/or higher quality pharmaceutical opinions.

I specialize in diabetes so I can recognize those [drug-related problems] in a wink, but for something else I am weaker, like blood pressure medication, then I lack that clinical knowledge and then it is less likely for me to be able to identify those drug-related problems.

Eight pharmacists believed that they would benefit from further training related to the technical aspects of the pharmaceutical opinion program, such as documentation and program criteria. Two pharmacists mentioned that it would be especially helpful to be provided with specific examples of billable scenarios, as this would allow them to better implement the program in the practice.

Physician relationships

Eleven pharmacists felt that having a better relationship with the physician allowed them to provide better patient care and it also allowed for quicker resolution of drug therapy problems. In these instances, pharmacists felt more encouraged to contact the prescriber and share their recommendations because they were more confident they would receive a supportive and timely response.

I have a physician working in the same building that I do and most of the prescriptions are coming from him, so we built a relationship. He understands my expertise and I understand his expertise. We communicate, and if there are any issues I can make recommendations.

MedsCheck

Four pharmacists reported that MedsChecks often led to opportunities to provide pharmaceutical opinions. However, they reported that the nature of those opinions was different from the opinions provided during the dispensing process. In particular, the pharmaceutical opinions arising from MedsChecks were more commonly related to nonadherence issues.

Discussion

This was the first study to determine pharmacists’ perceptions of the Pharmaceutical Opinion Program in Ontario. In general, pharmacists felt that this program is a step in the right direction and they were appreciative that their opinions were being valued professionally and remunerated financially. However, they encountered a number of barriers in implementing this service in their practice. One of the most commonly cited barriers was restricted eligibility. Pharmacists felt that they needed 2 separate work processes—one for non-ODB patients (who are not eligible for a pharmaceutical opinion) and one for ODB patients. Fragmenting their workflow in this way made it significantly more difficult to ensure effective uptake of the program.

Another barrier mentioned by a number of pharmacists was physician resistance. Pharmacists felt that physicians needed to be better educated regarding pharmacists’ professional responsibilities when it comes to addressing drug therapy problems. These findings are consistent with the results of a recent study,² which showed that physicians in British Columbia were generally uninformed about the intent of pharmacist independent adaptations. Similarly, it was suggested that a targeted campaign informing physicians about this pharmacy service would aid in mutual understanding and collaboration.

For pharmacists to feel comfortable contacting physicians, they need to feel confident that their opinions will be considered and respected, regardless of the ultimate decision. However, it cannot be assumed that this issue rests solely with physician attitudes. Pharmacists can help facilitate collaboration with physicians by communicating in a concise and patient-focused manner. Interestingly, several pharmacists in this study mentioned that when they changed their communication style to a more concise and structured format, physicians were more receptive to their recommendations. One of the pharmacists suggested using the “SOAP” (subjective, objective, assessment, plan) notes format that nurses and physicians frequently use.³

Many independent pharmacy owners reported that their staff and relief pharmacists were less likely to bill for pharmaceutical opinions and other professional services due to a lack of financial motivation. Pharmacists in Quebec have also described financial motivation as a barrier to the provision of pharmaceutical opinions.⁴ Staff pharmacists in that province did not see billing interventions as part of their job description because the income gained was rarely shared with them. To address this issue and motivate staff pharmacists, pharmacy owners could implement some form of fee-sharing or incentive-based pay.

This study provided information about pharmacists’ experiences with and perceptions of the pharmaceutical opinion program in Ontario. Future research should look to comprehensively evaluate the impact of this service on patient health outcomes and health system utilization. The work currently underway by the Ontario Pharmacy Research Collaboration (OPEN) will provide this evidence and help inform future discussions regarding program structure.⁵

Limitations

This study used a convenience sample of 15 pharmacies located in Toronto and Caledon, Ontario. Only 3 of the pharmacists interviewed practised in a chain pharmacy, which may not be representative of all pharmacists, most of whom practise in chain settings. Additionally, the majority of pharmacists interviewed were managers or owners.

Conclusions

Pharmacists in Ontario are generally supportive of the pharmaceutical opinion program and are willing and eager to implement it in their practice. To ensure that the uptake of this program continues to grow, some key challenges related to physician and pharmacist resistance will need to be addressed. In addition, the Ontario Ministry of Health and Long Term Care should look to enhance the clarity of program requirements, particularly the drug therapy problems eligible for reimbursement. ■