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Collaborative Medication Management

collaborationInsights on Collaborative Medication Management:

Collaboration in medication management is a concerted effort by the pharmacist, nurse and physician working closely together to achieve optimized results from the patient’s drug therapy. We have gathered the insights of physicians and nursing leadership in the hospital setting and asked them three questions on their vision of collaborative medication management in the Philippines.


 1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

It is a team-up that remains to be a dream across the board because of multiple and complex reason and hurdles beyond the control of one member of the team. It received realization in small sector but not yet to its fullest.

2. What are the perceived challenges in practicing collaborative medication management?

Various challenges confront the full bloom and successful implementation of the said project. Particularly if it involves member of the group with various orientation, mind set and belief where they do not want to compromise and understand the weakness of their system.

3. How can we advocate collaboration in the management of medications?

Members need to keep an open mind and collaborative mentality to reach the goal and purpose of the said team-up. Cultural, social and personality barrier must be hurdled and eliminated for you to see the success of the said project. A proactive mind set must also be in place for you to realize the success of the said approach.

DR. NOEL L. ROSAS
Chair, Department of Medicine
Immediate Past Chair, Therapeutics and Medication Safety Committee
Makati Medical Center

 

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

Collaborative medication management is an ideal framework for patient health care. Each participant (physician, nurse, pharmacist) contributes the skills and knowledge peculiar to their fields towards maximizing the benefit from treatment modalities. At the same time, each participant offers a check and balance to minimize possible adverse events and errors. In the context of Filipino culture where perceived hierarchy of professions and individuals may hinder full interaction among these professions, collaborative medication management allows for the different members of the collaborative team to be open to each other, inspiring creativity and initiative, promoting better acceptance of ideas and ensuring better promulgation of best practices in health care delivery.

2. What are the perceived challenges in practicing collaborative medication management?

People from different specialties have different cultures so that effective collaboration will require adjustments in perspectives. On top of this, the Filipino culture, being quite hierarchical, along with the traditional prominent position of physicians in the health care delivery set up, encourages barriers between the physicians and the members of the Nursing and Pharmacy fields. This poses many potential challenges. Nurses and Pharmacists may be intimidated to share their ideas and best practices to the doctors. The physician may adopt a narrow perspective and have difficulty seeing the other points of view.

3. How can we advocate collaboration in the management of medications?

Physicians, Nurses and Pharmacists should each educate their counterparts regarding their specialties. Joint forums and meetings should be encouraged to explore the similarities and differences of each field. Committees should be formed were doctors, nurses and pharmacists can actually work together and exchange ideas to formulate policies and carry out programs for collaborative medication management.

DARWIN A. DASIG, MD
Chair of Medication Safety Subcommittee
Makati Medical Center

 

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

Prescriptions are not just about generic names, strength and frequency — it is essentially prescribing safety and quality. Healthcare institutions cannot achieve this without cultivating teamwork and consistent collaboration between clinicians. In the patient care level, doctors, nurses, pharmacists, dieticians, therapists etc. communicate every minute and countercheck each other ensuring that safety is maintained from prescription, dispensing to administration. In the leadership level, multidisciplinary team discuss risk assessment, root-cause analysis, compliance check and of course, quality improvements. If they communicate openly and work with each other — uninhibited to speak up, “something feels wrong, let’s check again”—then medication prescribed, becomes safety and quality administered.

2. What are the perceived challenges in practicing collaborative medication management?

In finding out causes, quality reasoning directs us to look holistically: Person, Place, Product, and Process. Everyone in the organization (person) should have the conscious will to work as a Team, without prejudice. Believe it or not, space (Place) is a resource: a conducive area for collaboration. Short meetings settle decision from an interdisciplinary group. Large meetings take advantage of presenting outcomes and figures —such as medication error rates, turnaround time of antibiotics, and monitoring of off-label use of drugs.
Lack in resources (product) range from learning materials, documented standards, computer-generated data etc. impacts efficiency of information and supplies required to make collaborative medication management efficient.

3. How can we advocate collaboration in the management of medications?

Simple: it starts with every professional. Regardless if we handle medications, fact of the matter is we handle patient and their lives — and they take treatments such as drugs. The holistic approach obligates the patient-centered clinician to gather the heath team, talk to one another and take that inner passion to promote safety and quality in collaborative management of medications. Advocacy should be innate.

DARYL GABA
Nursing and Patient Care Services Division
Makati Medical Center

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

I agree 100% in setting up a system on collaborative medication management for each and every hospital.

2. What are the perceived challenges in practicing collaborative medication management?

Among the perceived challenges in collaborative medication management are reporting and disclosure of medication errors, scheduling of multiple medication to the patient and some doctors for always “being right”.

3. How can we advocate collaboration in the management of medications?

Promoting a culture of safety in drug prescription and by emphasizing advantages of pharmacist in checking food-drug interaction and drug-drug interaction.

MAY N. AGNO, MD
Head, Therapeutics Committee
The Medical City

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

It is a framework in which a synergy of involved health care providers works interdisciplinary to provide a meaningful experience, safe and better health outcomes to patients. A health care institution should have a team of physician, nurse, pharmacist, nutritionist and other health care providers. This framework also promotes better patient partnership towards any healthcare institution.

2. What are the perceived challenges in practicing collaborative medication management?

One challenge in adopting this framework is communication breakdown between the team.

3. How can we advocate collaboration in the management of medications?

Institutions that will be utilizing this framework should have a committee to oversee the team. Cooperation and teamwork should be in place in order to succeed and that is my advocacy as a nurse. I want to empower the nurses to communicate seamlessly with the rest of the healthcare providers. These efforts will promote patient safety culture.

RONNE ABELEDA, RN
AVP, Nursing Service Division
The Medical City

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

Collaborative medication management is a whole process of how a certain medication is administered to a patient correctly. This involve roles and functions of all people - selection of drug to arrive at formulary; purchase of drug, delivery and storage; how pharmacy regulates, ensure safety of drugs. Requirements how a drug is dispensed and administered. The process goes with the supply chain in JCI standards.

2. What are the perceived challenges in practicing collaborative medication management?

Ensuring how this process can seamlessly be implemented such as physician prescribing drugs included in the Formulary.

3. How can we advocate collaboration in the management of medications?

Leadership is highly needed, there must be a policy and facility in place and most of all is the accountability of all involved in the process. There is a need to harmonize communication, feedback, analysis and recommendation in order to be truthful on this advocacy.

VICTORIA I. CHING, RN, MGM-ESP
Patient Safety Department
The Medical City

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

Collaborative Medication Management (also known as Collaborative Drug Therapy Management by the Alliance for Pharmaceutical Care) is a "team approach to healthcare delivery whereby a pharmacist and prescriber establish written guidelines or protocols authorizing the pharmacist to initiate, modify or continue drug therapy for a specific patient."
The major thrust of CMM programs utilizes the expertise of pharmacists and motors in order to achieve best patient care outcomes by using medicine appropriately and by enhancing patient care services.
A good CMM should reduce delays in modifying drug schedules and lessen unnecessary physician office visits. It should also increase patient adherence to therapeutic management at the same time decreasing adverse events secondary to the medication being administered.
Many of the better hospitals that seek international accreditation or recognition as centres of excellence towards improving patient care have CMM programs that work at best practices for medication management. Example are ISO and JCI accredited institutions. A patient centric program is the heart of every CMM program. And documentation is the soul of every accrediting body. As every hospital is committed to patient care, all health institutions should work at creating a CMM program in the local setting - whether it is for primary, secondary or tertiary service.

2. What are the perceived challenges in practicing collaborative medication management?

Because the Philippines healthcare system is complex, this "complex" level of care becomes the challenge in creating and practicing CMM. For example, government hospitals are divided into both local government and national government run. The lack of funding in government hospitals (hence the lack of medicines) becomes a large factor from the get-go - of having to create a CMM. A collaborative medicine management system hinges on the patient as the centre-point of the program. However, if the hospital is unable to provide medicines for patients and patients still have to purchase medicines outside of hospital premises, this creates a problem in the responsibility and accountability of drugs patients take while confined in the hospital. This is evident in most of the government hospitals, even those affiliated with training institutions. Private hospitals are not spared from this dilemma as well. While the aim of patients purchasing their own medicines is to "lower the cost" of hospitalisation and expenditures for medications, this practice may not be prudent as treatment failures due to the overall poor quality of medicines purchased (sometimes even fake or counterfeit) available in out-patient pharmacies may even be detrimental to the patient.

3. How can we advocate collaboration in the management of medications?

Hospitals should also invest in training the pharmacists and nurses in collaborative programs aimed at patient-centric models. Purchasing additional smart apps, updated general references and attendance in conferences aimed at CMM are wise investments from the start. The need for a paradigm shift of having the patient the centre of our collaborative care is a much needed breather to delivery of better healthcare in the country.
Political will from the Department of Health plays a major role in the creation and implementation of a CMM program in every healthcare facility. The Food and Drug Administration and the PSHP (Philippine Society of Hospital Pharmacists) should also be proactive in providing & disseminating drug knowledge programs aimed at CMM. When the government and private sector are in unison with the goal of patient safety, only then can a program succeed.

BENJAMIN G. CO, MD, FPPS, FPSECP
Chair, Department of Pediatrics
Asian Hospital and Medical Center
Chair, Pharmacy and Therapeutics Committee
Cardinal Santos Medical Center

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

There is little information on Collaborative Medication Management that physicians here in the Philippines would know about. But the American College of Clinical Pharmacy (ACCP) had already published position papers since 1997 on this not-so-well-understood specialty of Pharmacy.
The practice model of clinical pharmacy, referred to by different names - Collaborative Medication Management (CMM) or Collaborative Drug Therapy Management (CDTM) - may be considered revolutionary if it is practiced as it is promulgated in the United States setting. This is because it carries the practice of Pharmacy beyond the traditional model and encourages the clinical pharmacist to assume responsibility for performing patient assessments; ordering drug therapy-related laboratory tests; administering drugs and selecting, initiating, monitoring, continuing and adjusting drug regimens. In certain states in the United States, the clinical pharmacists involved in CMM are even empowered to discontinue drug therapy. In the local setting, this can be quite unsettling as it may be perceived to violate both the laws governing the practice of Medicine and Nursing.
Touted as providing clinical pharmacists with the role of helping achieve optimal drug therapy outcomes, the extremely widened scope and range of functions provided the clinical pharmacist by CMM would inevitably also impose professional responsibility.

2. What are the perceived challenges in practicing collaborative medication management?

As the practice of CMM is not yet fully ingrained in medical centers here in the Philippines, one will wonder whether there is a full understanding of the concept and model. There may need to be adjustments to the model to have CMM accepted in our local setting. Some of the important concerns that local physicians may have in the present model of CMM as found in the United States and which could be adapted locally would be:

  1. The expanded role of the clinical pharmacist in CMM would create some questions on whether there may be a situation of “second guessing” the physician. After all, CMM will have the clinical pharmacist performing disease related history-taking and physical examination and then develop assessments where there is a possibility of authorized medication change and discontinuation. How would a physician look at this situation?
  2. As the clinical pharmacist would now have direct involvement in the therapeutic management of patients, what would be the legal liability of the clinical pharmacist in cases of allegations of malpractice?
  3. How would clinical pharmacists be compensated for these services? Would they now be billing patients for the additional service or would hospitals shoulder the costs incurred by the provision of the service?
  4. Is there comprehensive, validated training for pharmacists that will stand quality scrutiny under the benchmarks for CMM? And further - what IS the benchmark of CMM? Is it going to be the US Model or should we have our own local model adjusted to the needs of our patients and pertinent national laws governing practice of the medical and nursing professions?
  5. Will there now be formal agreements between physicians and clinical pharmacists before the latter is allowed to see the former’s patients or will CMM be imposed on physicians and their patients in the hospital setting?
  6. What happens to physician use of drugs in Off-Label indications where only the expertise and discretion of a physician can reasonably determine use? Will CMM practice automatically STOP these medications?
    While the objectives of CMM are praise-worthy, understanding its practice is important in determining its acceptability to physicians and perhaps even to patients who may have the traditional image of pharmacy practice in mind. Handled haphazardly and hastily, rather than encouraging cooperation, animosity and resentment, not to mention legal ramifications, may result.

3. How can we advocate collaboration in the management of medications?

We must be very careful that in the efforts to help patients, meaningful relationships and trust are not perceived to be betrayed by the practice of CMM. Patient care in other countries are different - patients are different, compensation is different, even some diseases are different. In the practice of CMM, “what is good for the goose, may not necessarily be good for the gander”. Careful thought and implementation should be the rule. Haste is never in the interest of competent patient care.

ROY J. CUISON, M.D., MBA
Chair, Pharmacy and Therapeutics Committee
Asian Hospital and Medical Center

1. What is your view on collaborative medication management (physician, nurse, pharmacist, patient) in the local setting?

The area of drug safety is such a vast scope to police such that if there are no clear and effective national laws that ensure it, collaborative medication management becomes essential as a local solution.
No stakeholder can have full and comprehensive monitoring of drug safety and thus a "Balikatan" approach must be adopted. Bottom line, we are all in this together.

2. What are the perceived challenges in practicing collaborative medication management?

The challenges to collaborative medication management are the challenge of getting people to work together harmoniously. As we have said no stakeholder can do it single-handedly. Each stakeholder must recognize and respect the years of expertise that the other offers.

3. How can we advocate collaboration in the management of medications?

To promote collaboration in Medication Management, we don't just wish it we must create the structures, mechanisms and policies to actually make it happen. This will not happen overnight, it is a process of education which involves a learning curve.

JEANETTE SILAO, M.D.
Chair, Pharmacy and Therapeutics Committee
Manila Doctors Hospital


Whenever pharmacists, nurses and physicians work collaboratively together, patients achieve better results from their drug therapies because of increased patient compliance and adherence to their medication.
This year’s theme focuses on improving patient outcomes through the collaboration of pharmacists with physicians and other healthcare professionals. Collaborative medication management improves clinical decisions regarding drug prescribing, monitoring, and drug regimen adjustments thereby sharing responsibilities with physicians and nurses for the patients’ outcomes. Recognizing the limitations and barriers in the system can be a start in achieving the goal that we all share…that is COLLABORATION.

Liza Sta. Maria