Publication Date 01/10/2010         Volume. 2 No. 9   
Information to Pharmacists

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So what are the liability implications of community pharmacists having access to laboratory results?

Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA)

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Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care.

We seem to be a precious lot when it comes to the privacy of our medical records.
Our medical privacy is sacrosanct.
Yet there are debates about how patient safety could be improved if more people had access to patient medical records.
This somewhat makes sense when medical records are shared between the hospital and the general practitioner, in case the patient turns up in the emergency department.

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It was on these grounds that the local District Health Board, covering 450,000 patients, decided to have a laboratory repository.
This repository is a database with the community and hospital laboratory results for all patients.
This makes sense – medical practitioners (and nurses) sharing data.
It could also save repetition of laboratory tests.
Of course you can ‘opt off’ if you read the small print, and understand the implications about who sees your laboratory tests.

Two things have since happened.
The community pharmacists now have access to a range of laboratory results, with some (albeit retrospective) security in place.
The next step is to share the hospital discharge summary – with a small amount of debate about whether this is the whole discharge summary or just the medicines section.
Of course, consultation has been undertaken with stakeholders (pharmacists), but the Primary Health Organisations, general practitioners and public are blissfully unaware of what is happening.
Change by stealth, through the back door?
Once done, it is not expected that it can be undone.

So, what are the implications of access to laboratory results?

* Will the pharmacist know how to interpret the laboratory results and have a suitable clinical understanding of the implications – I have grave concerns from my experience. Ask about the different picture for hepatotoxicity versus a cholestatic picture and how to determine which medicine may be causative (or not).
This also requires increased medicines information skills than simply looking up product datasheets. Scary.

* Will the pharmacist have time to consult the laboratory results anyway?
There is a constant complaint about lack of time now!!
The study by Weinberger et al., where patient medical records were made available to community pharmacists for the study, found the computer was accessed for only 50% of the people in the study, and then only 50% of those people had any action documented.1

 

So, what are the ethics of having patient medical information available to a large number of people who may not access it, and if they do, may not be able to interpret it safely. (In research you do not collect / have access to data that is not going to be used ethically).

Who is responsible and accountable?
What happens if there was a problem that could have been picked up if the pharmacist had accessed the laboratory results, and interpreted them correctly, but didn’t do so?
They had the information available and should therefore have used it.
A parallel is an After Hours general practitioner who had patient information available but failed to check it … and the patient died; the general practitioner was suspended from practice.
Community pharmacists seem ready and willing to be given access to this information, but has anyone explained the liability issues that also occur?

The next issue, which does have many staff members at our Primary Health Organisation and our general practitioners upset, is access to the full hospital discharge summary.
Access to the medicines portion is considered OK, but not the full discharge summary.

If you go into the After Hours pharmacy or a convenient pharmacy on your way home – should that stranger be able to access your records.
If you ask around, there are people who do not inform family and friends of medical conditions, but the person in the shop you get your prescription from can access your full data?

If there is concern about patient safety, then from a general practice patient survey of 900+ we did, they expect:

 * Coordination

 * Collaboration

 

 * Continuity

 * Confidentiality

This will not happen if community pharmacists continue to work in silos.
If we want to increase our collaboration and improve our relationships with general practitioners, then the answer is really to pick up the phone and talk to the other general practitioner or practice nurse for the small number of occasions this may be an issue.
You can also (heaven forbid) ask the patient so they know what you are doing.
Patients get a hard copy discharge summary as they leave the hospital and can share that with the pharmacist – if they want to (and to clarify, we have electronic discharge summaries that are sent to the general practitioner before the patient leaves the hospital – no delays).

There are many fishhooks in terms of privacy, but also in terms of responsibility and accountability when you have access to a person’s medical information.
There may be a nice ‘feel good’ factor in feeling like you are now part of the team – but with that comes increased responsibility and many ethical considerations.

PS:
Reported to me by a nursing colleague.
Her daughter was prescribed Tamiflu® and she went to collect it from the After Hours pharmacy next door.
She was offered $30 worth of OTC products (Echinacea etc) as a ‘companion sale”.
How professional is that?
And could you trust this environment not to check your lipid profile and offer you dubious OTC products to buy?

 Reference

1 Weinberger M, Murray MD, Marrero DG, Brewer N, Lykens M, Harris LE, et al. Effectiveness of pharmacist care for patients with reactive airways disease: a randomized controlled trial. JAMA. 2002;288(13):1594-602.

 

 

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