UNIVERSIDADE NOVA DE LISBOA
INSTITUTO DE HIGIENE E MEDICINA TROPICAL
DESIGN, IMPLEMENTATION AND
EVALUATION OF A NEW eHEALTH
PHARMACEUTICAL SERVICE FOR
COOPERATIVE DISEASE MANAGEMENT
USING AN INTERACTIVE PLATFORM:
OPPORTUNITIES TO IMPROVE HEALTH
SYSTEMS PERFORMANCE
JOÃO GREGÓRIO
DISSERTAÇÃO PARA A OBTENÇÃO DO GRAU DE DOUTOR EM SAÚDE
INTERNACIONAL
ESPECIALIDADE DE POLÍTICAS DE SAÚDE E DESENVOLVIMENTO
DEZEMBRO, 2016
Design, implemen a ion and e alua ion o a new eHeal h pha maceu ical se ice o coope a i e disease managemen using an in e ac i e pla o m:
oppo uni ies o imp o e heal h sys ems pe o mance ─ João Ped o G egó io, Julho de 2016
UNIVERSIDADE NOVA DE LISBOA
Ins i u o de Higiene e Medicina T opical
Design, implemen a ion and e alua ion o a new eHeal h
pha maceu ical se ice o coope a i e disease managemen
using an in e ac i e pla o m: oppo uni ies o imp o e
heal h sys ems pe o mance
Au o : João Ped o Be na do G egó io
O ien ado : P o esso Dou o Luís Velez Lapão
Coo ien ado : P o esso Dou o A onso Miguel Ca aco
Disse ação ap esen ada pa a cump imen o dos equisi os necessá ios à ob enção do g au de
Dou o em Saúde In e nacional, especialidade em Polí icas de Saúde e Desen ol imen o, nos
e mos do a igo 11º, alínea b, do Regulamen o Ge al do 3.º Ciclo de Es udos Supe io es
Conducen es à Ob enção do G au de Dou o pelo IHMT/UNL, publicado no Diá io da
República (Regulamen o n.º 474/2012 (2.ª sé ie, n.º 223, de 19 de no emb o de 2012)
i
SCIENTIFIC PUBLICATIONS AND COMMUNICATIONS
This hesis is based on he ollowing pape s, which a e e e ed o in he ex by
hei Roman nume als (I-IV):
Published pape s:
I GREGÓRIO, João; CAVACO, A onso; LAPÃO, Luís Velez. A scena io-
planning app oach o human esou ces o heal h: he case o communi y pha macis s in
Po ugal. Human esou ces o heal h, 2014, 12.1: 1. DOI: 10.1186/1478-4491-12-58
II GREGÓRIO, João; CAVACO, A onso Miguel; LAPÃO, Luís Velez. How
o bes manage ime in e ac ion wi h pa ien s? Communi y pha macis wo kload and
se ice p o ision analysis. Resea ch in Social and Adminis a i e Pha macy, 2016. (in
p ess)
III GREGÓRIO, João; RUSSO, Giuliano; LAPÃO, Luís Velez.
Pha maceu ical se ices cos analysis using ime-d i en ac i i y-based cos ing: A
con ibu ion o imp o e communi y pha macies' managemen . Resea ch in Social and
Adminis a i e Pha macy, 2016, 12.3: 475-485. DOI:10.1016/j.sapha m.2015.08.004
IV LAPÃO, Luís Velez; MIRA DA SILVA, Miguel; GREGÓRIO, João;
Implemen ing an Online Pha maceu ical Se ice using Design Science Resea ch. BMC
Medical In o ma ics and Decision-Making (Pape submi ed on 23/05/2016)
Communica ions (o al and pos e p esen a ions):
- GREGÓRIO, J. & LAPÃO, L. 2012, E-Heal h e a P es ação de Cuidados
Fa macêu icos: Con ibu o pa a a melho ia da qualidade da p es ação de se iços
de saúde. In: Cong esso Nacional dos Fa macêu icos, 2012, Lisboa. (pos e
p esen a ion – bes pos e awa d)
- GREGÓRIO, J., CAVACO, A., DA SILVA,M.M., LOVIS,C., LAPÃO, L.
2013. Challenges o In o ma ion Technologies Adop ion o enable Communi y
Pha macies eHeal h se ices. Abs ac s 8 h wo king con e ence o he
ii
pha maceu ical ca e ne wo k Eu ope, 6–8 Feb ua y 2013, Be lin, Ge many.
In e na ional Jou nal o Clinical Pha macy Volume 35, Issue 3, pp 488-506
(pos e p esen a ion).
- GREGÓRIO, J., LAPÃO, L. 2013. Uso de cená ios es a égicos pa a
planeamen o de ecu sos humanos em saúde: os a macêu icos comuni á ios em
Po ugal, 2010-2020. 2º Cong esso de Medicina T opical, Ins i u o de Higiene e
Medicina T opical, Lisboa, Po ugal. (o al communica ion)
- LAPÃO,L.V., GREGÓRIO,J., CAVACO,A., DA SILVA,M.M., LOVIS,C.,.
Implemen ing eHeal h Se ices o Enhanced Pha maceu ical ca e P o ision:
Oppo uni ies and Challenges. 2nd In e na ional Con e ence on Se ious Games
and Applica ions o Heal h, SeGAH 2013, Vilamou a. (o al communica ion)
- GREGÓRIO, J., FERREIRA,T., CAVACO, A., DA SILVA,M.M., LOVIS,C.,
LAPÃO, L. 2013. Communi y Pha macies and eHeal h Se ices: Ba ie s and
Oppo uni ies o Real P ima y Heal hca e In eg a ion. In: 26 h IEEE
In e na ional Symposium on Compu e -Based Medical Sys ems, Po o. (o al
communica ion)
- GREGÓRIO, J., FERREIRA, T., LAPÃO, L. 2013. De eloping eHeal h se ices
o pha maceu ical ca e using Design Science Resea ch Me hodology. In:
Eu opean Heal h Managemen Associa ion (EHMA) Annual Con e ence - Wha
heal hca e can we a o d? Be e , quicke , lowe cos heal h se ices, Milan.
(pos e p esen a ion)
- GREGÓRIO, J., LAPÃO, L., 2013. eHeal h echnologies o suppo p ima y
heal hca e in eg a ion wi h communi y pha macies. In: 20 h WONCA Wo ld
Con e ence on Family Medicine, P ague; Czech Republic. (o al communica ion)
- GREGÓRIO, J., LAPÃO, L. 2013. De eloping eHeal h se ices o suppo
Communi y Pha macis ’s p o ision o Pha maceu ical Ca e. In: Seminá io
In e nacional B asil-Po ugal “T abalho em Saúde, Desigualdades e Polí icas
Públicas”, Ins i u o de Ciências Sociais, Uni e sidade do Minho. B aga. (o al
communica ion)
iii
- GREGÓRIO, J., LAPÃO, L., 2013. Using S a egic Scena ios o Human
Resou ces Planning – The case o Po uguese communi y pha macis s. In:
Seminá io In e nacional B asil-Po ugal “T abalho em Saúde, Desigualdades e
Polí icas Públicas”, Ins i u o de Ciências Sociais, Uni e sidade do Minho.
B aga. (o al communica ion)
- GREGÓRIO, J., LAPÃO, L., 2013. Pha maceu ical se ices cos ing using ime-
d i en ac i i y based cos ing. In: 13 h Annual In e na ional Con e ence on
Heal h Economics, Managemen & Policy: A hens, G eece. (o al
communica ion)
- GREGORIO, J., RUSSO, G., & LAPAO, L. (2015, Ap il). Pha maceu ical
se ices cos analysis using ime-d i en ac i i y based cos ing in a sample o
Po uguese communi y pha macies. Abs ac s 9 h wo king con e ence o he
pha maceu ical ca e ne wo k Eu ope, 4-6 Feb ua y 2015, Mechelen, Belgium.
In e na ional Jou nal o Clinical Pha macy (Vol. 37, No. 2, pp. 403-404). (pos e
p esen a ion)
- GREGÓRIO, J., PIZARRO, Â., CAVACO, A., WIPFLI, R., LOVIS, C., MIRA,
D. S. M., & LAPÃO, L. V. (2014). Online Pha maceu ical Ca e P o ision: Full-
Implemen a ion o an eHeal h Se ice Using Design Science Resea ch. S udies
in heal h echnology and in o ma ics, 210, 261-265. 26 h Medical In o ma ics
Eu ope Con e ence, MIE 2015, Mad id, Spain. (o al communica ion)
- GREGÓRIO, J., PIZARRO, Â., CAVACO, A., WIPFLI, R., LOVIS, C., MIRA,
D. S. M., & LAPÃO, L. V. (2015). Implemen a ion o a ch onic ca e eHeal h
pha maceu ical se ice using design science. In: Cong esso Nacional dos
Fa macêu icos, 2015, Lisboa. (pos e p esen a ion)

i
ACKNOWLEDGMENTS
Fi s ly, I would like o exp ess my since e g a i ude o my supe iso P o . Luís
Lapão, o he con inuous suppo o my PhD s udy and ela ed esea ch, o his pa ience,
mo i a ion, c ea i i y and knowledge. I would like o hank o encou aging my esea ch
and o allowing me o g ow as a esea ch scien is .
Besides my supe iso , I would like o hank P o . A onso Ca aco and P o . Miguel
Mi a da Sil a o hei insigh ul commen s and encou agemen , bu also o he
ques ioning which led me o add ess my esea ch om a ious pe spec i es.
My since e hanks also goes o all he pha macies’ s a s who p o ided me an
oppo uni y o access hei acili ies and pe mi ed he obse a ion o hei daily wo k
p ac ices. Wi hou hey p ecious collabo a ion i would no be possible o conduc his
esea ch. Also, he collabo a ion o D . Tiago Fe ei a, D . Paulo Ab eu in he
p og amming o he pla o m mus be acknowledge as is he collabo a ion o D . Diogo
Mello in he design o he Se ice Expe ience Bluep in and D ª. Ângela Piza o o
conduc ing he demons a ion s age o he pla o m.
I hank my ellow PhD and depa men colleagues, o he s imula ing discussions
and o he decomp ession lunch alks ha yielded so much un and new ideas.
Las bu no he leas , I would like o hank my amily: my pa en s, my b o he and
my gi l iend, o encou aging me o pu sue a new ca ee pa h, o suppo ing me
h oughou he w i ing o his hesis and my li e in gene al. A special wo d also o my
iends and band ma es, o p o iding me a much app ecia ed sou ce o inspi a ion and
space o c ea i i y.
RESUMO
In odução: As doenças c ónicas são a p incipal causa de mo alidade em oda a
Eu opa. O aumen o da p e alência de doenças c ónicas es á a ge a a necessidade de
e o mas nos sis emas de saúde. Es as e o mas abo dam a ges ão de doenças c ónicas
com base em equipas mul idisciplina es, com no os papéis a ibuídos a p o issionais
não-médicos, como en e mei os e a macêu icos comuni á ios (CP). A comunicação
en e p o issionais e cidadãos é undamen al em odos os modelos mul idisciplina es,
o que o na o uso de Sis emas e Tecnologias de In o mação (IST) cada ez mais
indispensá el. É de ex ema impo ância pa a a ciência e a sociedade en ende como
se iços supo ados po IST - eHeal h - podem se desen ol idos e u ilizados pa a
en en a os cons angimen os e desa ios dos u u os sis emas de saúde.
Obje i o: O obje i o p incipal des e p oje o oi o de desen ol e , implemen a e
a alia um se iço a macêu ico de ges ão de doença supo ado po IST, no con ex o
da a mácia comuni á ia, u ilizando a me odologia Design Science Resea ch (DSRM)
como me odologia de in es igação.
Mé odos: A aplicação de DSRM deco e em seis ases, desde a de inição e
ca ac e ização do p oblema a é à a aliação da solução (ou a e ac o). A p imei a ase
oi cons i uída po um exe cício de cena ização, um es udo obse acional de empo e
mo imen o e um ques ioná io de p eenchimen o online, pa a a alia as u u as
possibilidades pa a os a macêu icos comuni á ios no sis ema de saúde, e a a ual
p es ação de se iços a macêu icos supo ados po IST em a mácia comuni á ia. Na
segunda ase, o am ealizadas en e is as quali a i as com u en es de se iços de
saúde. Es as duas ases in o ma am o desenho da pla a o ma web de supo e ao
se iço, que oi o obje i o da e cei a ase. De seguida, nas duas e apas seguin es, a
pla a o ma web oi es ada e a usabilidade a aliada a a és de um es udo de caso com
u en es selecionados numa uni e sidade sénio .
Resul ados: A pa i do exe cício de cena ização, oi possí el iden i ica as ince ezas
c í icas que se ão os “mo o es da mudança” pa a os a macêu icos comuni á ios. Es as
são a “capacidade de ino a e desen ol e se iços” e o “ambien e legisla i o”. Tan o
no es udo obse acional como no inqué i o, e i icou-se que odas as a mácias
u ilizam os IST pa a a dispensa de medicamen os e a e as adminis a i as; apenas
15% das a mácias esponden es usam os IST pa a esponde a ques ões de saúde dos
u en es; 50% do empo diá io do a macêu ico é despendido em in e ação com os
u en es da a mácia e 38% em a e as adminis a i as. Em média, os a macêu icos
obse ados êm 54 minu os de empo li e po dia, maio i a iamen e em mic opausas
dis ibuídas pelo dia de abalho. Os cus os calculados pa a os se iços a macêu icos
obse ados o am mui o semelhan es nas ês a mácias. O cus o médio do se iço de
dispensa de medicamen os oi de €3,66 e do se iço de aconselhamen o €1,34. Dos
u en es en e is ados, 46% admi i am que p ocu a am o a macêu ico pa a
in o mações sob e ques ões de saúde ligei as an es de i a um médico, enquan o a
en ega de medicamen os ao domicílio oi o no o se iço mais solici ado. Na ase de
demons ação da pla a o ma, e i icou-se que o egis o, moni o ização e
a mazenamen o de dados bioquímicos e isiológicos, an o pelo u en e como pelo
a macêu ico, con ibuiu pa a aumen a o in e esse comum na ges ão da doença, o que
pode á pe mi i uma melho ia nos esul ados da saúde. Na a aliação de usabilidade,
e i icou-se a necessidade de melho a o acesso ápido à in o mação, bem como a
i
necessidade de melho a a legibilidade da in o mação pa a melho a a expe iência de
u ilização dos u en es senio es.
Conclusão: A ualmen e, o uso de IST nas a mácias comuni á ias po uguesas es á
p incipalmen e ocado na dispensa de medicamen os. Pa ece exis i uma necessidade
de eo ganização in e na das a mácias de o ma a pe mi i aumen a a e iciência da
p es ação de se iços a macêu icos e pe mi i a p es ação de se iços a macêu icos
de eHeal h. Pa a os se iços a macêu icos de eHeal h es a em mais in eg ados no
modelo de negócio a ual, é necessá io melho a o ma ke ing do se iço, de o ma a
aumen a o ec u amen o de u en es e demons a o alo do se iço pa a os doen es
c ónicos e médicos. A qualidade e usabilidade da pla a o ma eHeal h é undamen al.
No en an o, ambém o acompanhamen o po um p o issional de saúde e a in eg ação
dos se iços a macêu icos com os cuidados de saúde p imá ios são impo an es pa a
uma melho ges ão da doença. A DSRM demons ou se ú il no desen ol imen o e
implemen ação de se iços de eHeal h, p opo cionando um maio en ol imen o dos
u ilizado es, aumen ando a u ilidade pe cebida do se iço. No p óximo ciclo de
DSRM, ão se necessá ios os inpu s de médicos de cuidados p imá ios e ou os
p o issionais de saúde, de modo a desen ol e um no o a e ac o, pa a es a e a alia
o alo clínico e económico dos se iços a macêu icos eHeal h.
Pala as-cha e: Se iços a macêu icos; eHeal h; Design Science Resea ch;
Cuidados de Saúde P imá ios;
ii
ABSTRACT
Backg ound: Ch onic diseases a e he main cause o mo ali y h oughou Eu ope.
The inc easing p e alence o ch onic diseases is leading o he necessi y o heal h
sys em e o ms. These e o ms add ess ch onic-disease managemen based on
mul idisciplina y eams, wi h majo oles o non-physicians, such as nu ses and
communi y pha macis s (CP). A co ne s one on e e y mul idisciplina y model is he
communica ion be ween s akeholde s, o which he use o In o ma ion Sys ems and
Technologies (IST) is inc easingly indispensable. I is o impo ance o science and
socie y o unde s and how IST suppo ed se ices – eHeal h - could be de eloped and
used o add ess he challenges and cons ains o u u e heal h sys ems.
Aim: The main goal o his p ojec was o design, implemen and e alua e a disease
managemen web-based in e ac i e pha maceu ical se ice, wi hin a communi y
pha macy se ing, using Design Science Resea ch Me hodologies (DSRM).
Me hods: The applica ion o DSRM six s ages’ is desc ibed, om he de ini ion and
cha ac e iza ion o he p oblem o he e alua ion o he a e ac . The i s s age
consis ed o a scena io exe cise, a ime and mo ion obse a ional s udy and an online
su ey, o assess u u e oles o communi y pha macis s and cu en pha maceu ical
se ices p o ision suppo ed by IST in communi y pha macy. In he second s age,
quali a i e in e iews wi h heal h se ices’ use s we e pe o med. These wo s ages
helped o in o m he design o he web-pla o m, which was he goal in he hi d s age.
A e his, he web-pla o m was es ed and he usabili y e alua ed in he wo
ollowing s ages, h ough a case s udy wi h selec ed pa ien s om he pa icipan
pha macies and om a senio uni e si y.
Resul s: The scena io exe cise allowed o iden i y he c i ical unce ain ies ha will
be he d i e s o change o he Communi y Pha macis s. These we e ound o be he
“Abili y o de elop Se ices”, and he “Legisla i e En i onmen ”. F om bo h he
su ey and obse a ional s udy, i was ound ha pha macies’ IST is mainly used o
dispensing medicines and adminis a i e asks wi h only 15% o he esponden
pha macies using IST o answe pa ien s’ que ies; 50% o pha macis s daily ime is
spen wi h pa ien s, 38% on adminis a i e asks, while s ill ha ing an a e age o 54
minu es o idle ime sp ead h ough he day, mainly in mic o-pauses. The o e all cos s
o Pha maceu ical se ices ac oss h ee pha macies we e ound o be e y simila ,
wi h he a e age dispensing se ice cos a €3.66 and €1.34 o he counselling
se ice; 46% o he in e iewed use s admi ed ha hey sough heal hca e p o ision
wi h he CP o mino issues be o e going o a physician, while home deli e y was
he mos eques ed new se ice. In he demons a ion s age, we ound ha he
egis a ion, moni o ing and s o age o biochemical and physiological da a, eco ded
by he CP and he pa ien s in he pla o m, con ibu ed o a common in e es ha may
allow an imp o emen in pa ien s’ heal h ou comes. F om he usabili y e alua ion,
conce ns abou he quick access o in o ma ion we e pe cei ed as well as he need o
imp o e legibili y, add essing senio use s’ di icul ies.
Conclusion: The cu en s a e o IST usage in Po uguese communi y pha macies is
mainly ocused on medicine dispensing. The e seems o exis a need o in e nal
eo ganiza ion o pha macies allowing o mo e e icien pha maceu ical se ices
p o ision and o enable eHeal h pha maceu ical se ices p o ision. To make eHeal h
INTRODUCTION
1
1. INTRODUCTION
The s udy epo ed in his hesis cen es i sel in he de elopmen and
implemen a ion o a new pha maceu ical se ice suppo ed by In o ma ion Sys ems and
Technologies (IST), using Design Science Resea ch Me hodology (DSRM). The p ojec
ha o igina ed his hesis – ePha maca e P ojec – was inancially suppo ed by he
Po uguese Founda ion o Science and Technology (Re : PTDC/CCI-
CIN/122690/2010). Du ing he DSRM p ocess, i was expec ed ha se e al indings
would be made, shedding new ligh on he de elopmen o new oles o communi y
pha macis s in u u e heal h sys ems.
This wo k is di ided in h ee main sec ions.
In he i s sec ion, he li e a u e e iew o he hesis desc ibes a con ex ual
amewo k o he s udy, om he ends a ec ing heal h sys ems o he de elopmen o
he communi y pha macis p o ession and use o Heal h In o ma ion Sys ems (HIS)
(chap e 1.1). The sea ch s a egy o his li e a u e e iew was o iden i y s udies ela ed
o heal h sys em con ex , bo h na ional and in e na ional, communi y pha macis s’ new
ole, and IST suppo ing communi y pha macies’ se ices. The main da abase used was
PubMed, wi h Google® Schola being used o aid he sea ch o addi ional pape s on he
subjec s. The goal o his li e a u e e iew was o p o ide a amewo k o unde s and he
implica ions o new pha maceu ical se ices suppo ed by IST in he con ex o u u e
heal h sys ems. In he inal chap e s o his ini ial sec ion (chap e 1.2 – chap e 1.4), he
aim o his s udy is s a ed, a concep ual amewo k wi h an explana ion o he DSRM and
a sho summa y o he pape s o be p esen ed in he Resul s sec ion a e p o ided. The
In oduc ion closes wi h he lis o bibliog aphic e e ences used o suppo he sec ion.
The second sec ion is he Resul s sec ion, which is cons i u ed by he ou pape s
p e iously men ioned (see page i - Scien i ic publica ions and communica ions).
The hi d sec ion con ains he Discussion. I begins wi h a summa y o he esul s
epo ed in he ou pape s (chap e 3.1), ollowed by a sec ion wi h implica ions o
p ac ice, esea ch and policy (chap e 3.2), ha will highligh he implica ions o IST o
p o essional de elopmen and communi y pha macis s’ in eg a ion in p ima y heal hca e.

INTRODUCTION
2
An ou line o possible emune a ion models is p o ided in sec ion 3.2.3. The Discussion
sec ion closes wi h he p oposal o a concep ual amewo k o Heal h In o ma ion
Sys ems esea ch in communi y pha macy and p ima y heal hca e (chap e 3.3) and an
o e iew o he esea ch limi a ions. A e his, he hesis closes wi h a inal Conclusion
sec ion, whe e he main indings and u u e esea ch di ec ions a e s a ed.
1.1. BACKGROUND AND STATE OF THE ART
An ageing popula ion in OECD coun ies, wi h inc easing p e alence o ch onic
diseases (see box 1 o na ional de ails), he associa ed ising cos s o ca e and lack o
human esou ces o heal h ha e long been conside ed he main h ea s o he
sus ainabili y o global heal h sys ems (Sacco e al., 2013; WHO, 2010). Adding o his
epidemiologic p o ile, he cu en economic c isis a ec ing some coun ies became
ano he d i e p essing heal h sys ems o a ion expendi u es while p ese ing quali y and
access o heal h ca e se ices (Leopold e al., 2014). These ac o s a e inspi ing poli ical
decisions o implemen heal h sys em e o ms, wi h a g ea e emphasis in Uni e sal
co e age, de- egula ion and p o-compe i i e policies ac oss heal h sys ems (Ba os,
2012; Campbell e al., 2014; Ca in e al., 2008; F enk e al., 1997; Vogle e al., 2014)
Unde lining his end, he Wo ld Heal h O ganiza ion (WHO) published a
pa adigm-shi ing epo in 2008, emphasizing he impo ance o p ima y heal hca e,
al eady a p io i y in In e na ional Heal h since he Alma-A a Con e ence in 1978 (WHO,
2008). To achie e p ima y heal hca e co e age, heal h sys em ocus u ned o people-
cen ed ca e. This would equi e heal h se ices o be o ganized acco dingly, wi h
mul idisciplina y eams ha a e esponsible o de ined popula ions, ha collabo a e wi h
social se ices and o he sec o s, and coo dina e he con ibu ions o hospi als, specialis s
and communi y o ganiza ions (WHO, 2008). P ima y heal hca e can be de ined as
“(…) he p o ision o in eg a ed, accessible heal h ca e se ices by clinicians who a e
accoun able o add essing a la ge majo i y o pe sonal heal h ca e needs, de eloping a
sus ained pa ne ship wi h pa ien s and p ac icing wi hin he con ex o amily and
communi y” (Ro hman and Wagne , 2003). The alue o p ima y heal hca e lies on being
a social and poli ical p ocess ha in ol es people, enabling hem o ake mo e con ol
INTRODUCTION
3
o e hei own heal h (Se en h Consul a i e Commi ee on P ima y Heal h Ca e Sys ems
o he 21s Cen u y, 1997).
To add ess he challenges o ch onic diseases and uni e sal p ima y heal hca e
co e age, in e p o essional models eme ged. One o hese models is he Ch onic Ca e
Model (CCM), de eloped by Bodenheime , Wagne and colleagues (Bodenheime e al.,
2002). The aim o he CCM is o ans o m he daily ca e o pa ien s wi h ch onic
illnesses om acu e and eac i e o a p oac i e, planned, and popula ion-based app oach.
This eme gence o in e p o essional models o p ac ice has b ough human esou ces o
heal h issues in o he in e na ional agenda o heal h sys ems s eng hening and public
heal h policies (Campbell e al., 2014; Dussaul and Fe inho, 2007).
Mos people wi h majo ch onic
illnesses such as diabe es, hype ension, o
as hma a e al eady ecei ing ca e om
p ima y ca e physicians o nu ses
(Bodenheime e al., 2002). Ex ending he
de ini ion o p ima y ca e p o essionals
beyond “clinicians”, se e al s udies ha e
shown ha non-physician p o essionals,
such as communi y pha macis s, may be
c i ical componen s o e ec i e ch onic
disease ca e eams (C ano e al., 2003; Makowsky e al., 2009; Willis e al., 2014).
1.1.1. COMMUNITY PHARMACISTS’ NEW ROLE – PHARMACEUTICAL CARE AND
PHARMACEUTICAL SERVICES
A he beginning o he 20 h cen u y, communi y pha macis s we e esponsible o
he p epa a ion, p o ision and assessmen o he medicines used in he ea men o
diseases. Thei main obliga ion was o ce i y ha he p oduc s we e pu e and p ope ly
p epa ed, al hough counselling was ano he impo an unc ion. This ole began o
disappea be ween 1930 and 1970 in mo e indus ialized coun ies, when he magis e ial
o mulas we e apidly eplaced by indus ially p epa ed o mulas (Ande son, 2002).
In Po ugal, he p e alence o diabe es,
hype ension, as hma and ch onic pain has been
inc easing in he las yea s. The p e alence o
diabe es in he gene al popula ion is 11.7%
(Ga de e-Co eia e al., 2010), he p e alence o
hype ension is 42.1% (Macedo e al., 2007), he
p e alence o as hma 6.8% (Sa-Sousa e al.,
2012) and ch onic pain, an incapaci a ing
condi ion, a ec s 37.0% o he Po uguese
popula ion (Aze edo e al., 2012).
Box 1 - Ch onic diseases p e alence in Po ugal
INTRODUCTION
4
Nowadays, communi y pha macis s a e playing a g owing pa in p ima y
heal hca e by ul illing an inc easing ange o oles and esponsibili ies, while e aining
he classical ole o medicines’ supplie (Kennie-Kaulbach e al., 2012). Communi y
pha macis s’ ac i i y is cha ac e ized by an easy accessibili y and a o dabili y, which is
a aluable asse in a heal h sys em (Chisholm-Bu ns e al., 2010). O en a i s poin o
con ac wi h he heal h sys em, communi y pha macis s can play a simila ole o p ima y
ca e physicians’ ga ekeeping, e e ing pa ien s o hei p ima y ca e physician when
needed. The e m “ga ekeeping” in heal hca e gene ally e e s o a p o essional
“posi ioned a an en y poin , o ga e, h ough which pa ien s mus pass o ecei e ca e
o se ices” (Riley and Manias, 2009). Physician ga ekeepe s iden i y pa ien s’ heal hca e
needs and, join ly deciding wi h he pa ien , choose se ices ha e ec i ely mee hose
needs (Fo es , 2003). Assuming his ole, pha macis s can simul aneously sa is y
pa ien s’ need o a close p o essional ollow-up in disease managemen (Os e be g and
Blaschke, 2005). This e e al p ocess is al eady a ea u e o Po uguese communi y
pha macis daily ac i i y bu mos o he imes i is done in o mally, wi h no emune a ion
associa ed (Ba os e al., 2012).
Communi y pha macis s’ skills ha e led o hei g owing public ecogni ion as a
heal h p o essional (Ande son, 2002). Howe e , he ini ial p omise o communi y
pha macis s’ in eg a ion in he p ima y heal hca e eam is coming o a s all. The
wo ldwide change in communi y pha macis s’ p ac ices and oles is occu ing a a slowe
pace han i s en isioned, wi h di e en speeds ac oss coun ies, in luenced by se e al
ex e nal ac o s and also pha macis s’ pe sonal and p o essional ba ie s (Box 2). Change
p ocesses o en ake longe han expec ed due o lack o awa eness o he many challenges
i implies.
In a 2005 e iew, Robe s e al. (2006), ound an ex ensi e lis o indi idual and
o ganiza ional acili a o s o p ac ice change, ha usually ma ch an equally long lis o
ba ie s. One o he consequences o such ba ie s is ha , despi e he de elopmen o
di e en se ices, he e idence ega ding hei implemen a ion, e ec i eness and
sus ainabili y is sca ce (Mossialos e al., 2015). No wi hs anding, some coun ies ha e
implemen ed na ional pha maceu ical policies, designing incen i es ha demand mo e
om communi y pha macis s han jus dispensing medicines (Be ns en e al., 2010).
INTRODUCTION
5
Box 2 - Ex e nal ac o s wi h in luence in Communi y Pha macis s' ole
Main Ex e nal Fac o s In luencing Communi y Pha macis s’ ole:
• Economic and legisla i e con ex
• Comme cial p essu es
• Go e nmen poli ics
• Technological inno a ions
• New he apies
• Suppo om o he p o essionals
• In eg a ion in he p ima y heal hca e sys em
1.1.2. THE PHARMACEUTICAL CARE MOVEMENT IN COMMUNITY PHARMACY
A e Alma A a’s con e ence and he onse o he p ima y heal hca e mo emen ,
he pha macy p o ession s a ed o expe ience se e al a emp s o an expansion o i s
ole. This ole expansion has i s oo s in he clinical pha macy mo emen , which s a ed
du ing he 1960s in some no h-Ame ican hospi als, whe e he ounda ions o he le el
and scope o p ac ice o a pa ien -o ien ed pha macy p ac ice we e laid (Be engue e al.,
2004). Se e al p og esses we e made in he ollowing decades un il 1989, when Cha les
Heple and Linda S and published he b eak h ough wo k in pha maceu ical ca e:
“Oppo uni ies and esponsibili ies in Pha maceu ical Ca e” (Heple and S and, 1990).
In hei wo ds, pha maceu ical ca e is “ he esponsible p o ision o d ug he apy o he
pu pose o achie ing de ini e ou comes ha imp o e a pa ien ’s quali y o li e”. I
in ol es a “p ocess h ough which a pha macis coope a es wi h a pa ien and o he
p o essionals in designing, implemen ing and moni o ing a he apeu ic plan ha will
p oduce speci ic he apeu ic ou comes o he pa ien ”. These ou comes a e he cu e o a
disease; elimina ion o a pa ien ’s symp oms; and slowing a disease p ocess o p e en ing
i . To do so, Pha maceu ical Ca e elies on h ee main asks: iden i ying, esol ing and
p e en ing po en ial d ug- ela ed p oblems (Heple and S and, 1990).
Due o he complexi y o esol ing d ug ela ed p oblems (DRPs), some
p o essionals s a ed o discuss ways o each and implemen pha maceu ical ca e
p ac ices almos immedia ely a e he wo k o Heple and S and. The i s sys em
de eloped by S and’s esea ch g oup o he Uni e si y o Minneso a consis ed in eigh
ca ego ies o DRPs (S and e al., 1990). In 1998, he esea ch g oup in Pha maceu ical
Adap ed om: (Ande son, 2002; Maddux e al., 2000; Robe s e al., 2005;
Van Mil e al., 2004; Zellme , 2010)
INTRODUCTION
6
Ca e o he Uni e si y o G anada held a mee ing o p o essionals and g oups wo king
on he iden i ica ion and esolu ion o DRPs. In his mee ing, he educ ion o six
ca ego ies o DRPs was ag eed, on wha has come o be known as he Consensus o
G anada ( able 1) (Panel de Consenso, 1999).
1.1.2.1. THE DÁDER METHODOLOGY
Recognizing he necessi y o ain g adua ed pha macis s on he eme ging new
p ac ices, he Uni e si y o G anada de eloped pos -g adua e ac i i ies and aining
cou ses in Pha maceu ical Ca e, he Dáde P og am on d ug he apy ollow up, ha would
gi e way o wha is now known has Dáde Me hodology (Ma ínez-Rome o e al., 2001).
A he ime, i was de ined ha he p o ision o ollow-up based on Dáde me hodology
could no need compu e applica ions, i should only be based on a simple sys em o
documen a ion o p ocesses and esul s. Nei he any special p e ious pha macological o
pha maco he apy ad anced knowledge was necessa y. This was done o a oid ba ie s o
pha maceu ical ca e p o ision ha a he ime we e beginning o be desc ibed in he
li e a u e (Mil e al., 2001).
Table 1 - De ini ion o d ug ela ed p oblems (DRP) acco ding o he Consensus o G anada
(adap ed om: Ma ínez-Rome o e al. 2001; Panel de Consenso 1999)
DRP classi ica ion
Desc ip ion
Necessi y
DRP 1
The pa ien does no use a medicine ha is needed
DRP 2
The pa ien uses a medicine ha is no needed
E ec i eness
DRP 3
The pa ien does no espond o ea men (non-
dosage-dependen )
DRP 4
The pa ien uses a dose o equency in e io o wha
is needed (Ine ec i eness dosage-dependen )
Sa e y
DRP 5
The pa ien uses a dose o equency supe io o
wha is needed
DRP 6
The pa ien uses a medicine which p o okes and
ad e se eac ion
The p o ision o pha maceu ical ca e wi h he Dáde me hodology is suppo ed on
he collec ion o pa ien in o ma ion on a scheduled pha macy isi . This in o ma ion can
be subjec i e in o ma ion (e.g. open ques ions abou gene al heal h issues), o objec i e
in o ma ion (e.g. blood p essu e, and o he measu emen s). Then, he pha macis makes

INTRODUCTION
7
an e alua ion o he pa ien ’s heal h s a us and possible DRPs ound should be epo ed
o he p ima y ca e physician esponsible o he pa ien . A plan is hen designed in
acco dance wi h he pa ien and a ollow-up isi should be scheduled, o e alua e he
p osecu ion o he plan.
1.1.2.2. PHARMACEUTICAL SERVICES
Fuelled by he ini ial wo k o Heple and S and and he consequen eme gence o
new oles, he pha macy p o ession de eloped a wide a ie y o pha maceu ical se ices.
Due o he con inuous de elopmen o nume ous se ices, he concep ual discussion
abou wha is “pha maceu ical ca e”, “pha maceu ical se ices” o “pha macy se ices”
is ongoing. One ecen pape ad oca es ha a “p o essional pha macy se ice” is de ined
as “an ac ion o se o ac ions unde aken in o o ganised by a pha macy, deli e ed by a
pha macis o o he heal h p ac i ione , who applies hei specialised heal h knowledge
pe sonally o ia an in e media y, wi h a pa ien /clien , popula ion o o he heal h
p o essional, o op imise he p ocess o ca e, wi h he aim o imp o e heal h ou comes
and he alue o heal hca e” (Moullin e al., 2013). To dis inguish se ices p o ides by
pha macis s om o he se ices, his de ini ion is hen di ided in “pha macis se ices”
and “O he Heal hca e P ac i ione Se ices”; Pha macis se ices a e hen di ided in
“pha maceu ical se ices”, when i e e s o he u iliza ion o pha macis s’ knowledge in
hei ield o s udies (e.g. hose ela ing o d ug he apy like pha maceu ical ca e) and
“O he Heal hca e Se ices” (e.g. heal h p omo ion se ices).
Al hough he e is no uni e sally accep ed de ini ion o pha maceu ical se ices ha
comp ises he en i e scope o ac i i ies, se ices, and p og ams p o ided by communi y
pha macies (Moullin e al., 2013), a b oad numbe o p o essional se ices pe o med by
pha macis s, ha may ma ch communi y pha macis ’s ole in p ima y heal hca e in
di e en coun ies, can be iden i ied. These se ices can be ca ego ized in o 2 main
g oups ( igu e 1):
a) Dis ibu ion se ices and P oduc -linked se ices
Dis ibu ion and p oduc -linked se ices a e undamen al o he pha macy
p o ession, including dispensing medicines, gene ic subs i u ion, and handling medicine
was e. They may also include educa ion abou speci ic medicines o pa ien and
INTRODUCTION
8
heal hca e pe sonnel, he apy compliance suppo and counselling. These se ices
cons i u e he i s ie o pha macy se ices, some imes called “essen ial” se ices
(B adley e al., 2007), and a e usually egula ed h ough legisla ion in he espec i e
coun ies.
Figu e 1 - Pha maceu ical Se ices Ma u i y F amewo k
b) Heal hca e se ices based on he pa ien ’s speci ic diagnosis and use o
medicines
Se ices p o ided by pha macis s based on pa ien ’s speci ic diagnosis ela e o
moni o ing o he apy e icacy and de ec ion o ea ly signs o disease. Medicines-use
based se ices can ocus ei he on he use o medicines as a whole, o on one speci ic ype
o medicine. These a e he some imes called “ad anced” and “enhanced” pha maceu ical
se ices (B adley e al., 2007, 2006).
Examples o ad anced se ices a e, sc eening, moni o ing, and counselling o
he apy managemen in ela ion o di e en diseases. Enhanced se ices may include
home deli e y o medicines, an icoagulan moni o ing, Disease speci ic medicines
managemen , Medica ion Re iew se ices, Needle and Sy inge exchange, Smoking
cessa ion se ices, and supe ised adminis a ion o medicines. A pa icula se o
enhanced se ices ha e also been e e ed o as pha maceu ical ca e, cogni i e se ices,
disease s a e managemen , medica ion he apy managemen (MTM), and clinical
INTRODUCTION
9
pha macy se ices in o de o di e en ia e hem om dispensing se ices (Nu escu and
Klo z, 2007).
This second g oup o se ices ha e been conside ed ex emely aluable o heal h
sys ems and p o essionals, no only because o economic sa ings bu also due o a g ea e
e iciency and imp o emen in heal h se ices quali y and in pa ien heal h- ela ed
ou comes (Be engue e al., 2004; C ano e al., 2003; Nkansah e al., 2010). Howe e ,
he e idence ega ding he e ec i eness o hese se ices is no comple ely clea
(Mossialos e al., 2013). The lack o solid e idence has been iden i ied as one o he
ba ie s o he in eg a ion o p o essional pha macy se ices in he heal h sys em, and
pa icula ly, in p ima y heal hca e (Mossialos e al., 2015).
1.1.3. INTEGRATING PHARMACISTS IN THE PRIMARY HEALTHCARE TEAM
Much discussion a ound he bes way o in eg a e pha macis s in he p ima y
heal hca e eam has happened (Mossialos e al., 2013). S udies ha e iden i ied bene i s
o pa ien s whe e pha macis s a e in eg a ed in o co e heal hca e eams, allowing g ea e
access and imp o ed public heal h (Campbell e al., 2014), as well as gains in aising
awa eness o pha macis s’ new ole amongs o he heal h p o essionals (Makowsky e al.,
2009).
Un il now, pha macis s con inue o exe hei supply ole in he heal hca e sys em
wi hou much inno a ion, in spi e o he de elopmen o pha maceu ical ca e p og ams
and o he disease managemen , he apeu ic managemen o public heal h se ices (S and
e al., 2016). Howe e , pha macis s can con ibu e immedia e solu ions h ough e o s o
enhance medica ion managemen , iden i y and sol e d ug‐ ela ed p oblems and ad e se
e en s, and help pa ien s achie e in ended ou comes, ecognizing ha ca ying ou his
esponsibili y equi es communica ion, collabo a ion and p o essionalism (Kennie-
Kaulbach e al., 2012).
The in eg a ion o communi y pha macis s in he p ima y heal hca e eam depends
g ea ly on bo h ecogni ion and accep ance o he di e en heal h p o essionals in ol ed
in disease managemen , pa icula ly gene al p ac i ione s (GPs) and o he physicians
(B adley e al., 2012; Edmunds and Calnan, 2001). Fo decades, his ela ionship has been
o e looked, many imes a sou ce o disag eemen and esen men be ween bo h
INTRODUCTION
10
p o essional o ganiza ions and o he p o essionals' bodies, becoming a majo ba ie o a
new ole o communi y pha macis s (Ba de e al., 2015; Edmunds and Calnan, 2001;
Paulino e al., 2010).
The idea o p ima y heal hca e in eg a ion can assume di e en a angemen s:
“con ac ing,” “coo dina ion,” “coope a ion,” and “collabo a ion” (Axelsson and
Axelsson, 2006). The di e ence be ween hese o ms o in eg a ion depends on he way
he o maliza ion o he ela ionship happens. I he a angemen s a e depending on
“con ac ing” i means ha he in eg a ion comp ises a o mal con ac ; collabo a ion on
he o he hand, is when in eg a ion is achie ed h ough olun a y a angemen s (Axelsson
and Axelsson, 2006). Examples o o mal con ac s amongs physicians and pha macis s
exis om he Uni ed S a es o Ame ica (USA) and Canada, o Eu ope o Aus alia
(Ben imoj and Robe s, 2005; B adley e al., 2012; K oge e al., 2000; Noyce, 2007;
Schulz, 2006). The e a e also examples o explici ag eemen s be ween GPs and
pha macis s conce ning hei p esc ip ion policy (Be ns en e al., 2009; Kooy e al., 2007;
an de Kam e al., 2001). Ne e heless, he mos common o m o p ac ice is s ill
in o mal collabo a ion (B adley e al., 2012).
Di e en concep ual models ha e eme ged in he las yea s seeking o de ine he
d i e s o he GP-CP collabo a ion. Among hem, B adley and colleagues (2012), p opose
a model wi h 3 le els o collabo a ion assessed on 7 dimensions: Locali y, Se ice
P o ision, T us , “Knowing” each o he , Communica ion, P o essional oles, and
P o essional espec (Table 2).
Se e al issues a ise om his model, mainly ega ding he dimensions o us and
p o essional oles. Physicians need o us he pha macis bu he con a y is no
necessa ily ue (B adley e al., 2012). To build us , physicians need o know he
pha macis , inding i di icul o wo k wi h mul iple chain pha macies, which usually
ha e many s a membe s wi h high u no e . This implies ha in se ings o high
p o essional u no e , any o m o collabo a ion is inhibi ed. Also, a p eoccupa ion o
ein o ce he adi ional oles o GPs and he con emp o pha macy’s comme cial aspec
leads he au ho s o his concep ual model o conclude ha collabo a i e a angemen s
may no be he mos app op ia e (B adley e al., 2012). O he s udies poin o simila key
elemen s in he GP-CP collabo a ion (Ba de e al., 2015). Howe e , all s udies emphasize
INTRODUCTION
17
1.1.6. PHARMACEUTICAL SERVICES REMUNERATION MODELS
The g owing impo ance o pha maceu ical ca e se ices wi hin he p o ession
b ough o ligh he discussion abou se ice emune a ion (Hu in, 1996). Pha macis s
a e ypically paid o supplying medicines and a en ion is a ely gi en o pha macy
se ices emune a ion in he con ex o he o al heal hca e budge . Ins ead, pha macy
se ices a e o en seen as a cos o he paye in addi ion o he cos o he medicines, a he
han an in es men in heal hca e ha esul s in imp o ed quali y, sa e y, be e ea men
ou comes and cos sa ings in he long e m (Mossialos e al., 2015). This is especially
ue in an en i onmen o e idence-based policy-making, whe e heal h sys em inance s
need o be con inced ha hei budge is being well spen on pha maceu ical se ices
(Geo ge and Silcock, 1999; Mossialos e al., 2013).
Paymen models o pha macy se ices ha e p og essed slowly, despi e e idence
ha such se ices p o ide a solid e u n on in es men and imp o e pa ien ou comes
(Pe ez e al., 2009; Schumock e al., 2003). Howe e , de ining he bes emune a ion
model o pha maceu ical ca e se ices is s ill a ma e o deba e wi hin he p o ession
and policy make s (Mossialos e al., 2013).
The e is an ex ensi e li e a u e desc ibing he a ious emune a ion models
h oughou he wo ld (Be ns en e al., 2010). Compa ing, and desc ibing hem, is di icul
since e e y coun y has i s own sys em ( igu e 4). Also, i is impo an o dis inguish
be ween emune a ion and eimbu semen . Remune a ion e e s o a paymen ha is due
o a p o ision o a se ice. In he case o pha macy se ices, some o he emune a ion is
in pa due o he selling o medicines ha may be eimbu sed. Reimbu semen usually
in ol es a hi d-pa y paye co e ing pa o he emune a ion, ei he be o e o a e he
acquisi ion o he good o se ice (Nu escu and Klo z, 2007). The eimbu semen o
medicines p ices is he mos common o m o pha macy emune a ion ac oss Eu ope
(Vogle e al., 2014).
Remune a ion models o p o essional pha macy se ices a e in luenced by he
heal hca e and heal h insu ance sys em. Fo ins ance, in he USA, he ede al go e nmen
pays o some se ices (Medica e), while he di e en s a es (Medicaid) and p i a e
insu ances pay o o he s (Fijalka e al., 2008). The pha maceu ical indus y may inance

INTRODUCTION
18
a small amoun o ca e o hose who canno a o d hei medicines. In coun ies such as
he Uni ed Kingdom (UK), Canada, Aus alia and New Zealand pha macis s a e paid o
p o iding a la ge numbe o p o essional se ices (Be ns en e al., 2009).
Figu e 4 - In e na ional compa ison o emune a ion models o communi y pha macies
(sou ce: (Be ns en e al., 2009))
INTRODUCTION
19
Wi hin Eu ope, he e a e 27 di e en pha maceu ical p icing and eimbu semen
sys ems (Be ns en e al., 2010). Pha macy emune a ion is egula ed in all coun ies, bu
he e a e di e ences in he way pha macis s a e paid o p o essional se ices beyond
dispensing and selling medicines (Vogle e al., 2014). Some coun ies ha e a mixed
sys em, while o he s ha e a p oduc -o ien ed sys em. As an example o di e en
emune a ion policies, he e a e o mal incen i es o pha macis s o wo k collabo a i ely
wi h physicians in Holland, Ge many, and Swi ze land (Be ns en e al., 2010). In England
and Wales, he emune a ion o p o essional se ices is di ided in o essen ial se ices,
ad anced se ices and enhanced se ices (Noyce, 2007). In he UK, communi y
pha macies wi h an NHS con ac need o p o ide he ull ange o essen ial se ices,
whe eas ad anced and enhanced se ices a e op ional, and migh equi e addi ional
educa ion and new pha macy layou (a p i a e consul a ion space is manda o y). The
essen ial and ad anced se ices a e commissioned by he UK’s NHS and co e people
h oughou he coun y. The enhanced se ices a e commissioned by he local P ima y
Ca e T us , and consequen ly a e no equally dis ibu ed o e he coun y (Noyce, 2007).
In Sco land, and in some pa s o England and Wales, pha macis s can be paid by
he NHS o hei p o essional se ices when selling O e - he-coun e (OTC) medicines
as pa o The Mino Ailmen s Scheme (Be ns en e al., 2009). Remune a ion o
p o essional se ices also implies a commi men o assu e he quali y o such se ices in
a numbe o coun ies. In he Uni ed Kingdom, communi y pha macies need o p o ide
e idence ha hey mee he condi ions o a comp ehensi e quali y assu ance amewo k
(Noyce, 2007).
In Po ugal, pha macy emune a ion is cu en ly de ined by he Dec ee-Law
19/2014, and is based on a di e en ial ma k-up, wi h an highe ma k-up o gene ics and
a ixed ma k-up o p esc ip ion medicines abo e €50 (Minis y o Heal h, 2014).
Recen ly, a small ee pe gene ic medicine package sold was also es ablished, looking o
p o ide pha macies wi h incen i es o inc ease he selling o gene ic medicines and
con ibu ing o educe na ional pha maceu ical expendi u e (Minis y o Heal h, 2015).
Re enues om dispensing p esc ip ion medicines usually ep esen be ween 85 and 92%
o pha macy e enues (An ão and G enha, 2012; Douce e e al., 2012; INFARMED,
2012). Unlike dispensing, all o he new pha macy se ices a e no manda o y, wi h hei
INTRODUCTION
20
p o ision and p ice depending on he will o he pha macy owne . Some pha macies
p o ide hese se ices ee o cha ge while o he s choose o cha ge a ee suppo ed by
pa ien s’ ou -o -pocke paymen s (Cos a e al., 2006; Ma ins and Quei ós, 2014).
1.1.6.1. FINANCIAL INCENTIVES IN COMMUNITY PHARMACY
The need o balance pha maceu ical expendi u e budge s will become mo e
challenging gi en ha new and expensi e medicines a e likely o gain ma ke ing
au ho isa ion in he u u e (Eichle e al., 2016). In his con ex , i is impo an o in oduce
incen i es o pha macis s ha a e o ien ed o suppo cos -e ec i e and high-quali y
medicinal he apy (Be ns en e al., 2009).
In spi e o he se e al issues ega ding pha maceu ical se ices implemen a ion and
sus ainabili y, some au ho s a gue ha is necessa y o in oduce a se o incen i es aimed
a communi y pha macis s wi hou which, all he po en ial o pha maceu ical se ices
goes la gely un apped (Be ns en e al., 2010; K oge e al., 2000; Mille and O meie ,
1995; Robe s e al., 2008). I is clea ha he exis ence o incen i es o pha maceu ical
se ices in luences i s p o ision, al hough i is no gua an y o u u e sus ainabili y
(Gas elu u ia e al., 2009; Robe s e al., 2008). O he aspec s such as communica ion
and eamwo k, leade ship, ask delega ion, ex e nal suppo o assis ance, and
eo ganiza ion o s uc u e and unc ion a e also o be conside ed (Robe s e al., 2008).
The undamen al pu pose o incen i es is o p o ide he igh mo i a ion o an agen
(e.g. heal h se ice p o ide ) o pe o m well. This includes p o iding he incen i e o
de elop he capaci y o pe o m well, o acqui e he igh in o ma ion, and o hen ac on
i acco dingly (Cus e s e al., 2008). Though he e a e issues wi h nomencla u e and he
de ini ions, he heal hca e a ea uses di e en ypes o inancial incen i es including : (i)
sala y (paymen o wo king o a speci ied ime pe iod); (ii) ee- o -se ice (paymen o
each se ice, episode o isi ); (iii) capi a ion (paymen o p o iding ca e o a pa ien o
o a special popula ion); and (i ) a ge paymen s and bonuses (paymen o p o iding a
p e-speci ied le el o change in a speci ic beha iou o quali y o ca e) (Flodg en e al.,
2011).
Conside ing he o e all emune a ion o pha macis s, Hu in and colleagues (1996),
analysed emune a ion sys ems om a sociological pe spec i e. They ound ha sys ems
INTRODUCTION
21
o emune a ion could be classi ied in o wo majo ypes: p oduc -o ien ed emune a ion
using a ma k-up o g adua ed ma k-up, and pa ien -o ien ed emune a ion using a ee o
se ice o capi a ion me hod. The adi ional pha macy ma k-up o ixed pha macy
ma gin sys em o e ibu ion o pha macis s is o en seen as p o iding inadequa e
incen i es o pha macis s; i appeals o hei inancial in e es in selling highe -p iced
d ugs and, in gene al, o inc ease sales (Espin and Ro i a, 2007). Fee s uc u es may be
de eloped ha se he ees based on he ype o se ice p o ided. Se e al examples can
be ound in he li e a u e o ees cha ged o clinical se ices in communi y pha macies;
in he USA, some p o ide s use a capi a ion ee s uc u e in which he pa ien migh en ol
in a se ice o a p ede e mined ee in exchange o a bundled package o se ices
p o ided o a gi en pe iod o ime (Snella e al., 2004).
One o he mo e challenging objec ions o p o ide pha macis s wi h incen i es is
ha , since pha maceu ical se ices ha e been associa ed wi h a p oduc - p esc ip ion and
OTC medicines - some assume he clinical se ices a e paid h ough he ma gins on he
dispensing o p esc ip ions (S ubbings e al., 2011). In coun ies ha ha e emune a ion
models o bo h d ug dispensing and p o essional se ices, i is possible o hese models
o p o ide con lic ing incen i es o pha macis s (Be ns en e al., 2010). This is because
emune a ion models o p o essional se ices in hese coun ies s ill end o emune a e
he pha macis p ima ily o he supply o medicines. In England and Wales, pha macis s
a e paid o p o iding p o essional se ices, bu hey a e also expec ed o add a ma gin o
he p ice o he medicine o hei income (Noyce, 2007). Fo example, in a case o a
pa ien in need o ad ice o ea his condi ion wi h li es yle changes, such as die and
exe cise, ins ead o a medicine, cu en emune a ion models end o inancially penalize
pha macis s o p o iding his ype o p o essional ad ice gi en he adi ional link
be ween emune a ion and he supply unc ion. The same happens in Po ugal and in
many o he coun ies ac oss Eu ope. The only example o a emune a ion model ha
acknowledges and ewa ds he ac ha a pha macy p o essional se ice in ol es he
decision no o dispense a medicine is he “Re usal o ill” o “Re usal o dispense” se ice
ound in some Canadian p o inces’ pha macy p og ams (Houle e al., 2014; K oge e
al., 2000).
INTRODUCTION
22
1.2. AIM OF THESIS
Conside ing cu en ends, he de elopmen o new p o essional pha macy se ices
will ine i ably equi e he use o sophis ica ed IST. Howe e , he success o IST
u iliza ion o he p o ision o heal h ca e is impending on mo e esea ch. The
echnology’s po en ial o dis up heal h p o essionals’ and use s’ oles ep esen s a h ea
o he success ul implemen a ion (Ka z and Moye , 2004; Mossialos e al., 2013;
Mo ulsky e al., 2011; Pe akaki e al., 2012). S udies show ha he use o IST by
heal hca e p o essionals may be a bu den when he sys ems a e no de eloped conside ing
he needs o p o essionals in p ac ice se ings (Da byshi e, 2004).
In o de o be e unde s and he link be ween he in oduc ion and use o IST in
p ac ice se ings, i is impo an o examine he echnical and o ganiza ional challenges
aised du ing implemen a ion. The e o e, i is necessa y o unde s and how heal h
p o essionals and pa ien s pe cei e IST use ulness o heal h ca e p o ision, and how a e
hey willing o pa icipa e in he de elopmen o new se ices. To do so, his p ojec
p oposes o add ess se e al esea ch ques ions: How will a web-based pha maceu ical
se ice impac pha macis s’ wo k and pa ien ’s own disease managemen ? Wha will be
he es ima ed cos ? A e pa ien s willing o pa icipa e in he de elopmen o pa ien -
o ien ed pha maceu ical se ices? Wha in o ma ion hey will alue? Wha kind o
challenges will a ise?
To be e isualize he di e en connec ions ha will be enhanced by IST suppo
o online pha maceu ical se ices, a concep ual model was de eloped ( igu e 5). In his
model, i is highligh ed ha communi y pha macis s suppo ed by IST may play a
ga ekeeping-like ole in disease managemen .

INTRODUCTION
23
Figu e 5 - Concep ual model o he use o IST in he Communi y Pha macy se ing (adap ed om
ePha maca e P ojec (PTDC/CCI-CIN/122690/2010))
To add ess he men ioned esea ch ques ions, he aim o his p ojec is o design,
implemen and e alua e a disease managemen web-based in e ac i e se ice,
es ablishing i s u ili y, accep abili y, easibili y, sus ainabili y, and adap abili y o a
communi y pha macy se ing, using design science esea ch me hodologies (He ne e
al., 2004). In his way, i is in ended o explo e new models o in e ac ion be ween pa ien s
and heal h p o essionals ha will allow some insigh s on he esea ch ques ions.
As mo e speci ic objec i es, i is p oposed o:
 Iden i y heal h sys em condi ions ha will be necessa y o implemen an
online pha maceu ical se ice.
 Iden i y he majo pa e ns o pha maceu ical se ices p o ision in a sample
o communi y pha macies, hus es ablishing he cu en s a e o
pha maceu ical se ices p o ision while explo ing u u e se ices’ demand;
 Es ima e he cos o cu en pha maceu ical se ices, es ablishing a gold
s anda d o compa ison wi h u u e se ices cos ing;
INTRODUCTION
24
 Iden i y po en ial se ice’s ea u es ha may ha e an impac on heal h
esul s and pa ien sa is ac ion
 Iden i y se ice’s ea u es ha mos con ibu e o he pe cei ed use ulness
and ease o use o he in e ne -based pa ien managemen se ice, in he
pa ien pe spec i e;
1.3. METHODOLOGY
The design and implemen a ion o an IST ool in a p ac ice se ing poses some
challenges. I is equen ha he in oduc ion o new ools is decided by policymake s
and expe s wi hou in ol ing u u e use s (F ied e al., 2012). Howe e , a use cen ed
app oach may be mo e use ul o be ce ain ha he sys em will sa is y use ’s needs and
ha hey will be en husias ic wi h i s use while, simul aneously, he sys em will be
adequa e and pe cei ed as use ul (A ms ong and Powell, 2008; Demi is e al., 2008).
The e o e, he need o use a me hodology ha allows he design o an inno a ion wi h he
end use ’s inpu is e iden .
One o he me hodologies IST esea che s ha e a hei disposal o s udy he
de elopmen o new p oduc s is he Design Science Resea ch Me hodology (DSRM)
(He ne e al., 2004; Pe e s e al., 2007). He ne and colleagues (2004), ha e es ablished
he ules o DSRM in he o m o guidelines. The mos impo an is ha he esea ch
should p oduce an a i ac o sol e a p oblem. O he guideline s a e ha he de elopmen
o he a i ac should be based on exis ing knowledge and heo ies o p oduce a solu ion
o he de ined p oblem. Mo eo e , he a i ac should be ele an o he esolu ion o a
p oblem in a pa icula business model and ha e i s use ulness, quali y, and e ec i eness
igo ously e alua ed. As a inal guideline, he esea ch should be communica ed o he
a ge audiences. These guidelines enlis six ac i i ies ( igu e 6) (Pe e s e al., 2007).
INTRODUCTION
25
Figu e 6 – DSRM cycle (adap ed om (Pe e s e al., 2007)
In Box 3, a de ailed desc ip ion o he ac i i ies acco ding o Pe e s and colleagues
(2007), is p esen ed. As shown in igu e 6, he DSRM p ocess can be seen as a design
cycle, as is common in in o ma ion sys ems esea ch.
The app oach ha his hesis es s is he applica ion o DSRM o he de elopmen
o a pha maceu ical se ice suppo ed by a web-based pla o m – he a i ac – o he
exchange o in o ma ion be ween pa ien s and pha macis s. As such, his p ojec
add esses he DSRM p ocess by designing explo a i e s udies wi h a speci ic se o asks
Ac i i y 1 – P oblem iden i ica ion and mo i a ion: De ine he speci ic esea ch p oblem and jus i y
he alue o a solu ion.
Ac i i y 2 – De ine he objec i es o a solu ion: In e he objec i es o a solu ion om he p oblem
de ini ion and knowledge o wha is possible and easible. Resou ces equi ed o his include
knowledge o he s a e o p oblems and cu en solu ions, i any, and hei e icacy.
Ac i i y 3 – Design and de elopmen : C ea e he a i ac . This ac i i y includes de e mining he
a i ac ’s desi ed unc ionali y and i s a chi ec u e and hen c ea ing he ac ual a i ac .
Ac i i y 4 – Demons a ion: Demons a e he use o he a i ac o sol e one o mo e ins ances o
he p oblem. This could in ol e i s use in expe imen a ion, simula ion, case s udy, p oo , o o he
app op ia e ac i i y.
Ac i i y 5 – E alua ion: Obse e and measu e how well he a i ac suppo s a solu ion o he
p oblem. This ac i i y in ol es compa ing he objec i es o a solu ion o ac ual obse ed esul s
om use o he a i ac in he demons a ion. A he end o his ac i i y he esea che s can decide
whe he o i e a e back o ac i i y 3 o y o imp o e he e ec i eness o he a i ac o o con inue
on o communica ion and lea e u he imp o emen o subsequen p ojec s.
Ac i i y 6 – Communica ion: Communica e he p oblem and i s impo ance, he a i ac , i s u ili y
and no el y, he igo o i s design, and i s e ec i eness o esea che s and o he ele an audiences
such as p ac icing p o essionals
Box 3 – Desc ip ion o he six ac i i ies o DSRM, acco ding o Pe e s and colleagues (Pe e s e
al., 2007)
INTRODUCTION
26
ha will allow o accomplish each DSRM ac i i y and he p osecu ion o his hesis’
objec i es ( able 3).
Table 3 - Design Science Resea ch ac i i ies and asks o pe o m
DSRM Ac i i y
Objec i es
Me hod/Tasks
1. Diagnose o
cu en si ua ion
and iden i ica ion
o p oblem
ele ance
Iden i y heal h sys em
condi ions ha will be
necessa y o implemen an
online pha maceu ical se ice
 Scena io design o Po uguese
pha macis s in 2020.
Iden i y he majo pa e ns o
pha maceu ical se ices
p o ision in a sample o
communi y pha macies, hus
es ablishing he cu en s a e o
pha maceu ical se ices
p o ision while explo ing
u u e se ices’ demand
 Online su ey o IT u iliza ion in
Po uguese pha macies.
 Obse a ional ime-and-mo ion s udy
o assess Pha macis s’ cu en wo k
pa e ns and po en ial demand o
pha maceu ical ca e se ices.
Es ima e he cos o cu en
pha maceu ical se ices,
es ablishing a gold s anda d
o compa ison wi h u u e
se ices cos ing
 Obse a ional ime-and-mo ion s udy
o es ima e cos o cu en
pha maceu ical se ices.
2. De ining he
objec i es o a
solu ion
(see (Mello, 2013))
 Se o quali a i e in e iews
pe o med wi hin p ima y heal h
cen es and hospi als
 Se ice Expe imen Bluep in
3. Design and
de elopmen
(ou sou ced o an independen
p og amme )
 Design o a i ac (online pla o m)
o pha maceu ical ca e se ices
p o ision
4. Demons a ion
Iden i y po en ial se ice’s
ea u es ha may ha e an
impac on heal h esul s and
pa ien sa is ac ion
 Case-s udy o es de pla o m wi h a
pu posi ely selec ed g oup o
pa ien s
5. E alua ion
Iden i y se ice’s ea u es ha
mos con ibu e o he
pe cei ed use ulness and ease
o use o he in e ne -based
pa ien managemen se ice, in
he pa ien pe spec i e
 Wi h an eye- acking glass, he
usabili y o he cu en e sion o he
pla o m as assessed h ough he use
o “ ask scena ios”
6. Communica ion
-
 Done h oughou he du a ion o he
p ojec , h ough jou nal, con e ence
communica ions, jou nal pape s and
his hesis.
INTRODUCTION
33
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2. RESULTS
2.1. PAPER I
GREGÓRIO, João; CAVACO, A onso; LAPÃO, Luís Velez. A scena io-planning
app oach o human esou ces o heal h: he case o communi y pha macis s in Po ugal.
Human esou ces o Heal h, 2014, 12.1: 1. DOI: 10.1186/1478-4491-12-58
RESULTS
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RESULTS
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RESULTS
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2.2. PAPER II
GREGÓRIO, João; CAVACO, A onso Miguel; LAPÃO, Luís Velez. How o bes
manage ime in e ac ion wi h pa ien s? Communi y pha macis wo kload and se ice
p o ision analysis. Resea ch in Social and Adminis a i e Pha macy, 2016. (in p ess)
RESULTS
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2.3. PAPER III
GREGÓRIO, João; RUSSO, Giuliano; LAPÃO, Luís Velez. Pha maceu ical
se ices cos analysis using ime-d i en ac i i y-based cos ing: A con ibu ion o imp o e
communi y pha macies' managemen . Resea ch in Social and Adminis a i e Pha macy,
2016, 12.3: 475-485. DOI:10.1016/j.sapha m.2015.08.004
RESULTS
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2.4. PAPER IV
LAPÃO, Luís Velez; MIRA DA SILVA, Miguel; GREGÓRIO, João;
Implemen ing an Online Pha maceu ical Se ice using Design Science Resea ch. BMC
Medical In o ma ics and Decision Making (Pape submi ed on 23/05/2016)
RESULTS
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DISCUSSION
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esponden s p esen ed in pape IV decla ing ha he lack o suppo om p o essional
o ganiza ions is a ba ie o he de elopmen o online pha maceu ical se ices.
Ano he end highligh ed in pape I is he g owing numbe o a ailable
pha macis s. The pha macy ma ke is abso bing hese p o essionals, wi h he a e age
numbe o pha macis s pe pha macy also g owing since he analysis epo ed in pape I
(Po uguese Pha maceu ical Socie y, 2013). The end o subs i u ing pha macy
echnicians by pha macis s also con inues. These ends along wi h he de ini ion o
emune a ion policies o new se ices, may ha e an impo an impac on pha macy
se ices p o ision and pha macis s’ ole de ini ion ha will be discussed in he
“implica ions o policy and p ac ice” sec ion.
3.1.2. PAPER II
The s udy o pha macis s’ wo kload pa e ns and se ice p o ision was he main
goal o he wo k epo ed in pape II. Unde s anding wha pha macis s do in “a day a he
o ice” and assessing he po en ial demand o ch onic ca e se ices was en isioned as a
c i ical s ep in he design o a new se ice. The esul s o his esea ch highligh he need
o ede ine oles wi hin he pha macy, as he pe cep ion o “lack o ime” o en epo ed
in he li e a u e, migh no be an accu a e excuse o no p o iding pha maceu ical ca e
se ices. In ac , wha needs o be highligh ed is ha pha macis s spend a signi ican
po ion o hei daily ime execu ing undi e en ia ed asks ha could e y well be
pe o med by pha macy echnicians o o he assis an pe sonnel.
The wo kload pa e ns iden i ied in his pape a e e y simila o wo kload pa e ns
in o he coun ies. This inding indica es ha pha macis s’ ole is nowadays qui e
s anda dized. Al hough each coun y has di e en heal hca e sys ems and a angemen s
o pha maceu ical se ice p o ision, unde s anding ha pha macis s ha e simila
wo kload pa e ns ac oss coun ies is impo an o p o essional de elopmen policy,
since i allows o hink in a common s a egy o pha macis s’ ole shi and
implemen a ion o new pha macy se ices. Ne e heless, a common legal amewo k in
Eu opean coun ies has so a been di icul o achie e (Mossialos e al., 2015, 2004).

DISCUSSION
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3.1.3. PAPER III
To be e assess he managemen implica ions o pha maceu ical se ices p o ision
in communi y pha macies, he e is a need o accu a ely measu e cos s. This was he
a ionale behind he s udy epo ed in pape III ha aimed o es ima e he cos o cu en
pha maceu ical se ices, es ablishing a gold s anda d o compa ison wi h u u e se ices’
cos ing.
Finding he cos o dispensing se ices, OTC consul a ions, and he cos o a
counselling se ice wi hou he medicine dispensing, we e impo an esul s ha will aid
he discussion a ound he de elopmen o new emune a ion models o communi y
pha macy. The counselling se ice has shown o be a low cos se ice ha can be used o
p omo e and o e o he pha macy se ices. Wi h he ac i i y cos s epo ed, one can
es ima e a cos o he online se ice de eloped. Conside ing ha he ac i i y “In e iew
pa ien /answe pa ien que y” is he suppo o he new se ice, i will cos a ound €32.04
pe hou in hese pha macies. Assuming a pha macis would use 20 minu es pe mon h o
p o ide he se ice o a pa ien , he online se ice in hese pha macies would cos a ound
€10.00 a mon h pe pa ien jus o each b eake en.
Besides calcula ing cos s, he choice o Time-D i en Ac i i y Based Cos ing
(TDABC) was made since he de elopmen o a TDABC model o pha maceu ical
se ices cos ing could p o ide communi y pha macy’s manage s wi h aluable
in o ma ion o edesign ac i i ies, aiming o achie e a mo e cos -e ec i e p o ision o
pha maceu ical se ices. As highligh ed in he discussion o pape III, he e is a clea need
o op imize he ac i i ies ha suppo pha maceu ical se ices p o ision.
3.1.4. PAPER IV
The implemen a ion o he online pha maceu ical se ice h ough he use o DSRM
was success ul as a p oo o concep . Using DSRM p o ided a me hod o add ess se e al
issues ega ding se ice de elopmen , s a ing wi h he desc ip ion o he cu en p ac ice
and he po en ial demand o no el y se ices, o he design and implemen a ion o an
online pla o m o suppo se ice p o ision in wo di e en se ings.
DISCUSSION
115
Pha macis s’ answe s o he ini ial su ey highligh ha Po uguese communi y
pha macis s a e accus omed o use IST-based dispensing sys ems o many yea s, bu
he e is a e y limi ed use o IST-based communica ion ools o assis pa ien ca e in
disease managemen . Pa ien s’ answe s abou new pha macy se ices we e an impo an
inpu . I seems ha pa ien s a e willing o use specialized pha macy se ices. The e was
li le su p ise when pa ien s e e ed ha hey wan ed home deli e y o medicines, since
his se ice is seldom p o ided. Mo eo e , pa ien s’ ecogni ion ha pha macy se ices
mus be in eg a ed wi h NHS’s p ima y ca e se ices, was also an impo an inding.
Pha macis s ha e now o b idge his gap and o e pa ien s eal al e na i es o hei
disease managemen .
The demons a ion s age o he DSRM p esen ed in Pape IV was hinde ed by he
low numbe s o pa ien s being ec ui ed o pa icipa e. The lack o pa ien ec ui men in
he h ee pa icipan pha macies led he esea ch eam o ind an al e na i e in Senio
Uni e si y pupils. This was a isiona y mo e since i allowed o explo e he p o ision o
pha maceu ical ca e by a pha macis ou side he communi y pha macy se ing. Due o he
success o his s a egy, he e seems o be an op ion o independen pha macis s in
de eloping disease managemen se ices o suppo ch onic pa ien s. This would be a ole
simila o a “pa ien ad oca e”, opening he possibili y o inno a o s in he pha macy
p o ession o ans o m disease managemen , as al eady pos ula ed by o he au ho s
(Als on and Wai zman, 2013). Fu he mo e, i communi y pha macis s e e “lack o
ime” o mask hei low in e es and mo i a ion in p o iding disease managemen
se ices, hey mus be awa e ha o he heal h p o essionals, like p ima y heal hca e
nu ses, may ake hei place in communi y-based disease managemen (Buchan e al.,
2013; Leese, 2006).
Due o he low numbe o use s, a speci ic ea u e could no be designa ed as ha ing
an impo an impac in heal h ou comes. Fo now, one can s a e ha he close pa ien
ollow-up, p o ided wi h he use o se e al ea u es, may ha e an impac on heal h
ou comes ha needs o be be e assessed. Use sa is ac ion wi h he pla o m, assessed
in he inal in e iew and by he will o con inue o use he pla o m beyond he end o
he esea ch, is one mo e sign o he po en ial ha communi y pha macis s a e lea ing
unexploi ed. Mo eo e , he need o communica e wi h he GP, ei he h ough
DISCUSSION
116
ePha maca e pla o m o email, el by bo h pha macis s and pa ien s, highligh s he
“ga ekeeping-like” ole ha pa ien s e e is a ole ha i s he pha macis . Acco ding o
use s’ eedback, his connec ion could g ea ly imp o e he pe cei ed use ulness o he
pla o m. Since i was no included in he design o he pla o m in his ini ial DSRM
cycle, he GP-pha macis connec ion will be s udied in he nex cycle. The use o DSRM
p o ides a s ong suppo o de elop he ePha maca e 2.0 pla o m in a con iden way.
Wi h he end o he i s cycle o DSRM desc ibed in pape IV, se e al issues
ega ding he p o ision o communi y pha macis s’ disease managemen se ices
suppo ed by IST ha e been ound. Mos o hem, ha e been discussed in he las yea s
wi hin he p o ession. In he ollowing sec ion, hese issues a e p esen ed and discussed
in he ligh o he indings epo ed in his hesis.
3.2. IMPLICATIONS FOR PRACTICE AND POLICY
3.2.1. ROLE DEFINITION INSIDE COMMUNITY PHARMACY
Wi h he di e en ia ion ha is needed o p o ide online pha maceu ical se ices,
new ca ego ies o wo king communi y pha macis s ha e o be de eloped. Nowadays in
Po ugal, only he echnical di ec o and he depu y pha macis a e in ac a di e en ia ed
unc ion in he pha macy. They play he ole o maximum esponsibili y in he pha macy,
being legally accoun able o medicines dispensing and p o ision o se ices by he es
o he s a . Howe e , nei he is obliga ed o ha e any special educa ion o aining in he
p o ision o pha maceu ical ca e. This causes a skill gap in he pha macy eam ha may
lead o low mo i a ion o inno a e and de elop new se ices. Wi h he aining p og am
o pha macis s’ p o ision o pha maceu ical ca e p og ams o diabe es and
hype ension, pushed by ANF in he u n o he cen u y, some pha macies a e s a ed wi h
capaci a ed p o essionals. In a compe i i e ma ke , his will be a p ecious asse . In a ecen
pape , Ma ins & Quei ós (2014), ound ha access o addi ional pha macy se ices may
inc ease as ma ke compe i ion inc eases. This is usually ue in u ban ma ke s, whe e he
a ailabili y o pha macies is g ea e han in in u al a eas. Howe e , i he heal h sys em
is o e ain i s equi y, a policy amewo k ha will allow se ice di usion h ough he
coun y in a way ha bes assu es equi y will be needed. Coun ies whe e he pha macy
DISCUSSION
117
ma ke is libe alized usually ha e o p o ide incen i es o u al pha macies o allow hem
o emain open (Lluch and Kana os, 2010).
I seems ha he end o hi ing mo e pha macis s and less pha macy echnicians,
highligh ed in pape I, has no con ibu ed o imp o e pha maceu ical se ices p o ision.
In ac , s a ing mo e pha macis s is no a p edic o o p ac ice change (Douce e e al.,
2012). Indeed, s a ing o less han 3 pha macy echnician has been iden i ied as a
nega i e p edic o o p ac ice change and new se ices implemen a ion (Douce e e al.,
2005). A i s glance, ha ing mo e pha macis s pe pha macy may seem a bes p ac ice,
leading o be e pha maceu ical se ice p o ision. Bu i pha macis s a e de o ing hei
ime o pe o m undi e en ia ed asks, hey will ha e li le ime o will o p o ide
pha maceu ical ca e se ices. As such, he high numbe o pha macis s pe pha macy
epo ed in pape II, e sus he ela i e absence o echnicians mus aise some conce ns.
I is o en men ioned ha pha macis s a e indis inguishable om o he pha macy
p o essionals, which in u n con ibu es o he low c edibili y o pha macy se ices
(Ca aco e al., 2005). Howe e , pha macis ’s c edibili y is essen ial o he de elopmen
o he new oles and se ices (Snyde e al., 2010). P omo ing pha macis s’ hi ing o
pe o m echnical asks may backlash and ins ead o pha maceu ical ca e se ices
p o ision, pha macis s’ ole will g adually slide back o a dispense o medicines.
Fu he mo e, he high supply o pha macis s had he e ec o lowe ing pha macis s’
sala ies (Po uguese Pha maceu ical Socie y, 2013). In hese condi ions, p o essionals’
mo ale may be low (Van Le be ghe e al., 2002). Toge he wi h “pull ac o s” pe cei ed
om o he coun ies, such as highe sala ies, be e ca ee de elopmen oppo uni ies and
o e all amily li e condi ions (Dussaul and F anceschini, 2006), i is na u al ha
pha macis s emig a ion may con inue o inc ease, endange ing he goals o uni e sal
co e age o pha maceu ical se ices p o ision (Campbell e al., 2014).
Pa ien s can pe cei e pha macis s as a sou ce o c edible heal h in o ma ion bu hey
can also ha e no idea o wha pha macis s do and wha i is igh o expec om hem
(Cos a e al., 2004; Gue ei o e al., 2010). Pha macy p o essionals ha e o ecognize ha
he new oles depend on he de elopmen o a specialized body o p o essionals, ha
pa ien s can ecognize as such and demand o hei pha macies (Kennie-Kaulbach e al.,
2012). I is necessa y ha only p o essionals wi h he igh c eden ials and expe ise can
DISCUSSION
118
be au ho ized o p o ide mo e ad anced se ices, con ibu ing o c edibili y,
accoun abili y and co- esponsibili y o pa ien s’ heal h ou comes (Noyce, 2006).
Di e encing such p o essionals, and assu ing ha pha macies ha a e willing o p o ide
pha maceu ical se ices ocusing on ch onic ca e managemen ha e one o hese
p o essionals, will be essen ial o he di usion o new o ms o p ac ice in Po ugal. The
la es de elopmen s on p o essional policy made by he Po uguese Pha maceu ical
Socie y ha e included he de ini ion o a compe ency amewo k, a ibu ing co e
compe encies and complemen a y compe encies o communi y pha macis s. The
co olla y o his s a egy poin s o he implemen a ion o a “Communi y pha macy”
speciali y in a nea u u e. Howe e , he amewo k is no clea as o wha will
di e en ia e pha macis s p o iding pha maceu ical ca e se ices om pha macis s ha
will assume a “dispense only” o managemen ole. I will also be ele an o s a
shi ing pha macis ’s public image om a d ug dispense o a heal hca e se ice p o ide ,
possibly h ough a mo e p oac i e a i ude gea ed o pha maceu ical ca e (Saba e -
Galindo e al., 2015).
The pha macis -pa ien ela ionship can be imp o ed h ough mo e in ense and
equen communica ion o achie e an accep able le el o se ice p o ision
(Bodenheime e al., 2002; Gidman e al., 2012; Pelicano-Romano e al., 2015). Besides
he e-o ganiza ion and ole de ini ion ha is necessa y wi hin indi idual pha macies,
communi y pha macis s need be e communica ion ools o enhance he physician-
pa ien -pha macis ela ionship, as has become clea om he demons a ion s age o his
esea ch. The esul s om he demons a ion s age o ePha maca e se ice p o o ype,
epo ed in pape IV, show ha using IST will con ibu e o a be e ollow-up, h ough a
highe equency o communica ion be ween p o ide and pa ien . Howe e , whe he his
ollow-up is e ec i e and aluable o pa ien s and heal h sys em, emains an open
esea ch ques ion.
3.2.2. ROLE OF INFORMATION SYSTEMS AND TECHNOLOGIES
The e has been some discussion abou he s a egic impo ance o in o ma ion
sys ems and echnology (IST) in suppo ing medicine dispensing and he inancial
managemen o communi y pha macies (Wes e ling e al., 2011). Undoub edly, IST will
be essen ial o p o ide pa ien ca e se ices in u u e heal h sys ems. As e‐p esc ibing,

DISCUSSION
119
elec onic medical eco ds, and o he echnological ad ances a e implemen ed and
in eg a ed, pa ien s will ha e inc eased access o p ima y heal hca e p o ide s o
diagnosis, moni o ing, and iage (Mossialos e al., 2013). The po en ial alue o hese
echnologies o imp o e heal h sys em e iciency, will make i an a ea whe e pha macis s’
expe ise and knowledge will be a p ecious asse (Pe akaki e al., 2012).
Communi y pha macies’ IST a e p esen ly mo e ocused on dispensing han
suppo ing pa ien ca e, a inding con i med in his esea ch and epo ed in pape IV.
This is an wo ldwide end, wi h IST o communi y pha macy being mainly used o
suppo s anda d dispensing o p esc ip ions, ei he in pape o by e-p esc ip ion (As and
e al., 2009; Mo ulsky e al., 2011). Ne e heless, he echnological capaci y exis s o
p o ide pa ien ca e. The use o IST may be he key ha unlocks pha macis s' ull
po en ial (Als on and Wai zman, 2013; Pe akaki e al., 2012).
In his hesis, a me hodology o implemen online pha maceu ical se ices was
explo ed. The pla o m suppo ing he se ice was de eloped using use s’ inpu s, which
con ibu ed o he pla o m’s pe cei ed ease o use, ollowing Da is e minology (Da is,
1993). Howe e , due o he low numbe o pa ien s ec ui ed and pha macis s’ esis ance
o ec ui pa ien s, he pe cei ed use ulness o he sys em could no be con enien ly
de e mined. I some hing can be in e ed om his ea ly explo a i e app oach, is ha he
h ee pha macis s ec ui ing pa ien s in he communi y pha macy se ing had no majo
p oblems using he pla o m, inding i easy o use, bu we e insu icien ly mo i a ed o
use he pla o m and p o ide he se ice, hus no ecognizing i s use ulness. This
eluc ance o use he pla o m was expec ed i hese we e olde pha macis s. Bu hese
pha macis s we e young, ha ing imp o ed IST skills in ela ion o hei colleagues. This
hin s a he necessi y o designing adequa e incen i es o se ice p o ision e en o
p o essionals wi h he igh a i ude owa ds pa ien ca e (Fele o e al., 2010). Mo eo e ,
in a scena io whe e IST a e p e ailing and pha macis s a e p o iding eHeal h
pha maceu ical se ices, he eluc ance in he use o IST solu ions highligh s he
impo ance o aining and educa ion on he use o IST. Beyond echnical compe encies
ega ding he p o ision o he pha maceu ical se ice i sel , communi y pha macis s will
ha e o de elop capaci ies o he use o IST, gain ma ke ing skills and imp o e
DISCUSSION
120
communica ion skills o u he inc ease he in eg a ion o pha maceu ical se ices wi h
p ima y heal hca e se ices.
As al eady s a ed in he in oduc ion sec ion, i was also an aim o his p ojec o
es ablish he online se ice accep abili y, easibili y, sus ainabili y, and adap abili y.
Se ice accep abili y has been demons a ed by pa ien s’ use o he pla o m du ing 8
mon hs, ac i ely con ac ing he pha macis and showing in e es in con inuing o use he
pla o m beyond s udy’s end. Howe e , one mus accoun ha o pa ien s’ good
accep abili y o he p og am, he “no cos ” na u e o he se ice may ha e played a
signi ican ole, as has been epo ed in o he con ex s (Gue ei o e al., 2010).
Fu he mo e, pha macis accep abili y o he se ice may be conside ed low, as e ealed
by he lack o pa ien ec ui men . The easibili y o he online pha maceu ical se ice has
been demons a ed o g ea ly depend on pha macis s’ a ailabili y o ac i ely ec ui
pa ien s o he se ice. Howe e , he obse ed low impac on pha macis s’ wo kload
hin s ha his kind o se ice migh be easible, depending on pha macis s’ p oac i e
a i ude in iden i ying he pa ien s who would bene i he mos . Fu he mo e, e e y pa ien
has i s own needs. Needs assessmen on an indi idual le el, done by p ima y ca e
p o essionals, mus be a collabo a i e ac ion (Asadi-La i e al., 2003). I is up o he
pha macis o iden i y pa ien s in he communi y ha will bene i he mos om a
di e en ia ed se ice p o ision and, wi h he collabo a ion o he p ima y heal hca e
eam, de elop se ices ha ul il indi idual pa ien s’ needs.
F om a inancial pe spec i e, his se ice is sus ainable i i gene a es mo e han 10
eu os a mon h pe pa ien in e enue. In eg a ing his se ice in he daily wo k o a
pha macy will depend on inding he igh emune a ion s a egy. Mo e discussion on his
issue and on emune a ion policies will ollow in he nex sec ion. Adap abili y could be
measu ed in wo dimensions. I was ound ha he online pha maceu ical se ice can
adap o di e en con ex s, when mos pa ien s we e ec ui ed ou side he communi y
pha macy se ing. In ano he dimension o adap abili y analysis, he se e al inc emen al
e sions u ilized du ing he demons a ion s age show ha he pla o m and he se ice
can adap o di e en se ings and o use s’ eedback.
Wha is also lacking is unde s anding wha , how, when, and why a communica ion
should be es ablished be ween wo p o essionals in p ac ice se ings. Suppo ing
DISCUSSION
121
mechanisms – clinical p o ocols, egis a ion, aining, licensing and acc edi a ion
p ocesses – need o be b ough up o da e and used (Alliance o Heal h and Sys ems
Resea ch Policy, 2009). Also impo an , is he in eg a ion o physicians’ (and o he
p ima y heal hca e p o essionals) wi h pha macis s’ in o ma ion sys ems. Any o hese
elemen s would p o i om a communica ion pla o m such as he one designed du ing
his wo k, which emphasizes he impo ance o con inuing o de elop he design o an
online pla o m o suppo GP-pha macis se ices’ in eg a ion. The a angemen o he
GP-pha macis in eg a ion has implica ions in he way disease managemen se ices
p o ided by pha macis s a e paid, which will be discussed in he ollowing sec ion.
3.2.3. ENVISIONING REMUNERATION MODELS FOR PORTUGUESE COMMUNITY
PHARMACISTS
Dispensing o p esc ip ion medicines is conside ed he co e ole o communi y
pha macis s. Conside ing ha a pa ien should ake as ew medicines as possible, he igh
incen i e o pha macis s in his i s ie o pha maceu ical se ices would be one ha
p e en s selling unnecessa y and cos ly medicines. Thus, he bes incen i e scheme o he
dispensing o medicines seems o be ee-pe -p esc ip ion, de aching he p o ision o a
medicine om a p o i ma gin. This way, pha macis s ha e no hing o gain in selling he
highes p iced medicine. O cou se, o he pha maceu ical policy o a coun y his implies
inding he co ec p ice o pay o each p esc ip ion and who should pay o i . In pape
III, an a e age cos o 3.66€ o he dispensing se ice was ound. Al hough mo e da a
om o he pha macies is needed o calcula e a mo e accu a e cos , his inding may help
in o m policy make s on new incen i es schemes o medicine dispensing.
A second ie o pha maceu ical se ices in ol es he p o ision o in o ma ion
abou medicines and heal h issues. In hese se ices, he e migh be no dispensing
in ol ed. Gi ing in o ma ion and ad ice, o dispensing OTC medicines o mino
ailmen s, is an impo an p ima y ca e ole seldom ecognized by heal h sys ems. Some
coun ies, such as he UK and Canada (Be ns en e al., 2010), ha e incen i es o his
mino ailmen s schemes and p o ision o in o ma ion bu Po ugal has no . When
someone goes o he pha macy and is ad ised o go o a doc o consul a ion, he
pha macis does no ecei e any paymen . Thus, he e is no incen i e o e e o he
clinician. This may lead o a si ua ion whe e pha macis s e e less han hey should,
DISCUSSION
122
p e e ing o sell OTC medicines ha migh no alle ia e symp oms and make he
si ua ion wo s . To a oid his, pa ien s’ e e al o p ima y ca e could be paid unde a
capi a ion scheme, whe e pha macies would ecei e a ee pe app o ed e e als, while
he OTC consul a ion could be paid by a mix o ee- o -se ice and business ma gin o e
he p oduc . Fo he capi a ion scheme, he a angemen o he GP-pha macis in eg a ion
( o mal con ac s. collabo a ion) has o be de ined, bu con ac ing seems o be he bes
p oposal. In he Po uguese con ex , his con ac ing could be included in he
commissioning o p ima y ca e se ices signed by Heal h Cen es G oup o he
geog aphical a ea se ed by a g oup o pha macies.
The hi d le el o ie is a mix o se ices such immuniza ion se ices, sc eening
se ices, o needle exchange p og ams. T adi ionally, Po uguese pha macies ha e
decided o p o ide hese se ices ee o cha ge o cha ging a small ee o se ice. Bu i
is no inancially easible o pha macis s o pe o m hese se ices a no cos when a
conside able amoun o ime and esou ces a e needed (Snella e al., 2004), as shown by
he indings epo ed in pape III. A ee o se ice ha pa ien 's pe cei e as small and
cos -e icien , seems o be he bes incen i e model o p o ide hese se ices, since he
heal h sys em i sel bene i s o a high p o ision o hese se ices. Sc eening se ices o
ch onic pa ien s hough, could be placed unde a scheme such as a disease managemen
p og am.
The disease managemen p og ams could be iewed as a ou h ie o se ices. The
incen i e s uc u e behind such a se ice could include he mul iple ees o incen i es
p o ided o he o he ie s. Fo example, a ch onic pa ien such as a diabe ic could
hypo he ically pay o hei disease managemen ins ead o paying o indi idual se ices.
In his way, a pa ien would only pay a ee ega ding hei si ua ion, ega dless o he
numbe o medicines ha s/he is aking. This would be op imal o pa ien s who ha e o
ake a la ge numbe o medicines, which a e gene ally he olde and ail pa ien s, o
whom he necessi y o pu chasing a la ge numbe o medicines disincen i es he pu chase
o disease managemen se ices, e en mo e i hey ha e o pay o i . This bundle o
se ices is some hing al eady ied in o he indus ies, wi h a iable deg ees o success
(Po e , 2010).The discussion a ound incen i es o pha maceu ical se ices p o ision
may open o he discussions and esea ch lines. One hing in common in all o he known
DISCUSSION
129
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CONCLUSION
130
4. CONCLUSION
Based on he esul s o he s udy, se e al conclusion can be d awn:
 F om he scena io exe cise, i is clea ha pha macis ’s new ole will equi e
signi ican legisla i e changes, adequa e inancial incen i es and o he
beha iou al changes, namely an en ep eneu mind-se . He e, p ope
capaci y s eng hening will be c ucial. Also, he ecen e olu ion o IST (e.g.
websi e and ch onic ca e senso s) is an impo an oppo uni y owa ds he
in eg a ion o new oles o communi y pha macis s (wi hin he heal hca e
sys em), while allowing a mo e ac i e ole om pa ien s in hei disease
managemen .
 The assessmen o a single day wo kload showed ha pha macis s spend
hal o hei day in e ac ing wi h cus ome s and pa ien s. Howe e , he sho
in e ac ion ime wi h a pa ien is insu icien o p o ide a p ope ollow-up
se ice, which calls o he oppo uni y o in oduce inno a i e pa ien
managemen se ices, suppo ed by new and adequa e In o ma ion Sys ems.
The pe cei ed lack o ime, many imes decla ed by pha macis s as a ba ie
o ole de elopmen , seems o be an impo an a ea o wo k on. Wi h
addi ional esea ch, he e is oom o imp o emen in in e nal o ganiza ion
and be e oles de ini ion wi hin he pha macy.
 The medicine dispensing se ice was ound o be he mos expensi e in all
he h ee pa icipa ing pha macies. This wo k shows ha he e is a clea
oppo uni y o imp o ing se ice managemen by op imizing medicine
dispensing, h ough he use o solu ions ha may educe pha macis ’s
wo kload. The cos s o OTC dispensing and he cos s o counselling wi hou
medicine dispensing shows ha he implemen a ion o mino ailmen
schemes in Po uguese pha macies may be cos -e ec i e. These low cos
se ices could be used o p omo e new se ices ocusing on longi udinal
pa ien ca e.
CONCLUSION
131
 The ePha maca e pla o m is able o o e pha macies a way o suppo new
pha maceu ical se ices and o be e moni o hei pa ien s, imp o ing he
quali y o hei he apeu ic moni o ing. By b inging o li e a needed ool,
his pla o m ul ils he de ec ed need o IST in pha maceu ical se ices
p o ision, o e ing pa ien s a new way o in e ac wi h hei da a and be pa
o hei own he apy as ac i e membe s on disease managemen . The use o
DSRM helped o design and implemen an online pha maceu ical se ice
h ough a highe in ol emen o he s akeholde s in a comp ehensi e way.
4.1. FUTURE RESEARCH
The ePha maca e pla o m p esen s a possible u ning poin in he way business is
done wi hin communi y pha macies, by eaching ou o new channels and shi ing he
ocus om he sale o p oduc s o he p o ision o se ices. Howe e , in spi e o he
quali y and usabili y o he pla o m being c i ical issues, he pla o m is no e e y hing.
De eloping and implemen ing eHeal h se ices akes p ope ly ained and mo i a ed
p o essionals. Fu u e p o essionals will ha e o acqui e ap i udes ha will acili a e he
implemen a ion o new se ices namely, communica ions skills, cus ome ela ion, social
ma ke ing skills bu also heo e ical and p ac ical compe encies o implemen he se ice
in a con iden way.
Fu he mo e, online pha maceu ical se ices need o be mo e in eg a ed in he
cu en daily p ac ices. A e hinking o he communi y pha macy business model in o de
o e ec i ely and cohe en ly in eg a e communi y pha macies se ices in o he u u e
heal h sys em models, whe e pa ien s will ha e an inc easing ole in disease managemen ,
is pa amoun . Mo e esea ch on he in eg a ion o pha maceu ical se ices and p ima y
ca e se ices is needed as is he de ini ion and expe imen a ion o new pha macy
emune a ion models. De ining a model o inance hese se ices will be i al o p ese e
communi y pha macis s’ con ibu ion and he o e all equi y o he Po uguese heal h ca e
sys em.
In he GP-pha macis collabo a ion, p ope ly designed in o ma ion sys ems and
echnologies will ha e a e y impo an ole. This p ojec did no add ess his ela ion,
choosing o add ess he pha macis -pa ien ela ion i s . A new DSRM cycle should
CONCLUSION
132
add ess his ela ion, ocusing on he de elopmen o a new e sion o he pla o m ha
co e s GPs needs in he in eg a ed disease managemen p ocess.
Pha macis s’ p o essional o ganiza ions ha e o show leade ship and coo dina e
s a egies wi h o he heal hca e p ac i ione s’ p o essional o ganiza ions, o ensu e ha
he new p ac ice migh each all p ac i ione s in a nea u u e o bene i heal hca e
sys em’s equi y. Resea ch on he bes o m o he GP-pha macis a angemen and
in eg a ion o o he heal hca e p ac i ione s’ con ibu ions, will g ea ly con ibu e o
in o m hese s a egies.
I is expec ed ha hese indings will help in o m heal h sys em manage s,
p o essionals and policy make s assessing new models o pha maceu ical ca e se ices
in eg a ion in Po ugal.
APPENDIXES
133
5. APPENDIXES
5.1. INITIAL SURVEY ON PHARMACY DESCRIPTION, PHARMACEUTICAL SERVICE
PROVISION AND USE OF INFORMATION SYSTEMS AND TECHNOLOGIES.
This p ojec aims o in es iga e how he communi y pha macy se ices will be in he u u e as well
as he da a and in o ma ion managemen ac i i ies in his con ex , including he use o in o ma ion
echnologies and e-heal h o implemen he new pha macy se ices. e-Heal h is de ined in he
in e sec ion o in o ma ics, heal h and se ices p o ision, wi h he objec i e o enhancing he
ela ion wi h he ci izens and pa ien s h ough he use o In e ne and o he echnologies.
The main objec i e o he p ojec is o explo e how he pha maceu ical se ices can imp o e disease
and he apy managemen , wi h he goal o imp o e he quali y o he heal h ca e p o ided, while
in eg a ing he pha maceu ical se ices in he heal h sys em, using in o ma ion echnologies.
In o de o a ain ou objec i e you pa icipa ion is essen ial. I you wish, we will p o ide you wi h a
p ojec epo wi h he syn hesis o he i s esul s.
Impo an no ice:
E e y da a collec ed by his su ey will be p ocessed wi h o al con iden iali y, wi h he highes
e hical s anda ds, as any se ious and esponsible esea ch mus ha e.
The su ey will ake 10 o 15 minu es o inish. Thank you e y much o you collabo a ion.
P ojec di ec o : P o . Dou o Luís Velez Lapão (IHMT/UNL).
Abou you
1. Wha ole bes desc ibe you unc ions
a. Technical di ec o pha macis
b. Supe ising pha macis
c. Pha macis
d. Pha macy manage
e. Pha macy echnician o assis an
. O he Please desc ibe____________
2. A e you:
a. Male
b. Female
3. How old a e you?
_______ (numbe )
APPENDIXES
134
4. Since when do you wo k in communi y pha macy?
a. _______ (yea )
5. How many hou s do you wo k in his communi y pha macy in a ypical week?
_______(numbe )
6. Wha is you academic deg ee:
a. High School
b. P o essional cou se
c. Bsc in pha macy
d. Pha mD
e. MSc
. PhD
7. I you a e a pha macis , in wha ins i u ion did you inished you deg ee?
8. Do you ha e ano he pha macy ela ed ac i i y ou side his pha macy?
i. Pha macy owne ’s associa ion
ii. Pha maceu ical Socie y boa d o di ec o s
iii. Union leade
i . P o iding p o essional aining
. Resea ch and Academia
i. Pa icipa ion in associa ion o o he p o essional g oup
ii. Pa icipa ion in discussion g oups abou Pha macy
Abou he pha macy whe e you wo k
9. Dis ic
a. Viana do Cas elo
b. Vila Real
c. B agança
d. B aga
e. Po o
. A ei o
g. Viseu
h. Gua da
i. Coimb a
j. San a ém
k. Cas elo B anco
l. Po aleg e
m. Lei ia
n. Lisboa
o. É o a
p. Se úbal
q. Beja
. Fa o

APPENDIXES
135
10. Type o pha macy
a. Independen pha macy
b. G oup o Chain owne ship wi h 2 – 5 ou le s
c. G oup o Chain owne ship wi h 6 o mo e ou le s
d. O he Please speci y______________
11. Wha kind o owne you ha e in his pha macy :
a. Non-pha macis owne
b. Pha macis owne
c. Bo h
12. Loca ion
a. Residen ial zone
b. Comme cial zone
c. Indus ial zone
d. Shopping cen e
e. Hospi al
13. Numbe o inhabi an s whe e he pha macy is loca ed
a. Less han 2000 inhabi an s
b. 2000-5000 inhabi an s
c. Mo e han 5000 inhabi an s
14. How close is you pha macy o he ollowing heal hca e se ices?
Heal h Se ices
Less han 500 m
500m - 1km
Mo e han 1
km
Acu e hospi al / Hospi al cen e o
e e ence
□
□
□
O he Pha macy
□
□
□
Heal h cen e
□
□
□
P i a e u gen ca e cen e
□
□
□
P i a e GP su ge y
□
□
□
Nu sing cen e
□
□
□
Clinical analysis lab
□
□
□
Physio he apis cen e
□
□
□
Den al clinics
□
□
□
15. Please ell us i he pha macy e e opens:
a. Be o e 9am (Mon - F i)
APPENDIXES
136
b. Un il 7pm (Mon - F i)
c. Un il 9pm (Mon - F i)
d. A e 9pm (Mon - F i)
e. Sa u day un il 2pm
. Sa u day a e 2pm
g. Sunday un il 2pm
h. Sunday a e 2 pm
16. Please p o ide a b eakdown o you pha macy’s pa ien p o ile. [Does no need o
add up o 100%]
Ca ego y
Less han 20%
20-40%
40-60%
60-80%
Mo e
han 80%
Ch onic condi ion
pa ien s
Families wi h child en
unde 12
Acu e condi ion pa ien s
Pa ien s li ing in
Ins i u ional Ca e se ings
( e i emen homes,
nu sing homes, p isons,
e c)
17. Please indica e wha pe cen age o you pa ien s a e egula / epea pa ien s
__________ %
18. How many pha macis s wo k in his pha macy?
________________ (numbe )
19. How many pha macy echnicians wo k in his pha macy?
________________ (numbe )
20. Is he e a consul a ion/counselling a ea in he pha macy whe e you can alk o
pa ien s in p i a e
a. Yes
b. No
21. Do you allow any o he p ac i ione s o un clinics o se ices om you pha macy?
P o essional
No
Yes
Nu i ionis
Die ician
Podia is
Nu se
Audiologis
Op ome is
APPENDIXES
137
Psychologis
Physio he apis
Al e na i e medicines p o essionals (e.g. acupunc u is )
Se ices
22. How many p esc ip ions a e p ocessed in he pha macy in a ypical mon h?
____________(numbe )
23. Do you p o ide any o he ollowing enhanced se ices? Fo each se ice lis ed,
please ell us whe he you p o ide hem now, o whe he you would like o p o ide
hese se ices in u u e [Tick all ha apply]
Se ices
I no
p o ided
cu en ly,
would no
like o
p o ide in
u u e
I no
p o ided
cu en ly,
would like
o p o ide
in u u e
P o ided
cu en ly by
o he
p ac i ione s
P o ided
cu en ly
by a
pha macis
o
pha macy
echnician
P o ided
cu en ly
and
exclusi ely
by a
pha macis
Medicines
managemen by
pa ien
□
□
□
□
□
Medicine
adminis a ion
□
□
□
□
□
P o iding Fi s aid
□
□
□
□
□
Vaccine
adminis a ion
□
□
□
□
□
Pha macis
consul a ion
□
□
□
□
□
Home suppo /
Home deli e y
□
□
□
□
□
Pha maco igilance
□
□
□
□
□
Pha maceu ical
ca e p og ams
□
□
□
□
□
Disposal o
unwan ed
medicines
□
□
□
□
□
Magis e ial
Medicine
p oduc ion
□
□
□
□
□
Non-p esc ip ion
medicine’s
moni o ing
□
□
□
□
□
Supe ised
me hadone
se ice
□
□
□
□
□
APPENDIXES
138
Needle exchange
□
□
□
□
□
Nu i ion/weigh
managemen
□
□
□
□
□
Smoking cessa ion
p og ams
□
□
□
□
□
Use o diagnos ic
equipmen (e.g.
E.C.G.)
□
□
□
□
□
24. Do you p o ide any o he ollowing heal h sc eening se ices? [Tick all ha apply]
Se ices
I no
p o ided
cu en ly,
would
no like
o
p o ide
in u u e
I no
p o ided
cu en ly,
would like
o p o ide
in u u e
P o ided
cu en ly by
o he
p ac i ione s
P o ided
cu en ly by
a pha macis
o pha macy
echnician
P o ided
cu en ly and
exclusi ely
by a
pha macis
To al
Choles e ol
sc eening
□
□
□
□
□
Blood p essu e
sc eening
□
□
□
□
□
BMI sc eening
□
□
□
□
□
Lung capaci y
sc eening
□
□
□
□
□
Diabe es
sc eening
□
□
□
□
□
PSA (p os a e
speci ic an igen)
sc eening -
quali a i e
□
□
□
□
□
PSA (p os a e
speci ic an igen)
sc eening -
quan i a i e
□
□
□
□
□
Lipid p o ile
(HDL + LDL +
iglyce ides
sc eening)
□
□
□
□
□