What the doctor orders

The Hebrew word for pharmacist, rokeah, implies that the person providing medications mixed them himself. For many decades, however, most drugs have come as a ready-made product, manufactured in a factory in pill, cream, capsule or liquid form and distributed and sold by a private or public health fund pharmacist.

Those who work in hospitals remain largely behind the scenes and are unknown to patients.

Yet licensed pharmacists are highly trained professionals who – given the shortage of physicians and nurses, not only in Israel and many other countries – should be utilized for more than filling prescriptions and persuading customers to buy cosmetics, unproven homeopathic preparations and even wallets over the counter.

Little known to the layman is clinical pharmacy, a health specialty in which pharmacists – usually with a doctoral degree – provide patient care that optimizes the use of medication and prevents disease and promotes good health. Clinical pharmacists, who often work with doctors and other professionals, care for patients in all healthcare settings, but the clinical pharmacy movement initially started inside hospitals and community clinics.

In countries where clinical pharmacists are given maximum authority, they may prescribe and administer drugs, prevent medication errors, provide drug information, counsel patients, review drug use and document professional services. They also have extensive knowledge about the synthesis, chemistry and preparation of drugs and their effects on patients. Among their functions are to use the most effective treatment for each type of patient, minimize the risk of treatment-induced adverse events and ensure patient’s adherence to the drug regimen.

The New York Times editorialized last week that in the US, pharmacists are “remarkably underutilized, given their education, training and closeness to the community... After an initial diagnosis is made by a doctor, federal pharmacists manage the care of patients when medications are the primary treatment, as is very often the case.”

The chief pharmacist of the US Public Health Service argued that pharmacists should be able to start, stop or adjust medications, order and interpret laboratory tests and coordinate follow-up care. But various state and federal laws make it hard for pharmacists in private practice to perform such services without a doctor’s supervision, even though patients often like dealing with a pharmacist, especially for routine matters.

One clinical pharmacist who will surely have an impact on Israel’s pharmaceutical sector and bring a breath of fresh air to the system is Dr.

Eyal Schwartzberg, the new director of the Health Ministry’s pharmaceutical division. Schwartzberg replaced Batya Haran, who served in the post for four decades.

He went to the UK to attend university along with his Israeli-born wife, who studied law.

“I initially thought of going into medicine,” said Schwartzberg in an interview with The Jerusalem Post in his office in Jerusalem’s Talpiot quarter (most Jerusalem staffers will soon move to a large, high-rise headquarters in the Romema quarter). “But I encountered pharmacists in their white coats and thought that could be a fun profession.”

So in 1996, he earned his bachelor’s degree in pharmacy at Cardiff University in Wales and his master of science degree in evidence-based pharmacotherapy at Aston University in Birmingham. After returning to Israel, he looked for a job and spent some time at the Taro pharmaceutical company. But as a clinical pharmacist, he sought a hospital post and wrote to most of the country’s medical centers.

“They said they needed dispensing pharmacists. But I had a vision of doing more,” he said.

Finally, he found Hillel Yaffe Medical Center in Hadera – convenient, as his family lived in a moshav near Hod Hasharon. He spent more than 13 years there and gained a reputation as an innovator. At the same time, he earned his doctorate in health system management at Ben- Gurion University of the Negev in Beersheba, and continues to lecture once a week on clinical pharmacy practice at BGU’s School of Pharmacy.

For the past decade, Schwartzberg was director of laboratories and pharmaceutical services at Hillel Yaffe and added to his experience in clinical pharmacology, risk management and in the promotion of quality and excellence. At present, only about eight to a dozen new clinical pharmacists with doctorates are produced by the Hebrew University each year.

“We hope BGU’s school will graduate clinical pharmacists for the community as well,” he said.

ONE OF his major accomplishments was bringing to the hospital a robot that dispenses drugs for patients in six in-patient departments. In most Israeli hospitals, the distribution of medications has been the same for decades, said Schwartzberg.

“The nursing team prepare the correct medicines and distribute them to patients in accordance with either a handwritten or computerized prescription doctors give their in-patients. This is very time-consuming and could potentially lead to mistakes in the administering of medicine. The great advantage of the robot is its ability to intercept problems with medications and prevent them before they happen.”

The new robot was manufactured by the Sinteco company in Italy, said Schwartzberg.

“There are other companies in the US and Switzerland, but we decided on this one. Introduced about a year ago in the Hadera hospital, it cost about $1 million and was purchased through Sarel, the government’s purchasing company for medical technologies. The robot is regarded as very effective in reducing medical errors significantly, and apparently, more robots will follow in other hospitals.”

Medical errors cause many preventable deaths around the world.

When patients receive the wrong medication, or the wrong dose of the correct drug, tragedies can occur.

Not all prescription errors are critical, but they often do cause harm.

Frequently, the prescribing doctor is to blame because of careless handwriting that forces hospital nurses or pharmacists to guess what he has written.

Pills reach the hospital pharmacy in large packages with bar codes, with individual pills in plastic blister packets. But once the blisters are cut apart, they are separated from the bar codes, and – when pharmacists distribute them – lose their identification.

The robot is better able to keep track of medications and eliminate identification errors; it also picks up drugs whose expiry dates have passed. It also reduces the burden on hard-pressed nurses in the wards, whose handling of medications is now much simpler, thus minimizing potential errors.

“This robot is currently receiving the patient’s demographic information.

It knows the patient’s age, and where they are staying at the hospital.

It knows all about the patients’ background as long as their department is defined. The robot can also interface with other hospital systems, such as the lab system, and receive lab results that might affect the administration of drugs and information about the patients’ sensitivities. It all goes into the robot’s system, and it can perform a clinical examination based on the patient’s situation.”

Yet Schwartzberg said it would take many years for “robot pharmacists” to replace people at their jobs.

“Human intervention will always be necessary. On a major scale, I can’t see a situation in which humans are completely replaced, not to mention the fact that modern medicine is only becoming more and more complex.”

But the sophisticated new system cross-checks a patient’s medical data with the doctor’s prescription and doesn’t distribute the drugs unless they match. Doctors use digital prescriptions that eliminate the problem of unreadable handwriting.

Patients’ medications handled by the robot are sent to the relevant department. The robot, he continues, brought down errors and nearerrors by a significant degree.

The chief of pharmaceuticals believes that the ministry has to computerize all hospital prescriptions, like what has occurred in the health funds, and integrate them fully with medical records. Ministry director-general Prof. Ronni Gamzu, said Schwartzberg, is promoting the establishment of a national drug catalogue that would contain all relevant data about medications.

THE MINISTRY’s chief pharmacist worries about the problem of “drug compliance,” which he prefers to call “adherence” so it doesn’t imply that doctors are dictating to patients.

“There are many reasons for refusal to buy prescribed medications or to take them after purchase.

Perhaps the doctor’s explanation was not convincing. Some people can’t afford the copayments for buying them. If patients don’t understand the importance of taking the medications, pharmacists must explain it. But in the first place, doctors have to be more aware of their patients’ reluctance.

Non-adherence is not a matter of age; the young, middle aged and the elderly all do it. There may be language and cultural barriers. If it’s a chronic condition and drug-taking regimen is complicated, this also discourages adherence.”

Also, physicians might not instruct patients how to take medicines.

For example, there are dozens of medications whose effects change if taken with grapefruit juice, or even after eating grapefruit. Even some pharmacists don’t know – but they must check to make sure. And individuals must also raise their awareness and responsibility for their health, he said.

Schwartzberg has just set up a “pharmaco-vigilance unit” in his division to ensure safety when drug formulas are changed somewhat.

“It’s headed by Dr. Dorit Nahlieli Dil, who is an expert in adverse drug reactions. We have started small, but I’m sure that in a year, the unit will have very high standards and expand,” he said.

The best-known recent case (before Schwartzberg arrived) involves Eltroxin, the widely consumed drug for hypothyroidism whose formula was changed without the ministry informing patients, some of whom claimed to suffer from moderate or severe side effects until the ministry issued a statement.

“The ministry learned from mistakes in the Eltroxin case. The drug is registered in 30 countries, so it is not just Israel’s problem. Changes are made frequently, and the process is very dynamic. The ministry now understands that it has to be better connected to the public and give information in real time.”

As to complaints that many drug companies pack only 30 pills in a packet rather than 31, when months have an additional day, Schwartzberg said the ministry is determined to ensure the companies do not leave patients short.

It is ministry and health fund policy to encourage the use of cheaper generics, he continued, but not at all costs, and physicians and patients must be informed when they are not as good as the originals, he promised. In addition, the ministry has already, through its Jerusalem Institute for Standardization and Control of Pharmaceuticals (ISCP), reduced red tape and now approves new medications within a year of application instead of the previous three years. His division takes into account the views of the US Food and Drug Administration and the CE of Europe, but “not everything they approve is safe, so we also consult with our own experts.”

Schwartzberg worries that international pharmaceutical companies are developing fewer drugs that don’t promise to be “blockbusters.”

The cost of research and clinical trials is such that they prefer surer things like lifestyle drugs and those for common diseases, and are devoting less effort to new antibiotics or “orphan drugs” for conditions that affect small numbers of patients.

He encourages doctors and laymen to contact to his division in Jerusalem if they have complaints about side effects, improper advertising of prescription drugs and other relevant matters.

Schwartzberg’s appointment has raised hopes in the sector.

“He is a knowledgeable pharmacist and an impressive administrator, he has proven this by his exceptional achievements at Hillel Yaffe and his work on the academic staff of BGU,” said Howard Rice, a pharmaceutical consultant and former head of the Israel Pharmacists’ Association.

“I am grateful that someone of his caliber, foresight and ability has taken the helm. He realizes that the added value that the pharmacist, if used correctly and remunerated accordingly, can bring to the Israeli public is a lowering of deaths and illness, and will save a great deal of money for the benefit of the public.”