Beyond Clinical Pharmacy

1. Beyond Clinical Pharmacy Mary Anne Koda-Kimble, PharmD Professor and Dean School of Pharmacy University of California, San Francisco

2. 5 Goals • Examine Clinical Pharmacy Today • Identify Gaps • Consider Healthcare Trends • Propose Future Needs • Share UCSF’s Story

3. Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Clinical Pharmacy Today

4. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Clinical Pharmacy Philosophy • Pharmacists are the most highly trained experts on drugs and drug products • Best professional to: • Promote rational drug prescribing • Teach patients to use drugs appropriately • Identify and prevent medication problems Silverman, M and Lee, PR: Pills, Profits, and Politics UC Press 1975

5. Drug product Pharmacy Solo Dispenser Knowledge As ordered Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Pharmacy 1960’s Clinical Pharmacy 2007 Therapeutics Bedside Team Caregiver Information As best prescribed

6. Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy How It Began – 1960’s

7. Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Model Works Well in Hospitals

8. Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Model Works Well in Hospitals • Therapeutic advisors • Patient education • Drug use review and policy • Formulary work • Medication safety

9. Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Why the Success in Hospitals? • Practice model originated there • All practitioners together • Access to medical records • Complex therapeutics • Economics • Cost avoidance • Safety • Captive patient population

10. Pharmacy Benefit Design and Management (PBMs) Pharmaceutical industry Poison control centers Academia Government Gaps Trends Future Needs UCSF’s Story Clinical Pharmacy Other Areas Of Success

11. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Gaps • Promote rational drug prescribing • Teach patients to use drugs appropriately • Identify and prevent medication problems

12. Gaps Trends Future Needs UCSF Story Clinical Pharmacy But We Have Not Yet Achieved Our Vision • A Mix of Medicines That Can Be Lethal • Study Finds Medicine Misuse Occurs All Too Frequently • Firefighter in Deadly Crash was Taking 4 Medications • Studies Show Anemia Drugs May Harm Patients • Judge Upholds Vioxx Verdict • Give Us This Day Our Daily Supplements • U.S. Reviewing Safety of Children’s Cough Drugs • In The World of Life-Saving Drugs, A Growing Epidemic of Deadly Fakes

13. Gaps Trends Future Needs UCSF Story Clinical Pharmacy New Awareness of Preventable Medication Errors and Adverse Drug Events • Medication errors alone cause more than 7000 deaths annually • Preventable adverse drug events in hospitals cost $2 billion • Side effects cost $20 billion • Pharmacists can reduce errors and minimize side effects Institute of Medicine (IOM) Report 2000

14. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Drug Therapy Problems • Access/Cost • Quality • Poor/uncoordinated prescribing • Adherence • Improper use • Ongoing assessment and management • Safety

15. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Most Drugs Are Used Outside of the Hospital

16. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Community Pharmacy Challenges • Isolated practices • No access to shared medical records • Limited practice scopes • Patient expectations • Payment policies • Environment • Time

17. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Overarching Healthcare Concerns • Access and cost • Quality • Safety • Misaligned payment systems • Episodic vs chronic care • Prevention and early screening • Political agenda vs health needs • Workforce shortages/maldistribution

18. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Confusion and Complexity

19. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Trends

20. Healthcare is big business Fewer new molecular entities despite increasing R&D spending Revolutionary information and diagnostic technologies Evolutionary practices toward lifetime and personalized care Gaps Trends Future Needs UCSF Story Clinical Pharmacy

21. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Science: Biology and Translation Era Whole-istic Biology Chemical Biology Quantitative Biology Bioinformatics Complex Systems

22. Gaps Trends Future Needs UCSF Story Clinical Pharmacy One Size Fits All

23. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Individualized Therapy

24. Gaps Trends Future Needs UCSF Story Clinical Pharmacy • Small • World • Internet • Manufacturing • Healthcare • Education • Research • Infectious diseases

25. Gaps Trends Future Needs UCSF Story Clinical’ Pharmacy Future Needs

26. Virtual teams Leadership with, not of Blended roles Preventive care Integrated/continuous care Post-marketing surveillance Translational research Systems thinkers Safety officers Drug use policy Gaps Trends Future Needs UCSF Story Clinical Pharmacy What is Needed?

27. Gaps Trends Future Needs UCSF Story Clinical Pharmacy …And More • Health services researchers • Drug benefit designers • Global leaders • Clinical scientists • Drug therapy managers • Drug information specialists • Medical informaticists • Pharmacogeneticists

28. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Next Steps • Create virtual health care teams - EMRs • Blend and expand roles • Conduct postmarketing surveillance • Apply technology • Telepharmacy • Electronic medical records • Educate visionary, collaborative practitioners • Learn from colleagues internationally • Partner: business, industry, government, community • And more…..

29. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Look at Who Needs Our Care

30. Gaps Trends Future Needs UCSF Story Clinical Pharmacy UCSF School of Pharmacy Story

31. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Our Mission: Mastering medicines to maximize health

32. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Our Plan Create a new framework for drug discovery and science Ensure that more patients get the best results from their drugs Shape the future of pharmacy science, policy, education and patient care by working in fresh and collaborative ways

33. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Some of our Tactics • Make the promise of personalized medicines a reality for patients • Help consumers take a central part in caring for their own health • Minimize medication errors and adverse events • Prepare more clinical scientists • Advance interprofessional learning and practice among student pharmacists, physicians, nurses, and dentists.

34. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Safer and More Effective, Targeted Therapies Pharmacogenomics

35. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Lung Adipose In Liver IF (OD<0.6) EXPRESS Antigen Target IF (OD>0.6 AND Tumor-Specific Signal) ADHERE to Cell Surface Target Target RELEASE Therapeutic Out Target Other Tissues (Non-metabolizing, non-accumulating)

36. UCSF Story Education for a Pharm.D. Degree K 1 2 3 4 56 7 89 10 11 12 1 2 3 4 5 6 7 8 Primary - Middle - Upper School College or University Pharmacy School >95% have degrees ( 4 years) at UCSF ~ 60-75% UCSF graduates pursue postgraduate training: residencies, fellowships, degrees

37. Gaps Trends Future Needs UCSF Story Clinical Pharmacy UCSF Pathway Curriculum UCSF PharmD Curriculum Core Curriculum 132 Units PharmD 190 Units

38. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Guiding Goals and Principles • A more “nimble” curriculum • Opportunities to pursue personal interests • All graduates will be: • Board eligible for licensure • High level, competent pharmacists • Adaptable to change • Common to all pathways • Research project • APPEs: acute care, ambulatory care, community

39. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Students Reaching Out

40. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Our Approach • Interdisciplinary • Entrepreneurial • Partnership based • Physically integrated • Patient centered

41. Gaps Trends Future Needs UCSF Story Clinical Pharmacy ? Why Do We Care?

42. Gaps Trends Future Needs UCSF Story Clinical Pharmacy • Adverse effects • Bleeding, fatigue, dizziness • Wrong drug • Calcium channel blocker • Long-acting nitroglycerin • Wrong dose • Drug interactions • NTG + BP meds • Aspirin + Fosamax • Adherence – Iron My Mother

43. Gaps Trends Future Needs UCSF Story Clinical Pharmacy Clinical Pharmacy Philosophy • Pharmacists are the most highly trained experts on drugs and drug products • Best professional to: • Promote rational drug prescribing • Teach patients to use drugs appropriately • Identify and prevent medication problems Silverman, M and Lee, PR: Pills, Profits, and Politics UC Press 1975