Design, implementation and evaluation of a new eHealth pharmaceutical service for cooperative disease management using an interactive platform: opportunities to improve health systems performance

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. 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J. Heal. Pha m. doi:10.2146/ajhp090539 Zuppo, C.M., 2012. De ining ICT in a Bounda yless Wo ld: The De elopmen o a Wo king Hie a chy. In . J. Manag. In . Technol. 4, 13–22. doi:10.5121/ijmi .2012.4302 RESULTS 41 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 42 RESULTS 49 RESULTS 50 RESULTS 51 RESULTS 52 RESULTS 53 RESULTS 54 RESULTS 55 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 56 RESULTS 57 RESULTS 58 RESULTS 65 RESULTS 66 RESULTS 67 RESULTS 68 RESULTS 69 RESULTS 70 RESULTS 71 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 72 RESULTS 73 RESULTS 74 RESULTS 81 RESULTS 82 RESULTS 83 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 84 RESULTS 85 RESULTS 86 RESULTS 87 RESULTS 88 RESULTS 89 RESULTS 90 RESULTS 97 RESULTS 98 RESULTS 99 RESULTS 100 RESULTS 101 RESULTS 102 RESULTS 103 RESULTS 104 RESULTS 105 RESULTS 106 DISCUSSION 113 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 114 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 Mossialos, E., Naci, H., Cou in, E., 2013. Expanding he ole o communi y pha macis s: Policymaking in he absence o policy- ele an e idence? Heal h Policy. 111(2), 135-48. doi:10.1016/j.heal hpol.2013.04.003 Mo ulsky, A., Sico e, C., Lamo he, L., Winslade, N., Tamblyn, R., 2011. Elec onic p esc ip ions and dis up ions o he ju isdic ion o communi y pha macis s. Soc. Sci. Med. 73, 121–128. doi:10.1016/j.socscimed.2011.04.009 Noyce, P., 2006. Go e nance and he pha maceu ical wo k o ce in England. Res. Soc. Adm. Pha m. 2, 408–419. doi:10.1016/j.sapha m.2006.07.005 Pelicano-Romano, J., Ne es, M.R., Amado, A., Ca aco, A.M., 2015. Do communi y pha macis s ac i ely engage elde ly pa ien s in he dialogue? Resul s om pha maceu ical ca e consul a ions. Heal. Expec . 18, 1721–1734. doi:10.1111/hex.12165 Pe akaki, D., Ba be , N., Wa ing, J., 2012. The possibili ies o echnology in shaping heal hca e p o essionals: (Re/De-) P o essionalisa ion o pha macis s in England. Soc. Sci. Med. 75, 429–437. doi:10.1016/j.socscimed.2012.03.033 Po e , M.E., 2010. Wha is Value in Heal h Ca e? N. Engl. J. Med. 363, 2477–2481. doi:10.1056/NEJMp1002530 Po uguese Pha maceu ical Socie y, 2013. Su ey o pha maceu ical sciences g adua es 2011/2012. Lisboa. Saba e -Galindo, M., Fe nandez-Llimos, F., Saba e -He nandez, D., Ma ínez-Ma ínez, F., Ben imoj, S.I., 2015. Heal hca e p o essional-pa ien ela ionships: Sys ema ic e iew o heo e ical models om a communi y pha macy pe spec i e. Pa ien Educ. Couns. 99(3), 339-347. doi:10.1016/j.pec.2015.09.010 Snella, K. a, T ewyn, R.R., Hansen, L.B., B adbe y, J.C., 2004. Pha macis compensa ion o cogni i e se ices: ocus on he physician o ice and communi y pha macy. Pha maco he apy 24, 372–88. doi:10.1592/phco.24.4.372.33179 Snyde , M.E., Zillich, A.J., P imack, B.A., Rice, K.R., Somma McGi ney, M.A., P ingle, J.L., Smi h, R.B., 2010. Explo ing success ul communi y pha macis -physician collabo a i e wo king ela ionships using mixed me hods. Res. Soc. Adm. Pha m. 6, 307–321. doi:10.1016/j.sapha m.2009.11.008 Van Le be ghe, W., Conceição, C., Van Damme, W., Fe inho, P., 2002. When s a is unde paid: Dealing wi h he indi idual coping s a egies o heal h pe sonnel. Bull. Wo ld Heal h O gan. 80, 581–584. doi:10.1590/S0042-96862002000700011 Wes e ling, A.M., Haikala, V., Ai aksinen, M., 2011. The ole o in o ma ion echnology in he de elopmen o communi y pha macy se ices: isions and s a egic iews o in e na ional expe s. Res. Soc. Adm. Pha m. 430–437. doi:10.1016/j.sapha m.2010.09.004 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) □ □ □ □ □