Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / In community pharmacies, at the time the pharmacist incorporates clinical practice into their routine, several barriers and facilitators influencing the implementation of patient care services. Objectives: To learn and understand the perception of a group of pharmacists on the process of implementation of Clinical Pharmacy Services in community pharmacies; Understand through a Scoping Review of literature, pharmacist perception about Clinical Pharmacy Services in community pharmacy. Methods: The study was structured in two stages. The first step corresponded to Scoping Review held in the Lilacs, PubMed, Scopus, Scielo and Web of Knowledge database. Studies should be of the pharmacist perception, and the pharmaceutical services should be patient-focused. The second stage corresponded to a qualitative study in which three focus groups were conducted with a group of 11 pharmacists. Data analysis was done using the technique of content analysis. Results: Step 1 - The literature search resulted in 29 articles that met the inclusion criteria. The studies were performed in eight different countries, had qualitative methods (focus groups, interviews, diaries and questionnaires) and quantitative (questionnaires) and 12 different classifications of pharmaceutical services were found. In most studies, pharmacists believed that their role in community pharmacies was positive for patients, barriers and facilitators for service were reported. Step 2 - The audio recording of the focus groups were fully transcribed and analyzed. The perception of pharmacists brought issues such as access to medication, barriers and facilitators to service, expectations, changes generated during the implementation of services, results achieved and consolidation of services. Conclusion: The Scoping Review made recommendations for implementation of Clinical Services Pharmacists in community pharmacies, making it easier to service delivery and enhancing practices in community pharmacies. The dissemination of positive experiences in implementations of services through perception studies have shown that it is possible to develop a model of clinical services in community pharmacies. / Em farmácias comunitárias, no momento em que o farmacêutico incorpora a prática clínica em sua rotina, várias barreiras e facilitadores influenciam a implantação de serviços de cuidado aos pacientes. Objetivos: Conhecer e compreender a percepção de um grupo de farmacêuticos sobre o processo de implementação dos Serviços Clínicos Farmacêuticos em farmácias comunitárias; Conhecer e compreender por meio de uma Revisão de Escopo da literatura, a percepção farmacêutico na provisão de Serviços Clínicos Farmacêuticos em farmácia comunitária. Metodologia: O estudo foi estruturado em duas etapas. A primeira etapa correspondeu a Revisão de Escopo realizada nas bases de dados Lilacs, PubMed, Scopus, Scielo e Web of Knowledge. Os estudos deveriam ser e se declarar de percepção de farmacêutico e os Serviços Farmacêuticos deveriam ser centrados no paciente. A segunda etapa correspondeu a um estudo qualitativo, no qual foram realizados três Grupos Focais com um grupo de 11 farmacêuticos. A análise dos dados foi feita por meio da técnica de análise de conteúdo. Resultados: Etapa 1 - A pesquisa bibliográfica resultou em 29 artigos que cumpriram os critérios de inclusão. Os estudos foram realizados em oito países diferentes, possuíam metodologias qualitativas (grupos focais, entrevistas, diários e questionários) e quantitativas (questionários), e foram encontradas 12 diferentes classificações de serviços farmacêuticos. Na maioria dos estudos, os farmacêuticos acreditavam que seu papel em farmácias comunitárias era positivo para os pacientes, barreiras e facilitadores para os serviços foram relatados. Etapa 2 - A gravação dos áudios dos grupos focais foi integralmente transcrita e analisada. A percepção dos farmacêuticos trouxe temas como acesso ao medicamento, barreiras e facilitadores para o serviço, expectativas, mudanças geradas ao longo da implementação dos serviços, resultados atingidos e a consolidação dos serviços. Conclusão: A Revisão de escopo apresentou recomendações para a implementação de serviços clínicos farmacêuticos em farmácias comunitárias, tornando mais fácil a provisão de serviços e valorizando as práticas em farmácias comunitárias. A divulgação de experiências positivas em implementações de serviços por meio de estudos de percepção têm mostrado que é possível desenvolver um modelo de serviços clínicos em farmácias comunitárias.

Background: Community pharmacists are legally required to evaluate and confirm the legitimacy of prescription opioids (POs) prior to dispensing. Yet, previous research has indicated community pharmacists perceive nearly 50% of dispensed POs to be issued lacking a legitimate medical purpose. Objective: To analyze correlates of PO legitimacy judgments across pharmacist and pharmacy setting characteristics. Methods: A cross-sectional study of 2000 Tennessee pharmacists was conducted during October and November of 2012. Community pharmacists' self-reported attitudes, beliefs, and behaviors specific to PO legitimacy were elicited. Step-wise multinomial logistic regression techniques were used to model correlates of PO legitimacy across low, moderate and high PO legitimacy estimations. Results: Being female, practicing in a chain or independent practice setting, fear of employer disciplinary action if PO legitimacy is questioned, and self-confidence in one's ability to detect PO abuse increased the odds of low (vs. high) PO legitimacy estimation (p < 0.05). Employment in chain and independent pharmacies, having POs as a greater percent of total prescriptions filled, and having the perception of PO abuse as a problem in the practice setting were significant positive correlates of moderate (vs high) PO legitimacy estimation (p < 0.05). Conclusions: Both modifiable and non-modifiable correlates were statistically significantly associated with PO legitimacy judgments. Distinct correlates were noted across low and moderate as compared to high estimations of PO legitimacy. Legitimacy judgments can inform theoretical exploration of PO dispensing behaviors and inform intervention development targeted at reducing and preventing prescription drug abuse.

Die Arzneimitteldistribution in Deutschland ist maßgeblich vom historischen Leitbild "des Apothekers in seiner Apotheke" geprägt und unterlag nur geringfügigen Änderungen. Die regulativen Bestimmungen, insbesondere das Fremdbesitzverbot, die eingeschränkte Mehrbesitzerlaubnis und die Apothekenbetriebsordnung, werden auf ihre Effektivität hinsichtlich einer ordnungsgemäßen Arzneimittelversorgung der Bevölkerung und ihre Effizienz untersucht. Hierbei werden alle relevanten Kräfte in der Arzneimitteldistribution kritisch untersucht und deren Verhandlungsposition dargestellt. Im nächsten Schritt wird ein Konzept zur optimalen Arzneimitteldistribution aus volkswirtschaftlicher Sicht entwickelt. Hierbei werden eine Abschaffung des Fremdbesitzverbotes, die Aufhebung der eingeschränkten Mehrbesitzerlaubnis und tiefgreifende Änderungen an der Apothekenbetriebsordnung vorgeschlagen. Diese Schritte sind aus volkswirtschaftlicher Sicht notwendig, um eine effektive und effiziente Arzneimitteldistribution zu gewährleisten.:1 Einführung … 1 1.1 Gesundheit und Gesundheitsausgaben … 1 1.2 Gesundheitsausgaben, Arzneimittel und Arzneimitteldistribution … 5 1.3 Problemstellung und Zielsetzung der Arbeit, Vorgehensweise … 7 1.4 Gegenwärtiger Stand der Forschung - Literaturüberblick … 11 2 Theoretischer Bezugsrahmen … 16 2.1 Terminologische Definitionen … 16 2.2 Auswahl des theoretischen Bezugssystems … 16 2.2.1 Das Structure-Conduct-Performance-Modell … 17 2.2.2 Strategiebestimmende, kompetitive Marktkräfte … 19 2.2.3 Modellsynthese … 20 3 Volkswirtschaftliche Effektivität und Effizienz in der Arzneimitteldistribution … 21 3.1 Funktion des Wettbewerbs … 21 3.2 Gütereigenschaften von Arzneimitteln … 22 3.3 Regulierungstheorie … 23 3.3.1 Marktmacht … 25 3.3.2 Externe Effekte … 26 3.3.3 Öffentliche Güter … 27 3.3.4 Unvollkommene Informationen … 28 3.4 Das Ziel: Ordnungsgemäße Arzneimittelversorgung … 30 3.4.1 Flächendeckende Versorgung … 32 3.4.2 Zeitliche Zugänglichkeit … 34 3.4.3 Quantitative und qualitative Versorgung … 35 3.4.4 Angemessenes Preisniveau … 36 4 Marktstruktur, Marktverhalten und kompetitive Kräfte in der deutschen Arzneimitteldistribution … 37 4.1 Die Marktsegmente … 37 4.2 Kompetitive Kräfte … 39 4.2.1 Wettbewerb zwischen Apotheken … 40 4.2.1.1 Produktpolitik … 47 4.2.1.2 Werbestrategie … 49 4.2.1.3 Preisstrategie … 49 4.2.1.4 Apothekenkooperationen … 52 4.2.2 Verhandlungsmacht von Leistungsnehmern … 59 4.2.2.1 Apothekenkunden … 59 4.2.2.1.1 RX … 66 4.2.2.1.1.1 Patentgeschützte RX … 66 4.2.2.1.1.2 RX-Generika … 66 4.2.2.1.2 OTC … 67 4.2.2.1.3 Freiwahl … 68 4.2.2.2 Krankenkassen … 69 4.2.2.2.1 RX … 70 4.2.2.2.1.1 Patentgeschützte RX … 71 4.2.2.2.1.2 RX-Generika … 72 4.2.2.2.2 OTC … 74 4.2.3 Verhandlungsmacht der Leistungslieferanten … 74 4.2.3.1 Der pharmazeutische Großhandel … 75 4.2.3.2 Die pharmazeutische Industrie … 81 4.2.3.2.1 RX … 84 4.2.3.2.1.1 Patentgeschützte RX … 84 4.2.3.2.1.2 RX-Generika … 85 4.2.3.2.2 OTC … 85 4.2.3.2.3 Freiwahl … 87 4.2.3.3 Die Ärzte … 88 4.2.4 Gefahr durch Substitute … 90 4.2.5 Potenzielle neue Konkurrenten … 91 4.2.5.1 Versandhandelsapotheken … 92 4.2.5.2 Pick-up-Modelle … 100 4.2.5.3 Selbstbedienungsterminals … 102 4.2.5.3.1 Geografische Ausweitung … 102 4.2.5.3.2 Ausweitung der Versorgungszeit … 103 5 Ergebnisse der derzeitigen Marktstrukturen … 104 5.1 Effektivität – Zielerreichung der ordnungsgemäßen Arzneimittelversorgung … 104 5.2 Effizienz … 108 5.2.1 Wirtschaftliches Ergebnis der deutschen Apotheken … 108 5.2.2 Gewinne und Kennziffern der Apotheken im Vergleich zum Einzelhandel …113 5.2.3 Einkommen der Apotheker im Vergleich zu anderen freien Berufen … 114 5.2.4 Internationaler Vergleich … 115 5.3 Ziele der Wettbewerbstheorie … 118 6 Marktstruktur, Marktverhalten und Marktergebnis als Ansatzpunkte zur Neugestaltung der Arzneimitteldistribution … 119 6.1 Marktergebnis … 119 6.2 Marktverhalten … 120 6.3 Marktstruktur … 120 7 Handlungsempfehlungen – Konzeptionelle Neugestaltung der Arzneimitteldistribution aus volkswirtschaftlicher Sicht …121 7.1 Ordnungsgemäße Arzneimittelversorgung der Bevölkerung … 122 7.2 Ordnungsgemäßer Apothekenbetrieb … 123 7.3 Marktzutrittsbarrieren … 125 7.3.1 Berufsqualifikation … 125 7.3.2 Fremdbesitz … 126 7.3.3 Mehrbesitz … 128 7.3.4 Apothekenbetriebsordnung … 129 7.3.4.1 Ausstattung der Geschäftsräume … 130 7.3.4.2 Freiwahlanforderungen … 131 7.4 Apothekenpflichtigkeit von Arzneimitteln … 131 7.4.1 OTC … 131 7.4.2 RX … 132 7.5 Mehrwertsteuersatz … 133   8 Zusammenfassung … 138 8.1 Zusammenfassung der Ergebnisse … 138 8.2 Ausblick und zukünftiger Forschungsbedarf … 139 Anhang 1: Übersicht über gesetzliche Regelungen des Arzneimittelmarktes seit 2002 … 141 Anhang 2: Empirische Untersuchung über den deutschen Apothekenmarkt … 143 2.1 Auswertung OTC-Industrie … 144 2.2 Auswertung Apothekenkooperationen … 145 2.3 Auswertung Versandhandelsapotheken … 146 2.4 Auswertung Freiwahlindustrie, nicht apothekenexklusiv … 147 2.5 Auswertung Freiwahlindustrie, apothekenexklusiv … 148 2.6 Auswertung Category-Management-Projekt … 150 Literaturverzeichnis … 151

OBJECTIF : L’hypertension est une maladie chronique pour laquelle seulement 68 % des patients étaient contrôlés en 2013. Les pharmaciens de la province de Québec ont récemment obtenu l’autorité législative pour ajuster la dose des antihypertenseurs lorsqu’une cible thérapeutique est entendue avec le médecin. Cette étude économique vise à estimer le ratio coût- utilité incrémental (RCUI) de ce nouveau modèle de soin au Québec. MÉTHODE : Un modèle de Markov a été développé pour extrapoler l’impact de cette pratique pharmaceutique sur les accidents vasculaires cérébraux (AVC), sur les infarctus du myocarde aigus et sur la mortalité. Les équations du modèle de risque de Framingham ont été utilisées pour estimer l’impact du contrôle de la pression artérielle sur la survenue d’AVC et d’infarctus. L’efficacité de l’intervention a été estimée à partir des résultats de l’essai clinique RxAction, conduit en Alberta. L’efficacité de l’intervention pharmaceutique est exprimée via la proportion de patients contrôlés. La perspective du payeur public a été utilisée et seulement les coûts directs des soins de santé ont été intégrés. L’issue principale observée par le modèle est le gain en années de vie ajustées par la qualité (AVAQ). Les AVAQ et les coûts ont été actualisés à un taux annuel de 1,5 %. Le modèle a simulé une cohorte de 1000 patients âgés de 65 ans, sur un horizon temporel de 20 ans en utilisant des cycles d’un an. RÉSULTATS: Le modèle a généré 0,051 AVAQs de plus par patient dans le groupe d’intervention pour une dépense supplémentaire de 268 $ par patient. Le RCUI est de 5 223 $/AVAQ gagnée. Si le seuil de volonté à payer du tiers public se tient à 50 000 $/AVAQ, cette intervention serait dite coût-efficace. Les résultats de cette simulation étaient surtout sensibles à l’efficacité de l’intervention pharmaceutique ainsi qu’à l’utilité attribuée à l’hypertension. CONCLUSION: Permettre aux pharmaciens d’ajuster la dose des traitements antihypertenseurs à l’intérieur du modèle de rémunération actuel apparaît coût-efficace. L’obtention de données d’efficacité issue d’une étude clinique conduite au Québec nous permettrait d’augmenter la validité externe de cette modélisation économique. / OBJECTIVE: Hypertension is a chronic disease for which only 68% of treated patients were controlled in Canada in 2013. Pharmacists in the province of Québec recently received legislative authority to adjust the dosage of antihypertensive drugs if there is an agreement with the prescriber of the therapeutic target. This research aims to estimate the incremental cost- utility ratio (ICUR) of this new model of care in Québec. METHODS: A Markov model was developed to extrapolate the impact of this pharmacy practice on strokes, myocardial infarctions and mortality. Framingham Risk Equations were used to derive the impact of blood pressure control on strokes and myocardial infarctions. The efficacy of the intervention was derived from the RxAction clinical trial, conducted in Alberta. Efficacy was expressed as the proportion of patients with controlled blood pressure. The model used the payer perspective and direct costs only. The main clinical outcome was expressed as the number of quality-adjusted life years (QALYs) gained. Both QALYS and costs were discounted at a 1.5% annual rate. A cohort of 1000 patients entered the model at 65 years old. The model used a 20 years time horizon, with a 1-year cycle length. RESULTS: The model yielded 0.051 QALYs per patient in the intervention group for an incremental expense of $268 per patient. The ICUR was 5,223 $/QALY. At a willingness-to- pay threshold of $50,000/QALY, the intervention is cost-effective. The results were sensitive to the comparative efficacy of the pharmacist intervention against usual care and to the utility of hypertension. CONCLUSION: Providing pharmacists the ability to adjust the dosage of antihypertensive drugs within the actual fee-for-service rational appears to be cost-effective. Obtaining data on the efficacy of this pharmacy practice from a trial conducted in Québec would provide better data to inform this economic evaluation.

Syftet med detta projekt var att identifiera om en implementering av en standardisering för receptbelagda läkemedelsförpackningar, skulle kunna bidra till en minskad risk gällande feldosering eller felmedicinering av patient. Resultatet av studien konstaterar att en standardisering för ordinationer har större effekt. / The purpose of this project was to identify if an implementation of a standardization for prescription drugs packaging, could contribute to a reduced risk of error when medicating a patient with prescription drugs and dosage. The outcome of the study states that a standardization for prescriptions has a bigger impact.

No description available.

L’amélioration de la qualité de l’utilisation des médicaments dans les soins primaires est devenue un enjeu crucial. Les pharmaciens communautaires se présentent comme des acteurs centraux dans l’atteinte de cet objectif, en réclamant une extension de leur rôle. L’objectif principal de cette thèse est de mieux comprendre comment les technologies de prescription informatisée (eRx) influencent la transformation du rôle des pharmaciens communautaires. Le premier article présente les résultats d’une étude de cas qui aborde la transformation du rôle des pharmaciens communautaires à partir du concept de professionnalisation. Elle propose un modèle logique des influences d’une technologie de eRx sur cette professionnalisation, élaboré à partir de la typologie de Davenport. Ce modèle logique a été validé en interviewant douze pharmaciens communautaires participant à un projet pilote typique de technologie de eRx. A partir des perceptions des pharmaciens communautaires, nous avons établi que la technologie était susceptible de soutenir la professionnalisation des pharmaciens en passant par cinq mécanismes : la capacité analytique, l’élimination des intermédiaires, l’intégration, l’automatisation et la diffusion des connaissances. Le deuxième article analyse les perturbations induites par les différentes fonctions des technologies de eRx sur la stabilité de la juridiction des pharmaciens communautaires, en se basant sur un cadre de référence adapté d’Abbott. À partir de trente-trois entrevues, avec des praticiens (médecins et pharmaciens) et des élites, cette étude de cas a permis de décrire en détail les influences des différentes fonctions sur les modalités d’action des professionnels, ainsi que les enjeux soulevés par ces possibilités. La perturbation principale est liée aux changements dans la distribution des informations, ce qui influence les activités de diagnostic et d’inférence des professionnels. La technologie peut redistribuer les informations relatives à la gestion des médicaments autant au bénéfice des médecins qu’au bénéfice des pharmaciens, ce qui suscite des tensions entre les médecins et les pharmaciens, mais aussi parmi les pharmaciens. Le troisième article présente une revue systématique visant à faire une synthèse des études ayant évalué les effets des technologies de eRx de deuxième génération sur la gestion des médicaments dans les soins primaires. Cette revue regroupe dix-neuf études menées avec des méthodes observationnelles. Les résultats rapportés révèlent que les technologies sont très hétérogènes, le plus souvent immatures, et que les effets ont été peu étudiés au-delà des perceptions des utilisateurs, qui sont mitigées. Le seul effet positif démontré est une amélioration de la qualité du profil pharmacologique accessible aux professionnels, alors que des effets négatifs ont été démontrés au niveau de l’exécution des prescriptions, tels que l’augmentation du nombre d’appels de clarification du pharmacien au prescripteur. Il semble donc que l’on en connaisse peu sur les effets des technologies de eRx de deuxième génération. Ces trois études permettent de constater que les nouvelles technologies de eRx peuvent effectivement influencer la transformation du rôle du pharmacien communautaire en perturbant les caractéristiques des prescriptions, et surtout, l’information et sa distribution. Ces perturbations génèrent des possibilités pour une extension du rôle des pharmaciens communautaires, tout en soulignant les défis intra et interprofessionnels associés à l’actualisation de ces possibilités. Dans l’ensemble, nos résultats soulignent que les perturbations associées aux technologies de eRx dépassent les éléments techniques du travail des utilisateurs, pour englober de multiples perturbations quant à la nature même du travail et du rôle des professionnels. Les décideurs et acteurs impliqués dans le déploiement des technologies de eRx auraient avantage à prendre en compte l’ensemble de ces considérations pour rapprocher les effets observés des bénéfices promis de ces technologies. / The quality of medication use in primary care needs to improve: this has become a crucial issue. Community pharmacists want to play a key role in meeting this objective and are calling for an expanded role. The main objective of this thesis is to better understand how electronic prescription (eRx) technologies are influencing the transformation of the role played by community pharmacists. The first article presents results from a case study on the transformation of the community pharmacists’ role, based on the concept of professionalization. It proposes a logical model of how an eRx technology influences this professionalization, developed from the Davenport typology. The logical model was validated by interviewing twelve community pharmacists participating in a typical pilot project involving an eRx technology. Based on the perceptions of community pharmacists, we have determined that there are five mechanisms by which the technology is likely to support the professionalization of pharmacists: analytic capacity, the elimination of intermediaries, integration, automation and the dissemination of knowledge. The second article analyzes the disturbances produced by the various functions of eRx technologies on the jurisdiction of community pharmacists, based on an adaptation of Abbott’s model. Using data from 33 interviews with practitioners, physicians and pharmacists, as well as elite members of these two professions, this case study provides a detailed description of how different functions influence professionals’ modalities of action, as well as the issues raised by these possibilities. The primary disturbance is associated with changes in the distribution of information, which can influence the diagnostic and inference activities of professionals. The technology may redistribute information on the management of medication to the benefit of both physicians and pharmacists, and this creates tensions, not only between physicians and pharmacists but also among pharmacists. The third article presents a systematic review that synthesized studies assessing the impacts of second-generation eRx technologies on the management of medication in primary care. It examined 19 studies that applied observational methods. The findings reveal that the technologies are very heterogeneous and often far from mature, and that their effects received little attention beyond the perceptions of users, which were mixed. The only positive impact shown is an improvement to the quality of the pharmacological profile available to professionals. Negative impacts touched on the execution of prescriptions, such as a greater number of calls from pharmacists to prescribers to clarify information. It would therefore appear that little is known about the impacts of second-generation eRx technologies. These three studies allow us to conclude that new eRx technologies may well influence how the role of the community pharmacist is being transformed, specifically by disturbing the characteristics of prescriptions and, above all, information and its distribution. These disturbances generate opportunities for extending the role of community pharmacists, while underscoring the intra and interprofessional challenges associated with their realization. Overall, our results suggest that the disturbances associated with eRx technologies go beyond technical aspects of users’ work, to include multiple disturbances of the very nature of the professionals’ work and role. The decision makers and actors involved in deploying eRx technologies would be well advised to take all these considerations into account to bring the observed effects of these technologies more in line with their promised benefits.

Final master work, 41 pages, 15 graphical scheme, 6 tables, 29 references and 2 annex. Keywords: Sociological investigation, self-medication, popularity of self-medication, treatment and self-treatment, medicaments, OTC drugs, non-OTC drugs, advertisement, respondent, gastro intestinal disorder, pharmacist in self-medication, herbal remedies. Self-medication should be understood as a treatment of easy and uncomplicated disorder without the help of a health care specialist. Self-medication process occur when the self-healer can exactly realize his or her disorder or symptoms of his or her disease, they can chose the most suitable medicament and use it properly for not longer than 7 days. The proper self-medicament should not cause any undesirable effects and worsen the patient’s health condition. Only OTC drug are suitable in self-medication. Before start using the medicament, the patient should always read carefully the note and information leaflet. Work object: citizen of Kaunas City. Work subject: patients, 2nd year students of the Technological University of Kaunas (KTU), company workers. Work aim: Evaluate the self-healing between the citizen of Kaunas City suffering from Gastrointestinal tract disorder. Task work: 1. Theoretical analysis of self-medication 2. Investigate the gastrointestinal problems between the citizen of Kaunas city. 3. Investigate the treatment peculiarity between the citizen of Kaunas city. Method of analysis :... [to full text]

L’amélioration de la qualité de l’utilisation des médicaments dans les soins primaires est devenue un enjeu crucial. Les pharmaciens communautaires se présentent comme des acteurs centraux dans l’atteinte de cet objectif, en réclamant une extension de leur rôle. L’objectif principal de cette thèse est de mieux comprendre comment les technologies de prescription informatisée (eRx) influencent la transformation du rôle des pharmaciens communautaires. Le premier article présente les résultats d’une étude de cas qui aborde la transformation du rôle des pharmaciens communautaires à partir du concept de professionnalisation. Elle propose un modèle logique des influences d’une technologie de eRx sur cette professionnalisation, élaboré à partir de la typologie de Davenport. Ce modèle logique a été validé en interviewant douze pharmaciens communautaires participant à un projet pilote typique de technologie de eRx. A partir des perceptions des pharmaciens communautaires, nous avons établi que la technologie était susceptible de soutenir la professionnalisation des pharmaciens en passant par cinq mécanismes : la capacité analytique, l’élimination des intermédiaires, l’intégration, l’automatisation et la diffusion des connaissances. Le deuxième article analyse les perturbations induites par les différentes fonctions des technologies de eRx sur la stabilité de la juridiction des pharmaciens communautaires, en se basant sur un cadre de référence adapté d’Abbott. À partir de trente-trois entrevues, avec des praticiens (médecins et pharmaciens) et des élites, cette étude de cas a permis de décrire en détail les influences des différentes fonctions sur les modalités d’action des professionnels, ainsi que les enjeux soulevés par ces possibilités. La perturbation principale est liée aux changements dans la distribution des informations, ce qui influence les activités de diagnostic et d’inférence des professionnels. La technologie peut redistribuer les informations relatives à la gestion des médicaments autant au bénéfice des médecins qu’au bénéfice des pharmaciens, ce qui suscite des tensions entre les médecins et les pharmaciens, mais aussi parmi les pharmaciens. Le troisième article présente une revue systématique visant à faire une synthèse des études ayant évalué les effets des technologies de eRx de deuxième génération sur la gestion des médicaments dans les soins primaires. Cette revue regroupe dix-neuf études menées avec des méthodes observationnelles. Les résultats rapportés révèlent que les technologies sont très hétérogènes, le plus souvent immatures, et que les effets ont été peu étudiés au-delà des perceptions des utilisateurs, qui sont mitigées. Le seul effet positif démontré est une amélioration de la qualité du profil pharmacologique accessible aux professionnels, alors que des effets négatifs ont été démontrés au niveau de l’exécution des prescriptions, tels que l’augmentation du nombre d’appels de clarification du pharmacien au prescripteur. Il semble donc que l’on en connaisse peu sur les effets des technologies de eRx de deuxième génération. Ces trois études permettent de constater que les nouvelles technologies de eRx peuvent effectivement influencer la transformation du rôle du pharmacien communautaire en perturbant les caractéristiques des prescriptions, et surtout, l’information et sa distribution. Ces perturbations génèrent des possibilités pour une extension du rôle des pharmaciens communautaires, tout en soulignant les défis intra et interprofessionnels associés à l’actualisation de ces possibilités. Dans l’ensemble, nos résultats soulignent que les perturbations associées aux technologies de eRx dépassent les éléments techniques du travail des utilisateurs, pour englober de multiples perturbations quant à la nature même du travail et du rôle des professionnels. Les décideurs et acteurs impliqués dans le déploiement des technologies de eRx auraient avantage à prendre en compte l’ensemble de ces considérations pour rapprocher les effets observés des bénéfices promis de ces technologies. / The quality of medication use in primary care needs to improve: this has become a crucial issue. Community pharmacists want to play a key role in meeting this objective and are calling for an expanded role. The main objective of this thesis is to better understand how electronic prescription (eRx) technologies are influencing the transformation of the role played by community pharmacists. The first article presents results from a case study on the transformation of the community pharmacists’ role, based on the concept of professionalization. It proposes a logical model of how an eRx technology influences this professionalization, developed from the Davenport typology. The logical model was validated by interviewing twelve community pharmacists participating in a typical pilot project involving an eRx technology. Based on the perceptions of community pharmacists, we have determined that there are five mechanisms by which the technology is likely to support the professionalization of pharmacists: analytic capacity, the elimination of intermediaries, integration, automation and the dissemination of knowledge. The second article analyzes the disturbances produced by the various functions of eRx technologies on the jurisdiction of community pharmacists, based on an adaptation of Abbott’s model. Using data from 33 interviews with practitioners, physicians and pharmacists, as well as elite members of these two professions, this case study provides a detailed description of how different functions influence professionals’ modalities of action, as well as the issues raised by these possibilities. The primary disturbance is associated with changes in the distribution of information, which can influence the diagnostic and inference activities of professionals. The technology may redistribute information on the management of medication to the benefit of both physicians and pharmacists, and this creates tensions, not only between physicians and pharmacists but also among pharmacists. The third article presents a systematic review that synthesized studies assessing the impacts of second-generation eRx technologies on the management of medication in primary care. It examined 19 studies that applied observational methods. The findings reveal that the technologies are very heterogeneous and often far from mature, and that their effects received little attention beyond the perceptions of users, which were mixed. The only positive impact shown is an improvement to the quality of the pharmacological profile available to professionals. Negative impacts touched on the execution of prescriptions, such as a greater number of calls from pharmacists to prescribers to clarify information. It would therefore appear that little is known about the impacts of second-generation eRx technologies. These three studies allow us to conclude that new eRx technologies may well influence how the role of the community pharmacist is being transformed, specifically by disturbing the characteristics of prescriptions and, above all, information and its distribution. These disturbances generate opportunities for extending the role of community pharmacists, while underscoring the intra and interprofessional challenges associated with their realization. Overall, our results suggest that the disturbances associated with eRx technologies go beyond technical aspects of users’ work, to include multiple disturbances of the very nature of the professionals’ work and role. The decision makers and actors involved in deploying eRx technologies would be well advised to take all these considerations into account to bring the observed effects of these technologies more in line with their promised benefits.

Background: The purpose of drug treatment is to reduce morbidity and mortality, and to improve health-related quality of life. However, there are frequent problems associated with drug treatment, especially among the elderly. The aim of this thesis was to investigate the impact of clinical pharmacy services within a multiprofessional healthcare team on quality and safety of patients’ drug therapy, and to study the frequency and nature of medication history errors on admission to hospital. Methods: A model for clinical pharmacy services within a multiprofessional healthcare team (the Lund Integrated Medicines Management model, LIMM) was introduced in three hospital wards. On admission of patients to hospital, clinical pharmacists conducted medication reconciliation (i.e. identified the most accurate list of a patient’s current medications) to identify any errors in the hospital medication list. To identify, solve and prevent any other drug-related problems, the clinical pharmacists interviewed patients and performed medication reviews and monitoring of drug therapy. Drug-related problems were discussed within the multiprofessional team and the physicians adjusted the drug therapy as appropriate. Results: On admission to hospital, drug-related problems, such as low adherence to drug therapy and concerns about treatment, were identified. Different statistical approaches to present results from ordinal data on adherence and beliefs about medicines were suggested. Approximately half of the patients were affected by errors in the medication history at admission to hospital; patients who had many prescription drugs had a higher risk for errors. Medication reconciliation and review reduced the number of inappropriate medications and reduced drug-related hospital revisits. No impact on all-cause hospital revisits was demonstrated. Conclusion: Patients admitted to hospital are at high risk for being affected by medication history errors and there is a high potential to improve their drug therapy. By reducing medication history errors and improving medication appropriateness, clinical pharmacy services within a multiprofessional healthcare team improve the quality and safety of patients’ drug therapy. The impact of routine implementation of medication reconciliation and review on healthcare visits will need further evaluation; the results from this thesis suggest that drug-related hospital revisits could be reduced. / Läkemedelsgenomgångar och läkemedelsavstämning - LIMM-modellen