Standardizing Medication Labels: Confusing Patients Less: Workshop Summary (2008)

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6 Other Stakeholder Reaction to Prescription Use Instruction Standardization: Educators of Pharmacists and Physicians Mary Ann F. Kirkpatrick, Ph.D. American Association of Colleges of Pharmacy Schools of pharmacy are very aware of the need for improvements in prescription medication labeling and counseling to improve health literacy and patient safety. This need is well documented in the litera- ture. There are also additional incentives to include such material in the curriculum. First, the Accreditation Council for Pharmacy Education has established new guidelines that emphasize cultural competence and health literacy. Second, the Joint Commission of Pharmacy Practitioners vision statement says that the foundations of pharmacy practice include optimizing medication therapy via patient-centered practices. In 2006 the entire interim meeting of the American Association of Colleges of Pharmacy (AACP) focused on cultural competence, closing gaps, and expanding access. Furthermore, there has been a call from the organization for examples of best practices in serving the underserved as well as a call for curricula frameworks for addressing special needs of the underserved. The association also provides online resources that are directly linked with its web page, and the annual meetings have both podium and poster sessions directed to this topic. Pharmacy students learn the mechanics of labeling in dispensing labs. In the law courses they learn about the legal requirements. In man- agement courses they learn how to select systems, including software systems, that are used for dispensing. Communication courses explain 39 

40 Standardizing medication labels how to augment information on instructions for use of medications, and communication training is enhanced during the introductory pharmacy practice experience as well as in other courses. One of the most popular courses is Spanish for health care providers. The demand for this elective has been so high that professors are brought from the academic campus to the medical campus to teach the courses on-site. A popular course on the psychosocial aspects of disease includes a description of the effect of health literacy on services received. During service learning experiences students learn about overcoming barriers to access. Internships expose on-the-job students to the unique needs of their patients. There are also national competitions, such as the one on patient counseling sponsored by the American Pharmacists Association, that expose students to these issues. With all the emphasis on communication and serving the under- served, why do problems with labeling and instructions still exist? What are the barriers to change? State boards of pharmacy regulate the informa- tion that must appear on the medication label and, as described earlier, this results in variation in labels. Some state boards of pharmacy do not require the capability of producing labels written in Spanish. Furthermore, how can one determine if the patient needs a label in another language? Does a pharmacist just look at the name and make an assumption? Does he or she wait until the patient comes in to discover if another language is needed? Another barrier relates to the small number of pharmacists who are bilingual or multilingual. Furthermore, there is reluctance to make major label changes. However, changes are under way. Target, for example, is trying to address some of the problems with its prescription label. The name of the medication is in a large font. Directions are in a large font at the top of the label where they can be seen. There are also increased dispensing software options. One software company provided a list of 524 different fields for which the pharmacist could suggest medication label changes. Font size on all of those fields can be adjusted for specific patients and also for routine labels. This particu- lar software can print labels in English, Spanish, or French. However, as mentioned previously, the entire label is in one language, and pharmacists who do not speak the language printed on the label are concerned about its accuracy. Auxiliary labels can be printed with or without the icons. The AACP and other pharmacy organizations are developing data that will help address the problems we have been discussing today. These data will also help in the proper training of students. In responding to a question from the floor, Kirkpatrick stated that pharmacy students are taught how to interpret the physicians’ dosage instructions or “sig.” However, what is printed on the label is what the pharmacy’s software 

OTHER STAKEHOLDER REACTION: EDUCATORS 41 system prints out. Pharmacy students are being prepared to address label- ing concerns. Software is being developed that can be manipulated to help address some of the labeling problems. Selected companies are trying to reengineer those labels to come up with new and better approaches. As a next step, academics need to continue to work with state boards of pharmacy and other stakeholders to address these issues. By law, cer- tain things must be taught to pharmacy students, but best practices must also be taught, and one must be alert to identify these best practices. In response to a question from the floor, Kirkpatrick said that the United States Pharmacopeia could play a major leadership role in the issues of medication labeling. Merrill Egorin, M.D. University of Pittsburgh School of Medicine The Association of American Medical Colleges (AAMC) recognizes the problems confronting safe and effective use of medications. Prescrib- ing medications is one of the activities that distinguishes a physician from other health care professionals. It is a privilege that carries with it serious responsibilities to patients, society, and the profession. For these reasons it is important that medical students understand what is involved in good prescribing practices. Additionally, too few physicians possess fundamental understanding of and training in pharmacotherapy and rational prescribing. It is striking that physicians rarely see their patients’ pill bottles and so they are unlikely to have any idea what is written on them. For some patients cost may be a barrier, so it is important to train medical students to call the pharmacy to determine what a prescription will cost. There have been increasing expressions of concern from physicians in the pharmaceutical industry, from pharmacology faculty, and from resi- dency program directors that medical students are not receiving sufficient education about the process of drug discovery, development, and regula- tion as well as the knowledge and skills involved in safely prescribing these medications. A group including representatives from the pharma- ceutical industry and from U.S. and Canadian medical schools convened to consider this issue for a Medical Schools Objective Project Report. The group considered several questions: What should medical students learn in order to become knowledgeable, safe, and effective prescribers of medicine? What is the ideal educational environment for learning about The Medical Schools Objective Project Reports are sent to all medical schools. They are not binding, but they are suggestions for improvement.   

42 Standardizing medication labels the optimal prescribing of medication? What kind of educational experi- ences would allow students to achieve those learning objectives? The framework in which this discussion took place was the six core principles recommended by the Accreditation Council for Graduate Medical Edu- cation: medical knowledge, patient care, interpersonal communication skills, professionalism, practice-based learning and improvement, and systems-based practice. A number of suggestions were made, including the need for multi- disciplinary involvement, particularly when students and house officers make rounds. It was pointed out that a number of medical schools do not have pharmacy schools associated with them, which is a barrier. Another barrier is the dwindling number of clinical pharmacology divisions. In response to a question from the floor, Egorin stated that the AAMC is willing to play a leadership role in issues of drug labeling and counseling. Discussion Sandra Guckian, from the National Association of Chain Drug Stores, said that the association had been working closely with the American Pharmacists Association to develop educational materials and templates for community pharmacists, both for chain pharmacists and indepen- dents. These materials could be used by ambulatory care centers as well. Much effort has focused on medication management and the role of the community pharmacist, particularly with patient populations that suffer from multiple chronic conditions and take multiple medications. One of the core components of the concept of medication therapy management is the personal medication record, which includes more than the prescription label. Information can be inserted for the patient such as when to take medication and reminders to match a patient’s drug regi- men to his or her particular lifestyle. The pharmacy can play a key role in developing and maintaining this record.