Can Technology Get in the Way of Patient-Centered Care?

One of the most colorful commentators on health care is Zubin Damania, MD, a University of California San Francisco and Stanford University–trained physician. Known as “ZdoggMD,” he has a huge following of health care professionals. His extensive repertoire of programs on Facebook and YouTube have focused on the COVID-19 pandemic over the past 18 months. But as so many of us are experiencing COVID-19 fatigue or psychosis, I would like to refer to one of his older programs, in which he chastises the major pharmacy chains.

In this 12-minute video he lambastes the major chains about performance metrics, understaffing, and “expecting pharmacists to do more with less. In this country we don’t reward safety and quality, we reward volume.” Additionally, he notes that chain pharmacies dispense 70% of the prescriptions in the United States.

I would venture to say that patients, usually not by choice, are not getting the care they need because of these chains’ performance and understaffing. Most pharmacists I’ve encountered over the past 40 years are passionate about providing quality care; however, most major chain pharmacists are unable to provide quality care if they want to stay employed. I learned this lesson well back in October 1981 when I requested an increase in staffing levels. The district manager said, “Pete, I’ve watched you work and if you quit talking to the patients, you will have plenty of time to get your paperwork done.” Six weeks later my license was hanging on a new nail.

Last Tuesday, while doing an intervention for one of the local health plans, I noticed that a patient with chronic obstructive pulmonary disease (COPD) hadn’t had his budesonide/formoterol (Symbicort) filled for 5 months. I called him on the phone and he told me he was mad at his doctor (and everyone else) and was so glad I had called. He was getting dizzy on the inhaler and had told his doctor. His doctor was supposed to send in a prescription but hadn’t done so. I told him I would investigate and finished up his COPD interview.

I checked our dispensing system and indeed his doctor had submitted a new prescription for tiotropium/olodaterol (Stiolto Respimat), but it was not covered by the patient’s Medicaid program. Because I sit on the Pharmacy and Therapeutics Committee for the State of Pennsylvania, I called the physician’s office and spoke with a nurse. I recommended umeclidinium/vilanterol (Anoro Ellipta), another combination product with the same mechanism of action that was covered by the formulary. The patient was delighted, just knowing that someone in health care was looking out for him. I could not have done this with performance metric screens flashing at me to do more with less.

The very same week, we had a patient come in with a prescription for nitroglycerin sublingual 0.6-mg tablets. As expected, we did not have this rare strength in stock. Most prescriptions of this nature are billed and dispensed when the order arrives the next day. I took the time to call the physician’s office and had the strength changed to the more common 0.4 mg. I explained this to the patient, and he was pleased. We went to my counseling area and sat down, and I showed him exactly how to use nitroglycerin tablets for angina. I discussed the 2006 American College of Chest Physicians recommendations to seek help after the first dose if he experienced no relief, to save 10 minutes of ambulance time.

He said, “Stop right there, buddy. I did have a heart attack last night with severe chest pains, but my doctor said there was no room in the hospital, due to the Delta variant surge, so they gave me this prescription.” Had I been following performance metrics and flashing screens, this patient would have spent the night without a most necessary nitroglycerin prescription.

At my pharmacy Nickman’s we are in full stride filling naloxone (Narcan) prescriptions to our at-risk population. We are using the standing order for naloxone to prevent overdose, as issued by Denise A. Johnson, MD, physician general for Pennsylvania. I spend at least 5 minutes with every medication-assisted treatment patient or others at risk discussing morphine milligram equivalents and the appropriate use of naloxone. My patients are most grateful and are experiencing compassionate care, which would not be possible with flashing screens pushing us to do more with less.

Now that you have read my thoughts on how evil performance metrics are, your homework assignment will be complete when you spend 12 minutes with ZDoggMD on your ride to work.