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© 2003 Pharmacy Manpower Project, Inc Pharmacy Manpower 2020: Meeting Needs of Patients Implications for Educators, Practitioners and Regulators Slide.

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Presentation on theme: "© 2003 Pharmacy Manpower Project, Inc Pharmacy Manpower 2020: Meeting Needs of Patients Implications for Educators, Practitioners and Regulators Slide."— Presentation transcript:

1 © 2003 Pharmacy Manpower Project, Inc Pharmacy Manpower 2020: Meeting Needs of Patients Implications for Educators, Practitioners and Regulators Slide Library 2003

2 © 2003 Pharmacy Manpower Project, Inc Today’s Objective Provide insight into the pharmacist shortage and projected growth in prescription use by US population Describe factors leading to expanded patient care roles as drug therapy managers by pharmacists Present findings of Conference convened to forecast professionally determined need for pharmacists in 2020 Discuss implications of the projected, significant shortfall of pharmacists in 2020 to pharmacy education, practice and regulation

3 © 2003 Pharmacy Manpower Project, Inc Section One Is There a Pharmacist Shortage?, How Are They Currently Deployed?

4 © 2003 Pharmacy Manpower Project, Inc Are We Experiencing a Pharmacist Shortage? Employer perspective: –Staffing problems –Job vacancies in community and institutional practice, industry, academia and government –Escalating salaries Customer/patient perspective: –Inconvenience –Decreased access –Published ADI analysis: 92% US population lived in areas where pharmacist demand exceeded supply

5 © 2003 Pharmacy Manpower Project, Inc US Population and ADI July 2001

6 © 2003 Pharmacy Manpower Project, Inc Are We Experiencing a Pharmacist Shortage? Pharmacist perspective: –Increased workload/stress –Longer working hours Education Perspective: –Formation of new pharmacy schools –12 since 1987 Government Perspective: –HRSA Report –Federal legislation on loan forgiveness –Bush initiatives to expand 340B eligible clinics and add pharmacy services to address growing number of uninsured

7 © 2003 Pharmacy Manpower Project, Inc So we have a shortage of pharmacists … A shortage of pharmacists to do what??

8 © 2003 Pharmacy Manpower Project, Inc Assure Safe & Accurate Medication Distribution Community Pharmacy, 2001: 3,000,000,000 prescriptions 132,000 community pharmacists 22,727 Rx/pharmacist/year One prescription every 5 ½ minutes

9 © 2003 Pharmacy Manpower Project, Inc Hospital Pharmacy, 2001: 1,898,000,000 drug orders 50,000 hospital pharmacists 37,960 orders/pharmacist/year One drug order every 3 minutes

10 © 2003 Pharmacy Manpower Project, Inc What About Tomorrow?

11 © 2003 Pharmacy Manpower Project, Inc Section Two Common Vision for Pharmacists: Helping People Make the Best Use of Their Medicines

12 © 2003 Pharmacy Manpower Project, Inc Common vision of pharmacy practice: helping patients make the best use of their medicines.

13 Pharmacists Roles in Patient Care Pharmacists as drug therapy managers Assessing, counseling and monitoring drug therapy Dealing with medication misadventures: $177 billion drug morbidity/mortality Ernst F, Grizzle A JAPhA 2001; Overseeing medication management systems Delivering pharmaceutical care: could save over $105 billion annually if universally available Johnson JA, Bootman JL AJHP :

14 © 2003 Pharmacy Manpower Project, Inc These new roles are not just assuring safe and accurate medication distribution….what about tomorrow?

15 © 2003 Pharmacy Manpower Project, Inc 2020 Rx and Order Projections Outpatient prescriptions: 7,500,000,000 (+5%/yr) Hospital drug orders: 3,000,000,000 (+2.5%/yr)

16 © 2003 Pharmacy Manpower Project, Inc Pharmacist Supply 2001: 200,000 active pharmacists 2020 projection: 260,000 active pharmacists Based on new graduates, adjusted for those leaving; assumes 20% enrollment growth existing schools and 3 new ones in addition to those slated to open

17 © 2003 Pharmacy Manpower Project, Inc If Nothing Changes….. Community Pharmacy, 2020: 7,500,000,000 prescriptions 172,000 community pharmacists 43,604 Rx/pharmacist/year One prescription every 2 ¾ minutes

18 © 2003 Pharmacy Manpower Project, Inc If Nothing Changes….. Hospital Pharmacy, 2020: 3,000,000,000 orders 65,000 hospital pharmacists 46,154 Rx/pharmacist/year One order every 2 minutes

19 © 2003 Pharmacy Manpower Project, Inc These figures reflect a supply/demand model that only focuses on order fulfillment. Something must change.

20 © 2003 Pharmacy Manpower Project, Inc How Does Need Fit Into Workforce Projections? Wants Demands Supply Professionally-determined needs

21 © 2003 Pharmacy Manpower Project, Inc What We Are Unsure About... Role of drugs in future health care Role of genomics and biotech as an adjunct, replacement, or addition to current drug therapy Organization and financing of drugs and pharmacy services Extent of adoption of new pharmacist roles

22 What Hasn’t Sunk in Yet... The baby boomers are not yet 60!--But they will be soon! A boomer will turn 65 every 10 seconds beginning in 2011 Everyday in the US, 6000 people reach the age of 65 The over-65 population will DOUBLE by 2030— they use 3 times the number of medicines Other special need populations, such as pedicatric patients or chronic disease sufferers, may influence demand

23 © 2003 Pharmacy Manpower Project, Inc Their drug use has not yet been factored into the workforce equation…

24 © 2003 Pharmacy Manpower Project, Inc One could already argue we need 150,000 more pharmacists now to help patients with their medication and tackle the $177 billion in annual drug related morbidity and mortality. Barbara Wells AACP President

25 © 2003 Pharmacy Manpower Project, Inc Section Three Manpower Conference: Why, What, How

26 © 2003 Pharmacy Manpower Project, Inc Led to: Conference on Professionally Determined Need for Pharmacy Services Convened by the Pharmacy Manpower Project, Inc. Held in Baltimore, MD October 29-31, 2001 Carried out by the University of Maryland School of Pharmacy

27 © 2003 Pharmacy Manpower Project, Inc Conference Goals Identify the future need for pharmacy services from a health professional viewpoint Describe “best practice” characteristics for providing these services Suggest the number of pharmacists to meet projected needs in 2020

28 © 2003 Pharmacy Manpower Project, Inc Participants and Process Two dozen experts: –All segments of pharmacy –Medicine –Economics –Workforce specialists Three days of deliberations – all discussions; no speakers

29 © 2003 Pharmacy Manpower Project, Inc Forecasting Need: Criteria for Best Practices IOM’s Quality Chasm Report aims are that practices must be: –Safe –Effective –Patient-centered –Timely –Efficient –Equitable

30 © 2003 Pharmacy Manpower Project, Inc External Trends Examined Population –325 million by 2020 –Older –More diverse People –Healthier –More Internet savvy Therapy –More targeted (biotech) –More expensive Health care organization –Managed care –Community pharmacy –Institutional pharmacy Reimbursement methods –Drug product related –Other Technology

31 © 2003 Pharmacy Manpower Project, Inc Technology Changes Influencing Pharmacy Electronic data processing and information transfer: –Electronic order entry –Expert systems to evaluate drug orders –Improved electronic communication systems Improvements in automated order fulfillment systems for both outpatient and institutional use

32 © 2003 Pharmacy Manpower Project, Inc Summary A 3-day conference of 25 selected participants evaluated the need for pharmacists in 2020 Best practice criteria were developed and applied to order fulfillment, drug therapy management (patient care), and other functions Estimates of professionally determined need were made and compared with the estimated supply of pharmacists A shortage of pharmacists with significant magnitude was forecast: 157,000 conservatively Next steps were suggested

33 © 2003 Pharmacy Manpower Project, Inc Strengths of Approach Knowledgeable participants Balance of viewpoints Rapid engagement with issues Global perspective Highly focused Substantial pre-meeting preparation Analysis based on “best practice” case examples

34 © 2003 Pharmacy Manpower Project, Inc Weaknesses of Approach Short 3-day meeting Small, selected group of participants Broad-brush discussions Quantitative estimates are rough Many assumptions about external environment, health care organization and financing, uptake of technology in communications and dispensing, and regulatory issues

35 © 2003 Pharmacy Manpower Project, Inc Section Four Conference Outcomes, Projections and Assumptions

36 © 2003 Pharmacy Manpower Project, Inc Current and Projected Need for Pharmacists 2001 Estimated Deployment 2020 Forecast Need Order fulfillment (Dispensing) 136,400100,000 Patient Care 48,000295,000 Other 12,30022,000 Total Need 196,700417,000 Total Supply 260,000 Projected Shortfall 157,000

37 © 2003 Pharmacy Manpower Project, Inc Order Fulfillment Functions Will Require 100,000 FTE Pharmacists Defined narrowly to include only order fulfillment functions (“bottling”) Best practices focus solely on assuring that a prescription is completed and delivered precisely as ordered Assumes that drug orders entering the dispensing system have been assessed, clarified and verified Pharmacist need will be to design, implement and oversee order fulfillment systems Pharmacists will not have to inspect every order personally Assumes that post-dispensing pharmacy services such as counseling and monitoring will be accomplished as patient care functions

38 © 2003 Pharmacy Manpower Project, Inc Best Practices for Order Fulfillment Concentration of fulfillment of maximum number of orders in sophisticated central fill facilities –Current examples include mail order pharmacy (Merck Medco) and the Veterans Health Administration Increase the efficiency of community pharmacy based order fulfillment: –Increase use of qualified pharmacy technicians –Increase use of automation –Reduce administrative burden of third party programs These are in addition to Quality Chasm criteria.

39 © 2003 Pharmacy Manpower Project, Inc Community Pharmacy Order Fulfillment Conference estimates that 101,400 FTE pharmacists currently dispense about 30,000 prescriptions per pharmacist per year Arthur Anderson report identified major inefficiencies in use of pharmacists in order fulfillment NACDS Education Foundation: Pharmacy Activity Cost and Productivity Study, November 1999,

40 © 2003 Pharmacy Manpower Project, Inc Many Initiatives Will Affect The Shortage... Automated dispensing/central fill/pre- packs/unit of use Bar-coding and electronic control of products e-prescribing, electronic record-keeping and drug use control Improved use of qualified technicians and other supportive personnel

41 © 2003 Pharmacy Manpower Project, Inc Outpatient Order Fulfillment Forecast 80% of time now spent by pharmacists in the order fulfillment function can be assumed by automation and/or technical personnel Therefore, best practices could increase order fulfillment output/pharmacist five times Conference projects outpatient prescriptions to grow at rate of 5% per year

42 © 2003 Pharmacy Manpower Project, Inc Pharmacists’ Time: Actual and Preferred Source: Schommer JC et al. Community Pharmacists’ Work Activities in the United States During 2000 Percent of Time Pharmacists Devote to Specific Tasks—Actual Percent of Time Pharmacists Devote to Specific Tasks—Preferred

43 © 2003 Pharmacy Manpower Project, Inc Hospital Order Fulfillment Forecast 35,000 FTE pharmacists currently fill about 1.9 million drug orders per year in hospitals Inpatient drug orders to grow at 5% per year, assuming that patient population stays about the same size with increased acuity Best practices could double order fulfillment output/pharmacist

44 © 2003 Pharmacy Manpower Project, Inc Long Term Care Order Fulfillment Conference estimated at 196 million prescriptions in 2001 Orders for assisted living, home care and hospice not estimated separately Conference forecasts assume these orders included in outpatient and inpatient totals

45 © 2003 Pharmacy Manpower Project, Inc Order Fulfillment Needs Forecast: Summary Assuming all conference projections hold, about 100,000 pharmacists will be needed in 2020 for the order fulfillment function. This assumes that utilization rises 5% annually, mail order and hospital productivity double, and community practice productivity improves by a factor of five

46 © 2003 Pharmacy Manpower Project, Inc Order Fulfillment Projection Assumes: Increased use of information technology and automation, with safety assurances Changes in regulatory environment Successful adaptation to HIPAA Changes in pharmacist attitudes and culture

47 © 2003 Pharmacy Manpower Project, Inc Patient Care Functions Will Require Nearly 300,000 FTE Pharmacists Expanded need will be due to: –Population demographics & special need populations –More drugs, increased potency, higher cost –Emergence of personalized drug therapy through gene therapy and biotechnology –Requirements of specialized drug therapy management for high-risk treatments –Increased need for communication among patients and providers

48 © 2003 Pharmacy Manpower Project, Inc Patient Care: Drug Therapy Management A core function of pharmacy: drug therapy management, and other aspects of pharmaceutical care Patient care needs were assessed in all settings Mechanisms for paying pharmacists for these services is prerequisite and assumed

49 © 2003 Pharmacy Manpower Project, Inc Ambulatory Drug Therapy Management Forecast Two best practices models were discussed: a highly-organized HMO (Kaiser Permanente- Denver) and community pharmacy Estimates of pharmacists needed based on two methods resulting in range of 165,000 to 358,000 pharmacists; used the more conservative number Agreed not all patients require same level of primary care

50 © 2003 Pharmacy Manpower Project, Inc Ambulatory Drug Therapy Management Forecast 2/3rds of population get at least 1 Rx/year while 40% receive 4 or more Rx/year Latter group requires complex primary care at best practice estimate of 1 FTE pharmacist per 1000 patients; while remaining population receives services at a ratio of 1 FTE pharmacist per 5,500 patients

51 © 2003 Pharmacy Manpower Project, Inc Hospital-Based Drug Therapy Management About 5,000 hospitals in the U.S. About one pharmacist per hospital performs population-based patient care: safety, policy, etc. Best practice estimate doubles this number

52 © 2003 Pharmacy Manpower Project, Inc Hospital-Based Drug Therapy Management 10,000 FTE pharmacists currently provide this service ASHP surveys find that only about 10% of best practice services are now routinely provided Conference estimates that 100,000 FTE pharmacists needed for this function

53 © 2003 Pharmacy Manpower Project, Inc Drug Therapy Management in LTC and Related Settings 3,000 FTE pharmacists currently provide this service Although over-65 population will be much larger in 2020, it will also be healthier Best practice estimate is 18,750 FTE pharmacists in 2020

54 Drug Therapy Management Needs Forecast: Summary Conference forecasts a need for almost 300,000 pharmacists to meet drug therapy management needs of patients in –Ambulatory patient care: 165,000 –Hospital-based patient safety, policy: 10,000 –Hospital-based patient care: 100,000 –Long term patient care settings: 18,750

55 © 2003 Pharmacy Manpower Project, Inc Non-Patient Care Needs Forecast Estimated at 22,000 in 2020 Relatively small but critical area Specialty and leadership positions in –Profession –Industry –Academia –Government

56 © 2003 Pharmacy Manpower Project, Inc Variables and Assumptions: Order Fulfillment Outpatient Order Fulfillment –2001 prescription number: confident –Growth rate (5%): conservative –Mail order growth (10%): conservative, given low base –Dispensing productivity increases: liberal Hospital, LTC Order Fulfillment –2001 drug order numbers: unknown (extrapolated from orders/patient/day) –Hospital growth rate: liberal (5%) –LTC orders: conservative

57 © 2003 Pharmacy Manpower Project, Inc Variables and Assumptions: Drug Therapy Management Ambulatory: –Highly-managed setting (HMO)(one pharmacists/1000 patients): confident/liberal –Community setting (1/1000): unknown/liberal Institutional: –Hospital patient safety/policy: confident –Hospital patient care: survey-based/confident –LTC patient care: conservative

58 © 2003 Pharmacy Manpower Project, Inc Variables and Assumptions: Other Needs; Pharmacist Supply Other Needs: –Category by category assessment: conservative Pharmacist Supply –Enrollment growth in existing schools (10% total): conservative –New schools (class size 100; 3 new ): moderate

59 © 2003 Pharmacy Manpower Project, Inc Assumptions Underlying Conference Projections Improved and compatible IT systems will be implemented throughout health care Patient data and reference information will be available to practitioners at the point of service in real time Health care teams will really work Quality and safety systems will be in place Financial incentives will be appropriate

60 © 2003 Pharmacy Manpower Project, Inc Manpower 2020: Conclusions A large shortage of pharmacists is forecasted in 2020 The supply of pharmacists needs to increase substantially Productivity of pharmacists needs to increase even more than projected Or services will remain unmet or be provided by others

61 © 2003 Pharmacy Manpower Project, Inc Additional Conclusions Conference forecasts demonstrate that professionally determined needs for order fulfillment services and for drug therapy management services are inextricably intertwined Unless an even more dramatic solution is adopted to meet the forecasted demand for dispensing, the expansion of direct patient drug therapy management by pharmacists will fall far short of need

62 © 2003 Pharmacy Manpower Project, Inc Section Five: Actions Needed by Profession

63 Actions Required By The Profession Embrace responsibility for drug therapy management Commit to obtaining and maintaining the knowledge, skills and abilities required by patient care Achieve provider status for pharmacists under Medicare Obtain a supporting payment mechanism Expand the size of the profession in order to meet unmet societal needs Fully utilize technology & technicians for order fulfillment

64 © 2003 Pharmacy Manpower Project, Inc Even If You Disagree with the Details… Each person will filter the forecasted numbers through their unique perspective and experience Where you find you might reduce the needed number of pharmacists in one area, you will find you raise it in others

65 © 2003 Pharmacy Manpower Project, Inc …You Will Agree at a High-Level Your revised forecasts compared against pharmacist supply estimates will show a significant shortfall of practitioners Findings should be used and challenged within the profession’s practices, educational and regulatory arenas and other stakeholder groups to assist in their long-term planning efforts

66 © 2003 Pharmacy Manpower Project, Inc What Does 2020 Look Like… If we don’t move ahead? Open discussion Top 10 Issues Summary

67 © 2003 Pharmacy Manpower Project, Inc Section Six Implications for Various Stakeholder Groups: Educators, Practitioners, Regulators, All

68 © 2003 Pharmacy Manpower Project, Inc Implications for Educators: How to Expand the Profession? Good news: today’s graduates are being educated at level consistent with profession’s long-term patient care vision Many new opportunities for pharmacists, especially with doctoral level training

69 © 2003 Pharmacy Manpower Project, Inc Implications for Educators Producing more graduates: –Enrollments rising; impact of PharmD transition closing –12 new schools since 1987 –Decade trend numbers show sizable increase –Role of foreign graduates? Foreign Pharmacy Graduate Equivalency Examination™ (FPGEE®).

70 © 2003 Pharmacy Manpower Project, Inc Entry-Level Pharmacy Graduates

71 © 2003 Pharmacy Manpower Project, Inc Projected Entry-Level Graduates

72 © 2003 Pharmacy Manpower Project, Inc Implications for Educators Expansion of programs that support current practitioner’s transition to new roles: –Accessible –Affordable –Flexible –Partnerships with practice organizations

73 © 2003 Pharmacy Manpower Project, Inc Challenges for Educators Faculty needs: new models & partnerships with practice; more residency trained faculty needed Training sites: new models, residencies Curriculum to address distributive/patient care roles Technology application to both: e.g. distance education Sharing resources across institutions: curricular resources, faculty? Financing for expansion in era of state budget issues Research enterprise: where will growing funding be secured?

74 © 2003 Pharmacy Manpower Project, Inc Challenges for Educators/Practice Determining how many practitioners will need to make the transition? –Decrease of 25,000 for order fulfillment (dispensing) over 20 years vs. need for 295,000 in drug therapy management services –Create tools to identify best practitioners to target?

75 © 2003 Pharmacy Manpower Project, Inc Implications for Practice: How to Accelerate Change? Continued, rapid implementation of technology and qualified pharmacy technicians to improve order fulfillment efficiency, patient safety and patient services

76 © 2003 Pharmacy Manpower Project, Inc Implications for Practice: How to Accelerate Change? Increase residency trained practitioners As of May 2003 * 383 Accredited pharmacy practice programs 242 Accredited specialized residencies 1,077 Residents/year *Programs that have been accredited or have applied for accreditation

77 © 2003 Pharmacy Manpower Project, Inc Stepping Stone Summit: Technology Recommendations APhA/NCPA/NACDS in 2/2002: #1 – Bar code verification #2 – e-prescribing systems & interface #3 – In pharmacy dispensing automation & central fill #4 – Broadband Internet connectivity #5 – Reduce regulatory barriers

78 © 2003 Pharmacy Manpower Project, IncFrom American Society of Automation in Pharmacy (ASAP) 2003 Hot Technologies: ASAP Survey E-signatures, primarily HIPAA driven E-prescribing will grow Continued system integration: IVR, dispensing, POS High-speed Internet connectivity

79 © 2003 Pharmacy Manpower Project, IncAdapted from July/August 2002 ComputerTalk Chain Use of Technology: July 2002 Chains using IVR Stores in chain with IVR installed Using IVR to route refills to doctors Chains evaluating robotic solutions Chains using scanners in the pharmacy Stores in chain using scanners Central fill on the agenda Central processing on the agenda Chains that applied for HIPAA extension Will be applying for HIPAA extension Want continued support of 3.2

80 © 2003 Pharmacy Manpower Project, Inc

81 Hospital Use of Technology Computerized Prescriber Order Entry (CPOE) –3.5% of hospitals use CPOE Use of Automated Storage and Distribution Devices (ASDDs) –58% have some ASDDs Bar Code Point-of-Care Technology –1.3% verify medication, patient id, and nurse at the bedside Pharmacy Robots –8% use robot filling devices Source: 2002 ASHP National Survey of Pharmacy Practice in Hospitals

82 © 2003 Pharmacy Manpower Project, Inc Adding Pharmacy Technicians to the Mix: 131,000++ (12-02)

83 And Ratios are Changing... Greater than 2:1 2:1 1:1 No Established Ratios No Data Alaska Hawaii Puerto Rico

84 © 2003 Pharmacy Manpower Project, Inc Implications for Community Practice Continued creation of opportunities for new service development in the community: –Residency programs in community practice: 65 programs with 32 that are accredited or have applied for accreditation –Participation in demonstration projects, e.g. Patient Self- Management: Diabetes –Partnerships with education and practice organizations Seeking payment mechanisms and provider status

85 © 2003 Pharmacy Manpower Project, Inc Challenges for Practice Generating sufficient capital to support practice transition Maintaining practitioner knowledge and skills: Does CE enterprise need to be different? Addressing attitudes and culture among practitioners to embrace new technologies and roles

86 © 2003 Pharmacy Manpower Project, Inc Challenges For Practice/Regulators Changing regulatory environment to embrace rapid practice change Securing collaborative practice authority Securing ability to immunize Immunizations Bill Passes in House

87 © 2003 Pharmacy Manpower Project, Inc Implications for Regulators: “Technologically Facilitated Care” How to regulate “technologically facilitated care” Remove impediments to change that can improve dispensing efficiency and patient care: –Qualified pharmacy technicians –Automation –information sharing: HIPAA concerns and security

88 © 2003 Pharmacy Manpower Project, Inc Implications for Regulators Focus on outcomes vs. structure, process How to ensure continuing competence among a changing workforce

89 © 2003 Pharmacy Manpower Project, Inc Implications for All How to implement services that people don’t know they need –Physicians, public not overly concerned about medical errors NEJM 2002: 347: –Public not aware of health professional shortage AmerisourceBergen Poll 7/2002 Continued learning from those successfully implementing among patients Publicizing outcomes from practices widely

90 © 2003 Pharmacy Manpower Project, Inc Implications for All People outside the profession care about drugs and believe they are: –Expensive –Toxic –Complex

91 © 2003 Pharmacy Manpower Project, Inc Implications for All They are not a no-risk proposition and must be actively managed

92 © 2003 Pharmacy Manpower Project, Inc What if This Was Your Mom? What Will You Do When You Leave? Elderly consume 34% of all Rx’s Many have issues related to medication access and coverage Adverse drug reactions (ADRs) are among the top 5 threats to senior’s health

93 © 2003 Pharmacy Manpower Project, Inc What If This Was Your Child? Little known about ADR’s in children Pediatric ADR Reporting System--Pediatric Pharmacy Advocacy Group 2 to 17% of children admitted to hospitals were admitted due to ADRs Mitchell et al AmJEpid: 1979: % of FDA-approved meds not approved for use in children Yaffe et.al Ped. Pharmacology 1992: 3-9. What Will You Do When You Leave?

94 © 2003 Pharmacy Manpower Project, Inc How Are You Spending Your Time? I’ll get to that project tomorrow? My colleagues are tackling that issue That issue is the responsibility of X, Y and Z? What can I do? Or…

95 © 2003 Pharmacy Manpower Project, Inc How Are You Spending Your Time? Are you moving ahead to: –Implement new programs? –Implement technology? –Use qualified support personnel? –Collaborate with colleagues? –Stay current with new developments? Or taking other steps to help patients?

96 © 2003 Pharmacy Manpower Project, Inc Where To Go From Here? Open Discussion: what are top 5 issues for Educators, Practitioners, Regulators?


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