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WEN-SHYONG LIOU, PH.D., is Assistant Professor, School of Pharmacy, National Defense Medical Center, Taipei, and Assistant Professor, College of Pharmacy, China Medical University, Taichung; Taiwan, Republic of China.

Address correspondence to Dr. Liou at the School of Pharmacy, National Defense Medical Center, Taipei, Taiwan (wlswlsgod{at}gmail.com).

The International Pharmaceutical Federation (FIP) is the world’s leading nongovernmental organization to serve pharmacists in the world. The strategic plan for the Hospital Pharmacy Section (HPS) of the Board of Pharmaceutical Practice in the FIP specifies the section’s goals and major elements.¹ These elements include partnering with patients, enhancing pharmacy practice, using better financial models, implementing evidence-based practices, ensuring pharmacist competency, and maintaining a sufficient work force. These essential elements will help pharmacist organizations worldwide in planning the future of hospital pharmacists.

It is necessary to differentiate the needs and meet the expectations for each region, other than the essential components. The HPS of FIP and the American Society of Health-System Pharmacists conducted a global survey to investigate the state of hospital pharmacy in most regions within FIP. A global conference was held at the 2008 FIP congress in Basel, Switzerland, to discuss the future of hospital pharmacy throughout the world. This meeting produced significant consensus statements that promote global standards for future global cooperation and collaboration of hospital pharmacists.

Current issues

To advance global collaboration, several issues related to the current practice of hospital pharmacy have been brought into focus. First, the ownership and characteristics of a hospital pharmacy are primary concerns in some regions. Most hospital pharmacists are also hospital employees, and some hospitals use outsourcing to provide pharmacy services. Hospital employment may complicate the pharmacist’s autonomy due to the possible conflicts between hospital interests or company profits and professional practice.

The characteristics of the health system may also affect the autonomy of pharmacists in hospital and community settings.^2,3 The Bureau of National Health Insurance in Taiwan has contracted with hospital and community pharmacies to provide prescription medication to the insured. People have the freedom to fill their prescriptions at any hospital or community pharmacy. However, some private hospitals profit from reimbursed prescription medication when there is a difference between the reimbursed price and purchase price. Sometimes, hospital pharmacists in Taiwan have to compromise between hospital profit and professional autonomy.

Computerized prescriber-order-entry (CPOE) and other systems whose purpose is to prevent medication errors during the prescribing, dispensing, and administration stages of medication use contribute to significantly improved patient safety.^4–6 The CPOE system has been well enough developed in some countries that hospital pharmacies now focus on other systems to improve patient safety, such as online drug interaction systems, warning systems to prevent overdosages as well as an alert system to provide alerts regarding duplicate medications. Other countries use handwritten prescriptions and are focusing on the implementation of CPOE systems. Nevertheless, a significant number of countries lack such systems and should develop computerized systems suitable for their practice model.

Other issues, such as automated systems that help pharmacists perform routine tasks in hospitals—dispensing, providing pharmaceutical care, serving other outpatient or inpatient needs, and conducting quality-assurance programs—are current key areas of focus for pharmacy practices in hospital settings. All of these issues significantly affect the model of hospital pharmacy practice in different regions or countries and should be considered when developing strategic plans in order to promote the future collaboration of hospital pharmacists worldwide.

Factors affecting global collaboration

Three significant factors should be addressed to ensure global collaboration of hospital pharmacy: environment, culture, and pharmacy education. The development of pharmacy practice in the world is diverse.⁷ For example, Western countries separate dispensing from prescribing activities, but other countries still struggle to make this distinction.^8–10 As the availability of pharmacist and pharmacy specialists in the hospital setting varies by country, so do the type of pharmacy services provided to patients. In some countries, the assistance of pharmacy technicians is vital to complete daily tasks. Some countries do not require pharmacists to operate pharmacies; therefore, pharmacy technicians may take pharmacists’ job opportunities, which may compromise medication safety. Such differences make the creation of universal standards for pharmacy practice difficult.

Pharmacy education is also diverse around the world. The doctor of pharmacy (Pharm.D.) degree is the entry level pharmacy degree in most Western countries,^11–13 compared with a four-year bachelor of science in pharmacy (B.S.Pharm.) degree in other countries. Still other countries are transitioning from the B.S.Pharm. to Pharm.D. degree.¹⁴ However, there seem to have some debates regarding the purpose of pharmacy education. The core value of pharmacy education is generally recognized to produce pharmacy practitioners well trained in caring for patients. However, pharmacy education in some countries does not meet such expectations and is unable to fulfill current requirements completely.¹⁵ In addition to the traditional topics of pharmaceutical chemistry and pharmacognosy, pharmacy education should concentrate on developing a positive attitude and self-confidence in pharmacists and teach them that the core value of the pharmacy profession is to provide adequate pharmaceutical care to patients and to promote public health.

Patient education is another important aspect of pharmaceutical care. Successful pharmaceutical care also depends on patient compliance and appreciation of pharmacists’ work. The perception of pharmacists as health care providers is not universal throughout the world. Some countries view the community pharmacy as a business, while others consider community pharmacists to be health professionals. Hence, pharmacy educators should take every opportunity to educate patients and improve the perception of pharmacists as health professionals.

The cultural perspective regarding the seeking of medical care is an additional issue that needs to be addressed. Traditionally, Western countries provide primary care through physician’s offices and patients obtain their prescription medication in community pharmacy, while most Asian countries provide care through the hospital setting, which results in different pharmacy practice models. Hospital pharmacists in Asian countries focus on outpatient care and inpatient services equally. There are thousands of outpatients in a typical medical center in Taiwan, and almost every patient obtains prescription medication in the hospital due to the well-developed CPOE system that allows patients to obtain their medication within 30 minutes.

This discrepancy makes the global collaboration for hospital pharmacy more complicated, as the pharmacy services offered in hospital pharmacies differs. This culture issue has not been addressed significantly within FIP. The effects of culture should be taken into consideration for global collaboration.

Example of global collaboration: Good pharmacy practice in developing countries

The Good Pharmacy Practice (GPP) outreach project was initiated in 2005 by the FIP Foundation of Research and Education. The overall aims of the project were to improve standards, drug distribution, and drug utilization using the FIP/World Health Organization (WHO) Guidelines for Good Pharmacy Practice as the framework through regional pharmaceutical forums of WHO.¹⁶

This project provided financial and technical support to countries selected for developing GPP. Thailand and Uruguay were selected in 2005. Several other international organizations and pharmaceutical forums, such as the Taiwan Society of Health-System Pharmacists, were involved. The overall results and performance were satisfied and significantly improve these countries’ practice standards.

Guidance for preferred practice model

To provide the best pharmacy services to domestic patients, a country should develop the individual preferred practice model regarding hospital pharmacy to fit the needs. Several recommendations can be made. The best initiative is to follow the GPP guidelines developed by FIP and WHO as universal and general standards. These guidelines can be modified to fit specific requirements for local pharmacists and national pharmacy organizations. For example, for a country whose patients obtain primary care through the hospital setting, the preferred model for pharmacy practice could be to (1) develop more efficient and safer out-patient pharmaceutical services and (2) advocate for and educate patients to fill prescriptions in community pharmacies to allow hospital pharmacists to concentrate on patients with critical conditions.

This modification for a preferred practice model should consider other important issues. Culture is one such issue. For example, Asians commonly take prescription medications with herbal products or traditional medicines, which frequently results in drug interactions. Pharmacists in Asia must manage these drug interactions. In addition, pharmacy education curricula must support a suitable and specific practice model. The model should concentrate on patient-centered instead of product-oriented care. It may not be a primary concern in some developed countries, but it is certainly a major issue in developing countries where the presence of a pharmacist is not required within a pharmacy. In these countries, the pharmacy services will be product oriented, not patient focused. The individual preferred practice model for pharmacy services in each country should take such issues into consideration.

Establish global collaboration networks

There are some significant approaches to promote future global collaboration of hospital pharmacists, other than the issues mentioned. This first global conference on hospital pharmacy is an excellent starting point for establishing global collaboration networks. Pharmacists, national and international pharmacy organizations and governments that were enthusiastic to share ideas with other hospital pharmacists gathered to develop consensus statements of hospital pharmacy. These statements are not only fundamental for developing international standards but also provide the opportunity for future collaboration.

This platform for communications can be held in diverse formats. Forum or website communication can offer real-time information exchange and communication. Seminars and workshops can provide formal information exchange and communication, while onsite training courses can provide physical support to organizations. Project-based experience sharing can also advise to countries in developing stage of preferred practice model. A good example is how the experience of separating dispensing from prescribing in Taiwan offered the opportunity for other Asian countries to reconsider the strategies for their successful performance.^8–10

The function and role of government

Pharmacists provide professional services to patients under the laws of each country. Hence, government support will be the essential element for pharmacy profession. The example of separation of dispensing from prescription in Taiwan offers the unique experience. The Taiwanese government would like to execute this policy; however, there are different obstacles to implementing it. One development was the opening of "next-door" pharmacies (pharmacies under the same roof as clinics) and their unexpected consequence.² Hence, it is necessary for pharmacy organizations to build consensus with the government.

Government support of pharmacy education is also required to acquire optimal pharmacy practitioners.¹⁷ The debate of the transition from the B.S.Pharm. to Pharm.D. degree is one issue that needs government support from a policy perspective.

Consensus should also be obtained from legislators. Without legislative support, it will be virtually impossible to gain policy and financial supports for the future of pharmacy profession. In addition, support from international organizations, such as FIP and WHO, will be crucial to advocate for government and legislative support of an evidence-based pharmacy practice model.

Opportunities for global collaboration

The GPP outreach project provides a unique experience for future global collaboration; however, it focuses on community pharmacy; hospital pharmacy had not received special attention until the Basel meeting. The recent economic crisis has affected virtually every country. It is reasonable to assume the health status in general is worsening. The provision of efficient medical and pharmaceutical care is the best way to maintain basic health, and recognition of this fact offers opportunities for hospital pharmacists to collaborate worldwide.

Patient-centered care, respect for other cultures, mutual support, and experience-sharing programs within international pharmacy organizations will be the essential components for countries to develop individual preferred practice models. This collaboration needs time to reach the ultimate goal: patient safety worldwide. It is also necessary to consider the urgency of setting global standards for the pharmacist workforce and accreditation for hospital pharmacy. Pharmacist opinion leaders with characteristics of enthusiasm and willingness to share can work together to seek further consensus on patient safety in hospital pharmacy worldwide.

View larger version (137K): [in this window] [in a new window]   Working Group on Human Resources and Training deliberating consensus statements.

View larger version (104K): [in this window] [in a new window]   Lisa Nissen (standing, left) leading discussion of Working Group on Prescribing of Medicines.

The author has declared no potential conflicts of interest.

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