CONTEMPORARY PHARMACY PRACTICE

Pharmacists practice in a variety of areas including community pharmacies, hospitals, clinics,

extended care facilities, psychiatric hospitals, and regulatory agencies. Pharmacists can
specialize in various areas of practice including but not limited to: hematology/oncology,
infectious diseases, ambulatory care, nutrition support, drug information, critical care, pediatrics,
etc.

Community pharmacy Practice

Community pharmacies usually consist of a retail storefront with a dispensary where

medications are stored and dispensed. In most countries, the dispensary is subject to pharmacy
legislation; with requirements for storage conditions, compulsory texts, equipment, etc.,
specified in legislation. Where it was once the case that pharmacists stayed within the
dispensary compounding/dispensing medications, there has been an increasing trend towards
the use of trained pharmacy technicians while the pharmacist spends more time communicating
with patients. Pharmacy technicians are now more dependent upon automation to assist them in
their new role dealing with patients' prescriptions and patient safety issues.

Pharmacies are typically required to have a pharmacist on-duty at all times when open. It is also
often a requirement that the owner of a pharmacy must be a registered pharmacist, although
this is not the case in all jurisdictions, such that
many retailers (including supermarkets and mass merchandisers) now include a pharmacy as a
department of their store.

Likewise, many pharmacies are now rather grocery store-like in their design. In addition to
medicines and prescriptions, many now sell a diverse arrangement of additional items such
as cosmetics, shampoo, office supplies, confections, snack foods, durable medical
equipment, greeting cards, and provide photo processing services.

Hospital pharmacy
Pharmacies within hospitals differ considerably from community pharmacies. Some pharmacists
in hospital pharmacies may have more complex clinical medication management issues
whereas pharmacists in community pharmacies often have more complex business and
customer relations issues.

Because of the complexity of medications including specific indications, effectiveness of

treatment regimens, safety of medications (i.e., drug interactions) and patient compliance issues
(in the hospital and at home) many pharmacists practicing in hospitals gain more education and
training after pharmacy school through a pharmacy practice residency and sometimes followed
by another residency in a specific area. Those pharmacists are often referred to as clinical
pharmacists and they often specialize in various disciplines of pharmacy. For example, there
are pharmacists who specialize in hematology/oncology, HIV/AIDS, infectious disease, critical
care, emergency medicine, toxicology, nuclear pharmacy, pain management, psychiatry, anti-
coagulation clinics, herbal medicine, neurology/epilepsy management, pediatrics, neonatal
pharmacists and more.

Hospital pharmacies can often be found within the premises of the hospital. Hospital
pharmacies usually stock a larger range of medications, including more specialized
medications, than would be feasible in the community setting. Most hospital medications are
unit-dose, or a single dose of medicine. Hospital pharmacists and trained pharmacy technicians
compound sterile products for patients including total parenteral nutrition (TPN), and other
medications given intravenously. This is a complex process that requires adequate training of
personnel, quality assurance of products, and adequate facilities. Several hospital pharmacies
have decided to outsource high risk preparations and some other compounding functions to
companies who specialize in compounding. The high cost of medications and drug-related
technology, combined with the potential impact of medications and pharmacy services on
patient-care outcomes and patient safety, make it imperative that hospital pharmacies perform
at the highest level possible.

Clinical pharmacy
Clinical pharmacy is the branch of Pharmacy where pharmacists provide patient care that
optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical
pharmacists care for patients in all health care settings but the clinical pharmacy movement
initially began inside hospitals and clinics. Clinical pharmacists often collaborate
with physicians and other healthcare professionals.

Clinical pharmacists have extensive education in the biomedical, pharmaceutical,

sociobehavioral and clinical sciences. Within the system of health care, clinical pharmacists
are experts in the therapeutic use of medications. They routinely provide
medication therapy evaluations and recommendations to patients and other health care
professionals. Clinical pharmacists are a primary source of scientifically valid information and
advice regarding the safe, appropriate, and cost-effective use of medications. Clinical
pharmacists are also making themselves more readily available to the public. In the past,
access to a clinical pharmacist was limited to hospitals, clinics, or educational institutions.
However, clinical pharmacists are making themselves available through a medication
information hotline, and reviewing medication lists, all in an effort to prevent medication errors in
the foreseeable future.

In some states, clinical pharmacists are given prescriptive authority under protocol with a
medical provider (i.e., MD or DO), and their scope of practice is constantly evolving. In the
United Kingdom clinical pharmacists are given independent prescriptive authority.

Basic components of clinical pharmacy practice

1. Prescribing drugs
2. Administering drugs
3. Documenting professional services
4. Reviewing drug use
5. Communication
6. Counseling
7. Consulting
8. Preventing Medication Errors

Scope of clinical pharmacy:

Drug Information
Drug Utilization
Drug Evaluation and Selection
Medication Therapy Management
Formal Education and Training Programs
Disease State Management
Application of Electronic Data Processing (EDP)

Ambulatory care pharmacy

Since the emergence of modern clinical pharmacy, ambulatory care pharmacy practice has
emerged as a unique pharmacy practice setting. In 2011 the board of Pharmaceutical
Specialties approved ambulatory care pharmacy practice as a separate board certification. The
official designation for pharmacists who pass the ambulatory care pharmacy specialty
certification exam will be Board Certified Ambulatory Care Pharmacist and these pharmacists
will carry the initials BCACP.
Ambulatory care pharmacy is based primarily on pharmacotherapy services that a pharmacist
provides in a clinic. Pharmacists in this setting often do not dispense drugs, but rather see
patients in office visits to manage chronic disease states. In the federal health care system
(including the VA, the Indian Health Service, and NIH) ambulatory care pharmacists are given
full independent prescribing authority. In some states such North Carolina and New
Mexico these pharmacist clinicians are given collaborative prescriptive and diagnostic authority.

Compounding pharmacy
Pharmaceutical compounding (done in compounding pharmacies) is the creation of a
particular pharmaceutical product to fit the unique needs of a patient. To do this, compounding
pharmacists combine or process appropriate ingredients using various tools. This may be done
for medically necessary reasons, such as to change the form of the medication from a solid pill
to a liquid, to avoid a non-essential ingredient that the patient is allergic to, or to obtain the exact
dose(s) needed or deemed best of particular active pharmaceutical ingredient(s). It may also be
done for more optional reasons, such as adding flavors to a medication or otherwise altering
taste or texture. Compounding is most routine in the case of intravenous/parenteral medication,
typically by hospital pharmacists, but is also offered by privately owned compounding
pharmacies and certain retail pharmacies for various forms of medication. Whether routine or
rare, intravenous or oral, etc., when a given drug product is made or modified to have
characteristics that are specifically prescribed for an individual patient – it is known
as "traditional" compounding.

Due to rising cost of compounding and shortage of drugs in recent times, many hospitals have
shown a tendency to rely more upon large-scale compounding pharmacies to meet their regular
requirement, particularly of sterile-injectable medications. When "compounding" is done on bulk
production of a given formulation rather than patient-specific production, it is known as "non-
traditional" compounding(which as discussed below, is arguably not "compounding" but rather
"manufacturing") This development raises concerns about safety and calls for proper regulatory
control and monitoring.

Roles
During research and development
Pharmaceutical compounding is a branch of pharmacy that continues to play the crucial role
of drug development. Compounding pharmacists and medicinal chemists develop and test
combinations of active pharmaceuticals and delivery systems for new pharmaceutical
formulations so that the active ingredients are effective, stable, easy to use, and acceptable to
patients. However, for actual clinical trials, production of drug products is generally considered
"manufacturing" because "compounding" is typically defined as being for small batch or single
individual patient production only.

Patients with unique or unusual medication needs

Physicians may prescribe an individually compounded medication for a patient with an unusual
health need. This allows the physician to tailor a prescription to each individual. Compounding
preparations are especially prevalent for:

 Patients requiring limited dosage strengths, such as a very small dose for infants
 Patients requiring a different formulation, such as turning a pill into a liquid or
transdermal gel for people who cannot swallow pills due to disability
 Patients requiring an allergen-free medication, such as one without gluten or colored
dyes
 Patients who absorb or excrete medications abnormally
 Patients who need drugs that have been discontinued by pharmaceutical manufacturers
because of low profitability
 Patients facing a supply shortage of their normal drug
 Children who want flavored additives in liquid drugs, usually so that the medication
tastes like candy or fruit
 Veterinary medicine, for a change in dose, change to a more easily-administered form
(such as from a pill to a liquid or transdermal gel), or to add a flavor more palatable to the
animal.
 Many types of bioidentical hormone replacement therapy

Personalized medicine and polypharmacy

While the regulatory boundaries are not always clear, there is general acceptance of the need
for physicians to have wide discretion to prescribe customized drug products containing unique
drug-dosage combinations and/or formulations thereof specifically for individual patients. Most
mass-produced drugs often have only one or two readily available dosage levels (except the
most dominant drugs), and fixed-dose combination products – despite their many benefits – are
even less likely to have the optimal combination of drugs and respective dosages for any given
patient. Hence, the opportunity to tailor the drug(s)/dosage(s) in a given drug product as
specifically contemplated for individual patients (as deemed optimal by one's physician) is an
application of the classic principles underlying compounding.

Some kinds or compositions of "polypills" or other drug products are more amenable to custom-
compounding than others, and most retail pharmacies no longer offer compounding services at
all (although hospital pharmacies still commonly compound intravenous medications). But while
fewer pharmacists are trained and experienced in the relevant skills anymore, especially
regarding oral dosage forms (which are almost always mass-produced now instead), such
compounding pharmacies nevertheless can be found and utilized via mail-order (if not available
locally) with sufficient notice and planning.

Technologies are under development to facilitate production of customized polypills, such as for
example by the use of ink-jet printing mechanisms to precisely deposit selected drug
substance(s) onto sheets which can then be inserted into capsules (enabling "individualized
dosing and automated fabrication of medicines containing multiple drugs," in addition to custom
single-drug products). Similar technology can also be used to print tablets, more directly. Ink-jet
or fluid-jet approaches do require each drug substance to be dissolved in a liquid solvent, but
they can be particularly conducive to custom formulation with various possible excipients (in
addition to custom drug/dose selections).

Consultant pharmacy
Consultant pharmacy practice focuses more on medication regimen review (i.e. "cognitive
services") than on actual dispensing of drugs. Consultant pharmacists most typically work
in nursing homes, but are increasingly branching into other institutions and non-institutional
settings. Traditionally consultant pharmacists were usually independent business owners,. This
trend may be gradually reversing as consultant pharmacists begin to work directly with patients,
primarily because many elderly people are now taking numerous medications but continue to
live outside of institutional settings. Some community pharmacies employ consultant
pharmacists and/or provide consulting services.

Internet pharmacy
Since about the year 2000, a growing number of Internet pharmacies have been established
worldwide. Many of these pharmacies are similar to community pharmacies, and in fact, many
of them are actually operated by brick-and-mortar community pharmacies that serve consumers
online and those that walk in their door. The primary difference is the method by which the
medications are requested and received. Some customers consider this to be more convenient
and private method rather than traveling to a community drugstore where another customer
might overhear about the drugs that they take. Internet pharmacies (also known as online
pharmacies) are also recommended to some patients by their physicians if they are
homebound.

While most Internet pharmacies sell prescription drugs and require a valid prescription, some
Internet pharmacies sell prescription drugs without requiring a prescription. Many customers
order drugs from such pharmacies to avoid the "inconvenience" of visiting a doctor or to obtain
medications which their doctors were unwilling to prescribe. However, this practice has been
criticized as potentially dangerous, especially by those who feel that only doctors can reliably
assess contraindications, risk/benefit ratios, and an individual's overall suitability for use of a
medication. There also have been reports of such pharmacies dispensing substandard
products.

Of particular concern with Internet pharmacies is the ease with which people, youth in particular,
can obtain controlled substances (e.g., Vicodin, generically known as hydrocodone) via the
Internet without a prescription issued by a doctor/practitioner who has an established doctor-
patient relationship. There are many instances where a practitioner issues a prescription,
brokered by an Internet server, for a controlled substance to a "patient" s/he has never met. In
the United States, in order for a prescription for a controlled substance to be valid, it must be
issued for a legitimate medical purpose by a licensed practitioner acting in the course of
legitimate doctor-patient relationship. The filling pharmacy has a corresponding responsibility to
ensure that the prescription is valid. Often, individual state laws outline what defines a valid
patient-doctor relationship.

Canada is home to dozens of licensed Internet pharmacies, many of which sell their lower-cost
prescription drugs to U.S. consumers, who pay one of the world's highest drug prices. In recent
years, many consumers in the US and in other countries with high drug costs, have turned to
licensed Internet pharmacies in India, Israel and the UK, which often have even lower prices
than in Canada.
Veterinary pharmacy
Veterinary pharmacies, sometimes called animal pharmacies, may fall in the category of
hospital pharmacy, retail pharmacy or mail-order pharmacy. Veterinary pharmacies stock
different varieties and different strengths of medications to fulfill the pharmaceutical needs of
animals. Because the needs of animals, as well as the regulations on veterinary medicine, are
often very different from those related to people, veterinary pharmacy is often kept separate
from regular pharmacies.

Nuclear pharmacy
Nuclear pharmacy focuses on preparing radioactive materials for diagnostic tests and for
treating certain diseases. Nuclear pharmacists undergo additional training specific to handling
radioactive materials, and unlike in community and hospital pharmacies, nuclear pharmacists
typically do not interact directly with patients.

Primary tasks include:

 Order, receipt, storage and inventory control of radioactive drugs

(radiopharmaceuticals), other drugs used in nuclear medicine, and related supplies
 Preparation of radiopharmaceuticals by combining radioisotopes with reagent kits, and
compounding radiopharmaceuticals that are not commercially available
 Functional checks of instruments, equipment and devices and determination of
radiopharmaceutical quality and purity
 Filling of prescription orders
 Packaging, labeling and transport of radiopharmaceuticals
 Proper handling of hazardous chemicals and biological specimens
 Communicating radiopharmaceutical-related information to others
 Assuring that patients receive proper preparation before radiopharmaceutical
administration and trouble-shooting unanticipated outcomes
 Laboratory testing of new radiopharmaceuticals, new compounding procedures, quality
control methods and participation in clinical trials

Pharmacy informatics
Pharmacy informatics is the combination of pharmacy practice science and applied information
science. Pharmacy informaticists work in many practice areas of pharmacy, however, they may
also work in information technology departments or for healthcare information
technology vendor companies. As a practice area and specialist domain, pharmacy informatics
is growing quickly to meet the needs of major national and international patient information
projects and health system interoperability goals. Pharmacists in this area are trained to
participate in medication management system development, deployment and optimization.

The future of pharmacy

In the coming decades, pharmacists are expected to become more integral within the health
care system. Rather than simply dispensing medication, pharmacists are increasingly expected
to be compensated for their patient care skills. In particular, Medication Therapy
Management (MTM) includes the clinical services that pharmacists can provide for their
patients. Such services include the thorough analysis of all medication (prescription, non-
prescription, and herbals) currently being taken by an individual. The result is a reconciliation of
medication and patient education resulting in increased patient health outcomes and decreased
costs to the health care system.

This shift has already commenced in some countries; for instance, pharmacists
in Australia receive remuneration from the Australian Government for conducting
comprehensive Home Medicines Reviews. In Canada, pharmacists in certain provinces have
limited prescribing rights (as in Alberta and British Columbia) or are remunerated by their
provincial government for expanded services such as medications reviews (Medschecks in
Ontario). In the United Kingdom, pharmacists who undertake additional training are obtaining
prescribing rights and this is because of pharmacy education. They are also being paid for by
the government for medicine use reviews. In Scotland the pharmacist can write prescriptions for
Scottish registered patients of their regular medications, for the majority of drugs, except for
controlled drugs, when the patient is unable to see their doctor, as could happen if they are
away from home or the doctor is unavailable. In the United States, pharmaceutical care
or clinical pharmacy has had an evolving influence on the practice of pharmacy. Moreover,
the Doctor of Pharmacy (Pharm. D.) degree is now required before entering practice and some
pharmacists now complete one or two years of residency or fellowship training following
graduation. In addition, consultant pharmacists, who traditionally operated primarily in nursing
homes are now expanding into direct consultation with patients, under the banner of "senior
care pharmacy."