-_u.-..... 
THE CLINICAL ROLE OF THE

COMMUNITY PHARMACIST

CASE STUDIES 
Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-01-B9-B9161  NOVEMBER 1990  " '
10 
THE CLINICAL ROLE OF THE

COMMUNITY PHARMACIST

CASE STUDIES 
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TABLE OF CONTENTS

INTRODUCTION................................................. .

ANALYSIS OF CASE STUDIES......................................

CASE STUDIES 
Calvin Knowlton and Amherst Pharmacy 
Howard Juni and Capitol Drug 
Linda Garrelts and Jones Pharmacy. . . 
Nancy Culberson and 
Lexington Family Practice Pharmacy. . . . . . 
Julee Alexander and Lifesource ..............................

Madeline Feinberg and 
Accredited Surgical Company. . . . . 
APPENDIX 
Case Study Methodology. . . . . 
1 - 1
 '''--' ''''''
INTRODUCTION 
This is a companion report to the January 1990 Office of the InspectOr General report entitled 
The Clinical Role of the Community Pharacist. " That report describes the current level of 
clinical services available in community pharacy settings, discusses the barers that limit 
the availability of such services, and suggests actions that can be taen to improve 
pharmaceutical care for ambulatOry patients. 
This report provides an analysis and summar of the case studies that are referenced in the 
above report. These studies focus on six community pharacists who provide a broad range 
of clinical services to their patients. Clinical services are those patient-oriented functions that 
identify, resolve, and prevent drug-related problems. 
Our purpose in conducting the case studies was twofold: (1) to detertne the extent and type 
of clinical services offered by the pharacists, and (2) to identify methods they use to 
overcome barers to clinical care. These barers, which ar discussed at length in the 
companion report, include: 
Economic: product-based reimbursement strctue and uneven use of supportve 
personnel. 
Interprofessional: lack of collaboration between physician and pharacist. 
Informational: incomplete patient profIe information. 
Training: inadequate training in clinical pharacy skills. 
Patient demand: uneven demand by patients for clinical pharacy services. 
In this context, it is important to note that our case-study pharacists are not representative of 
community pharacists as a whole. They were selected, in fact, because of the atypical nature 
of their practices. In each case, we observed their daily activities, interviewed patients served 
and spoke with physicians with whom they collaborate. Based on these observations and 
interviews, we documented the rage of services offered in each of the four componenis of 
drg 
clinical pharacy services: collection of patient information,  utilization review (DUR), 
patient counseling, and physician consultation. Measuring their performance agaist the mean 
level of clinical services offered in community pharacy settngs as documented in research 
literature, we can safely say that all provided an exceptional mix of clinical care to their 
patients. (See appendiX: I for a description of the case study methodology.  In the first par of this report, we present an analysis of how the four case-study pharacists 
who practice in traditional community settings were able to overcome the barers to clinical 
practice. These pharacists are: Calvin KnowltOn, owner of Amherst Pharacy in 
LumbertOn , New Jersey; Howard Juni , co-owner of Capitol Drug in White Bear Lake 
Minnesota; Linda Garelts, co-owner of Jones Pharacy in Spokane, Washington; and Nancy 
Culberson, owner of Lexington Family Practice Pharacy in Lexington, South Carolina. 
In the second par of the report , we offer a detailed summar of the practices of each of the 
above pharacists and of the two others who do not practice in traditional community 
settings: J ulee Alexander of Lifesource Inc. in Larkspur, California, and Madeline Feinberg of 
Accredited Surgical Company in Columbia, Marland.  ANALYSIS OF CASE STUDIES 
Our analysis of how the case-study pharacists have overcome barers to clinical practice 
indicates that the methods used are typically a function of individual skills and personal 
commitment. We note that the flexibility inherent in managing one s own independent 
pharacy is one condition in which these skils can be applied; nevertheless, as discussed in 
the companion report, the independent pharacy setting does not, in itself, guarantee that a 
full range of clinical services will be provided. 
There were no unusual environmental or market conditions that allowed the case-study 
pharmacists to develop clinical practices. All operate in highly competitive markets and 
compete for custOmers with chains, discount pharacies and mail service pharacies (MSPs). 
Populations served by the pharacists are quite diverse, ranging from working class urban 
patients to more affuent suburban patients. In sum, these pharacists enjoy no external 
advantage over their colleagues. Instead, a combination of skills in clinical pharacy, 
business management and communications, coupled with an unusually strong professional 
commitment appear to be the ingredients for a successful clinical pharacy practice. 
Our conclusion from the case study analysis is that this formula cannot be duplicated easily 
either through reimbursement incentives or regulatory requirements. The conditions that 
obtain in these four cases where barers to clinical pharacy have been overcome are largely 
idiosyncratic and do not suggest an immediate or generalzable solution to the current gap in 
clinical pharacy services for ambulatory patients. 
Below is a summar description of how the case study pharacists manage the barers 
providing clinical patient care as described in this report: 
All of the case study pharacists have developed financially 
The Economic Barrie':: 
successful practices that include a broad range of clinical services, despite the constraints of a 
transaction-based reimbursement system. Their ability to do so is the result of two factOrs. 
The first is an aggressive, entrpreneurial approach to the business management aspect of their 
practice. As independent pharacists, they are able to control all aspects of their practice and 
each has a history of experimenting with new products, services and marketing techniques. 
drg  car 
Several have expanded their traditional prescription  services to home health 
products; one has experimented with marketing his practice as a specialized geriatrc service. 
Several offer blood pressure and cholesterol testing services for their patients. The 
development of new markets and services such as these appears to loosen the economic 
constraints and subsidize the clinical service aspect of the practice. One may conclude that the 
view of the pharacist as a busiqessperson, traditionally associated with the view of the 
pharacist as a non-professional, seems quite compatible with a clinically-oriented 
professional role.  The second factor that reduces economic barers is the use of technicians. Each of the 
case-study pharacists uses technicians to count and pour pils and to perform other technical 
and supportive activities. Economically effcient allocation of personnel allows these 
pharmacists to spend their time interacting with patients, analyzing clinical problems and 
consulting with physicians.

Each of our study pharacists appears to have a strong sense
The I nterprofessional Barrier: 

of his/her own professionalism. In day-to-day activities of their practice , they are nO! hesitant 
to initiate contact with physicians and each is aggressive in doing so when a question arises on 
located with medical practices and are able to consult with 
patient care. Several are co-
physicians regularly on a face-to-face basis. One pharacist who is co-located with a family 
practice has an arangement with the physicians whereby she reviews each patient s char 
every time a physician prescribes a drg. In no case did we sense that the pharacists 
consider themselves inferior to the physicians with whom they dealt; rather, they see 
themselves as one par of a primar health car team. 
In addition to collaborating closely with individual physicians, the study  are 
pharacists  also 
quite active in professional associations, and some use those affiliations to educate local 
groups of physicians about the clinical services pharacists can offer. One of our study 
pharacists is involved in a project with her local pharacy association in which pharacists 
drg 
appear at local medical association meetings to present continuing education modules on 
therapy and the role of clinical pharacy in the community setting. A physician who is 
involved in the project reponed to us that he believes this education effort has encouraged his 
colleagues to collaborate more effectively with local pharacists. Some other pharacists we 
visited also lecture to groups of physicians in less formal settings. In sum, the case-study 
pharacists have managed to improve intet'rofessional relationships though both individual 
and group efforts in the context of promoting their profession. 
All of the pharacists we visited place strong emphasis on
The Informational Barrier: 

gathering patient information, including prescription and over-the-counter medications, 
allergies and diseases/conditions. The information is then automated (all use computerized 
screening tools) and updated when there is a change in status. As mentioned previously, some 
provide monthly blood pressure scrning and all routinely request lab
of the pharacists  also 
data information from physicians or patients when they suspect a dosage level problem. The 
most elaborate information review occurs in the case of the pharacist who is co-located with 
a family practice and is able to review complete medical fies for each patient. 
All of the pharacists we visited graduated in the past 20 years from 
The Training Barrier: 

colleges of pharacy with currcula  have other 
in clinical services. Several  also
undergraduate or graduate degrees and one has a Phar.D. degree. Additionally, all are 
affiliated in some way with nearby academic institutions. All allow their pharacies to be 
used as clerkship or internship sites by local colleges of pharacy and some teach par time in 
these colleges.
 These contacts with academic institutions help to keep the pharacists in touch not only with 
trends in pharacy education, but also more generally with the latest thought concerning their 
profession. In paricular, ideas concerning clinical pharacy, although they may be wide1y 
discussed and endorsed, are not so firmly entrnched in the mainstream of professional 
practice as they are in colleges of pharacy. Thus, continued contact with these leaming 
centers helps to reinforce pharacists ' commitment to clinical pharacy practice. 
This barer is reduced in a number of ways by the pharacists
The Patient Demand Barrier: 

we visited. All provide some written information to their patients and discuss basic 
medication issues with each new prescription, whenever there is a status change in the 
patient s profie, and in cases that are deemed as high risk by the  make 
pharacist. (They  also
themselves available by phone when the pharacies ar closed.) The pharacists believe that 
this information sharng and counseling both encourage patients to raise questions and create 
expectations among patients that afect demand. 
sensitive to issues of privacy and every pharacy we visited had some
Each pharacist is  also 
semi-private space for patient counseling. One pharacist who operates an apothecar has 
designed the physical setting so that the waiting ara is separted from the space in which he 
counsels patients. 
Several pharacists publish newsletters on health car and drg topics that are avaiable for 
their patients in the waiting ara.  encourages patients to be 
This technique, they believe,  also
more aggrssive in requesting additional information. Most of the  attend 
pharacists  also
brown-bag sessions with elderly patients to discuss their drg regiens and educate them 
about clinical pharacy services.  CASE STUDIES

CASE STUDY No. I: 
Ca!i,in Knowlton and Amherst Pharmacy 
GENERAL BACKGROUND 
Amherst Pharacy is located in Lumberton , New Jersey. Amherst was purchased by its 
current owner, Calvin Knowlton, in 1975 at which time it was it full-scale drgstore that 
included both pharacy and non-pharacy items. Over the next three years, Mr. Knowlton 
transformed the operation into an apothecar, which offers only pharacy products. (At 
Amherst, the stock of non-prescription drg items is quite limited and represents only a small 
percentage of the overall pharacy transactions.) In addition to drug products, Amherst also 
sells and leases durable medical equipment. 
Lumberton is a suburb of Philadelphia and Amherst s client base is a mix of middle and 
working class patients. Approximately 11 percent of prescriptions are Medicaid-reimbursed, 
45 percent are paid for by private third pary insurers and the remainder are paid for in cash. 
Amherst services two nursing homes and one hospice as a provider of prescrption drgs, but 
does not act as a consultat in those facilities. (Although pharacies in New Jersey are 
. perttted to provide both consulting and dispensing services to a nursing home, such 
arangements are highly unusual. ) Amherst competes with seven other pharacies within a 
two-mile radius. 
Approximately 1650 prescriptions are filled at Amherst on a weekly basis. Eight hundred 
twenty five or 50 percent are for nursing home and hospice patients and the remainder are for 
ambulatory patients. 
PHARMACIST' S BACKGROUND 
The pharacy is owned and managed by Calvin Knowlton, who received his B.S. degree in 
1972 from the Temple University School of Pharacy. Mr. Knowlton is currntly in the 
process of completing a doctorate degree in Pharacy Admnistation and Health Policy at the 
University of Marland. 
For the past eight years, Mr. Knowlton has taught at several universities, including Temple 
Rutgers and the Philadelphia College of Pharacy (PCP), where he is currently a Clinical 
pharacy 
Associate Professor. He has also been continually involved in national and local 
and health care organizations, and paricipates regularly in seminars and conferences that 
focus on health care issues.  From the onset of his practice, Mr. Knowlton has emphasized clinical pharmacy services and 
drg 
his transformation of Amherst from a full-service  store to an apothecary reflects his 
commitment to confine his own practice of pharacy to patient care. Although he has no 
formal training in business administration, he is a highly successful entrepreneur and a strong 
pharacy 
proponent of building business skil training into  school currcula. 
Mr. Knowlton is currently in the process of developing an executive management program at 
PCP that wil focus on preparng recent pharacy school graduates to purchase their own 
pharmacy. It is Mr. Knowlton s belief that pharacists would be more likely to purchase and 
manage their own businesses, if they had an opportunity to develop fundamental business 
skills. He feels that owner-pharacists control the policies and procedures of the pharacy 
much more than employee pharacists, and that the most expedient way to implement clinical 
or patient-oriented policies in community pharacies is first to empower pharacists with the 
authority to set such policies. 
STAFF 
Consistent with his philosophy aboUt effcient business practice, Mr. Knowlton s staf includes 
a high proportion of pharacy technicians. Amherst employs four full-time pharacists, 
seven full-time technicians and three par-time technicians. Technicians conduct routine 
counting and pouring activities, data entr on the pharacy s information system, and stock 
management. Mr. Knowlton believes that liberal use of technicians is the most critical 
requisite to providing clinical patient care. Additionally, Amherst serves as an internship site 
for pharacy students from PCP who are actively involved in all operational aspects of the 
pharacy. 
PHYSICAL SETTING 
The patient waiting ara at Amherst is similar in design to that of a physician s offce with a 
seating area that is separated from the section where patients meet with the pharacists. The 
waiting area is equipped with magazines as well as newsletters on health topics and is adjacent 
to a small section of non-prescription drg items. Beyond the waiting area and separated from 
it by a four-foot room divider is a counter section where patient consultation occurs. This ar
rangement allows for a great deal of privacy; conversations with patients are held outside the 
hearng rage of other staf and patients. Next to the counseling ara is a private room which 
is used for closed-door consultations as well as blood pressure monitoring.  .----...
CLINICAL ACTIVITIES

Data Collected 
Each new patient at Amherst completes a patient information form which includes 
name, age, allergies, chronic conditions and currnt drg regimen. (In New Jersey, 
pharacists ar required to maintain patient profiles. ) Mr. Knowlton reports that 
patients are quite cooperative in supplying this information; he has never encountered 
any serious resistance from his patients on this account. All of the patient profie 
information is maintained on the pharacy computer system. 
Unavailable Patient Data 
Mr. Knowlton believes that the pharacist s ability to monitor patient care would be 
enhanced considerably if he had access to lab information. Lab data would enable him 
drg 
to conduct more thorough  utilization review and to identify adverse drug 
reactions (ADRs) on a more tim ly basis. At Amherst, blood pressure screenings are 
routinely offered to patients who are being treated for hypertension; however, New 
Jersey prohibits pharacists from perfortng other stadard tests that can be 
conducted through fingers tick procedures.. 
DUR/Patient Counseling

Each patient is interviewed by the pharacist prior to receiving a drg, and a computer 
screening and pharacist review is conducted each time a drug is dispensed. In 
addition to providing the patient profie information, each patient is asked why the 
drug is being prescribed and what over-the-counter (OTC) drgs the patient is using. 
After reviewing the patient s drg regimen, pharacists then provide each patient. with 
information on the name of the drg, its purpose, strength of dosage, how it should be 
taken and potential interactions and side effects. For new prescriptions and at the time 
of a first refill, this interview process is most extensive. Mr. Knowlton feels that the 
first refill is a critical time for pharacist intervention with the patient; he places 
strong emphasis on the monitoring aspect of patient counseling and asks very specific 
questions at first refill time to assess the patient s reactions to the drg and to reinforce 
, side effects and interactions. Additionally, for 
instrctions on proper administration
patients who are deemed at high risk (e.  , have complex drug regimens or multiple 
conditions), or patients who ar taing drgs that ar parcularly sensitive, more 
elaborate interviews are held throughout the course of treatment. One technique that 
Mr. Knowlton uses to monitor drg therapy is that of providing staer doses to 
patients who are at high risk and are staring a new prescription. (In some cases, he 
extends this policy on drgs that are parcularly costly.) This allows for timely follow 
up by the pharacist; once the patient, pharacist and physician have ascertained that 
the drug can be tolerated, the length of fill is extended.  Physician Consultation 
Approximately 50 percent of the prescriptions filled at Amherst are called in by a 
physician or staf of a physician s office. Other than orders placed by phone, most 
pharacist/physician contact is initiated by the pharacist when he has a question or 
concern about the physician s orders. Mr. Knowlton reports that over time he has 
developed good working relationships with the physicians who treat his patients and 
drg . 
in general, has found most of them open to discussing the specifics of their 
therapy decisions. Occasionally, some physicians contact Mr. Knowlton and consult 
With him prior to making a drug selection for a patient 
One issue that frequently arses in his daily practice is that of prescribing high cost 
me-too" drgs. During our site visit, Mr. Knowlton identified a number of newly 
marketed and very expensive drgs that ar not therapeutically different from 
alternative, lower-cost medications. When one of these higher-cost drgs is 
prescribed, Mr. Knowlton often contacts the physician to discuss the cost issue; in 
many cases, he reports, the physician is totally unaware of the retail cost and, when 
told, is willng to substitute a lower-cost alternative. Mr. Knowlton believes that 
patterns of high-cost drg prescribing ar a direct result of marketing blitzes by 
drg 
to as detailers. During our site visits, a 
manufacturer representatives, referrd 
detailer visited Mr. Knowlton and we were permtted to observe their conversation. In 
the course of the visit, Mr. Knowlton asked the detaler if she routinely discussed drug 
costs with physicians and she responded that she did not unless specifically asked by 
the physician. Mr. Knowlton believes an important component of his own clinical roJe 
is that of educating physicians about lower-cost therapies, notwithstanding the issue of 
who is paying for the drg. 
EDUCATIONAL AND ASSOCIATION ACTIVITIES 
Mr. Knowlton is actively involved in a number of local and national professional 
organizations. He currently chairs the American Pharaceutical Association s section on 
Pharacy Practice and Management in Ambulatory and Home Health Care and is Vice 
President of the American College of Apothecares. He is a member of the Professional 
Affairs Committee of the American Association of Colleges of Pharacy and Chairman of the 
Community Pharacy Credentials Committee of the American College of Apothecares. As 
Pharacy 
mentioned previously, Mr. Knowlton is on the faculty of the PCP, and Amherst 
students at that school. 
pharacy 
serves as an internship site for 
Mr. Knowlton publishes a newsletter on health care issues which is distrbuted at the local 
level, and Amherst pharacy staf conduct meetings on a regular basis with elderly patients in 
the Lumberton area and with nursing staff of his contracted nursing homes and hospice on 
drg 
issues associated with  therapy.  CASE STUDY No. 
Howard Juni and Capitol Drug 
GENERAL BACKGROUND 
Capitol Drug s primar location is in White Bear Lake, Minnesota, a suburb of St.Paul with a 
population of approximately 23,000. There are two other locations: one in Minneapolis and 
one in Apple Valley, a suburb of the twin cities. Capitol Drug was established in 1908 and is 
now co-owned by Norman Carlson, Steven Carlson and Howard Juni , Phar. 
Originally located at a single site across the street from the state capitol in St. Paul, Capitol 
was a traditional drug store until 1967 when the owner, Norman Carlson, decided to convert 
the operation to an apothecar. Currently, Capitol is a community pharacy which offers 
prescription and IV services to ambulatOry and institutionalized patients. CapitOl provides 
both pharacy and consulting services to 18 long term care facilities and ten group homes 
representing over 2000 beds. Capitol' s staff are paricularly proud of their accomplishments in 
the area of nursing home consulting. (As an example, the percentage of patients given 
sedative/hypnotic medications in one facility they serve has been reduced from 50 percent to 
10 percent as a result of their clinical monitOring activities.) Additionaly, Capitol sells, rents 
and services medical equipment, including durable medcal equipment, colostomy and ostomy 
supplies, urologicals and oxygen. 
par 
Approximately 75 percent of Capitol's drug transactions are covered by third 
reimbursement; the remainder are cash transactions. Among its three locations, CapitOl 
dispenses 400-500 prescrptions per day, 20 percent of which are for walk-in patients. 
Capitol' s primar site competes with four other pharacies within a one-mile radius, several 
of which are discount pharacies. Capitol markets itself as a specialist in geriatrc care, but 
its ambulatory patients are of a wide age range. The primar site is located in an offce 
houses a physician who specializes in family practice and Capitol services
building which  also 
a number of his patients on a routine basis. Capitol has a reputation for innovation; within the 
State,it was the first pharacy to use patient profies to monitor therapy for its nursing home 
patients, the first community pharacy to employ a Phar.  , and the second pharacy to 
use computers in its practice. 
PHARMACIST'S BACKGROUND 
Dr. Howard Juni graduated from the University of Minnesota College of Pharacy in 1974 
after which he was employed by Capitol Drug for four years. From 1978 to 1982 he served as 
Assistant Pharacy Director in charge of clinical services at a St. Paul hospital, returning to 
Capitol in 1982 where he has remained. In 1986 he became a co-owner of the business. Dr. 
Juni works directly with ambulatory patients at CapitOl, in addition to supervising four other 
pharacists and directing the consulting service for institutionalized patients.  Dr. Juni is a preceptor for the University of Minnesota College of Pharacy and instituted at 
Capitol one of only six post graduate community residency programs recognized by the 
American Pharaceutical Association. Throughout his career, he has been associated with a 
variety of national and local pharacy and health care organizations. 
Dr. Juni' s practice philosophy is centered on expanding clinical pharacy care from teaching 
hospitals into community settings. He and his parners have used aggressive marketing 
strategies and experimented with new products and services to build an economic base that 
enables them to provide a broad range of clinical services for their patients. He believes that 
the combination of good communication and business skils along with a physical 
environment that is conducive to effective patient counseling are the primar ingredients for a 
successful clinical practice. Although he recognizes the constraints of a product-based 
reimbursement structure and supports the notion of compensating pharacists for their 
professional services, he also believes that the issue of service fees is often an. excuse rather 
than a reason for pharacists' inability to offer clinical car in community settings. 
STAFF 
At its primar site, Capitol employs eight pharacists and three full-time technicians in 
addition to the pharacy students who rotate through the facility. Four pharacist work years 
are devoted to nursing home consulting; however, all of the pharacists staf the wal
component of the business to varing degrees. This stafng pattern is designed to keep the 
pharmacists who are primarly involved in consulting in touch with patient counseling 
activities. 
Although four of the pharacists on staff have Phar D. degres, provision of clinical 
services is not limited to that group. Dr. Juni believes that pharacists with bachelor 
. science degres can be as effective in providing clinical services as those with more advanced 
degrees. From his perspective, the most important prerequisites for providing clinical patient 
care are staying current in the field and concentrating on good communication with patients. 
Capitol makes liberal use of its technicians who perform routine tasks of counting and pouring 
as well as data input and stock management. The organization enjoys a stable stafng pattern; 
of its 25 employees across thee sites, the average length of tenure is seven years. 
PHYSICAL SETTING 
As mentioned previously, Capitol stocks only pharacy items and medical equipment. At its 
White Bear Lake facility non-prescription drgs are stocked in the front of the pharacy with 
the equipment and supply section immediately behind. Adjacent to the display area is the 
pharacy section with a front counter where pharacists and other staff interact with patients  at eye level. Although there is no section isolated for patient counseling, Capitol is 
sufficiently spacious to create a sense of separation from sections of the store where customers 
may be browsing through displays. There is also a small waiting area where patients can sit 
while prescriptions are being filled. The general environment is quiet and, from our 
observations, patients feel comfortable engaging in conversation about their drug regimens 
with the pharacists even though there is no physical separation from the rest of the facility. 
CLINICAL ACTIVITIES

Data Collected 
Each ambulatory patient completes a profie sheet which includes name, age , allergies 
chronic conditions and current drg regimen. Capitol uses an automated information 
system to maintain patient profies and patient information is entered into that system 
at the onset of treatment. Dr. Juni reports that he encounters no resistance from 
patients in gathering basic profile information as well as any other information the 
pharacist may solicit in an interview. In fact, Dr. Juni reports that his patients appear 
to enjoy that aspect of clinical service. . 
Unavailable Patient Data 
Dr. Juni believes that diagnostic information and lab data would significantly improve 
his ability to provide clinical services, parcularly for the large proporton of geriatrc 
patients he serves. His experience in providing consulting services to nursing home 
patients for whom this information is available has convinced him that services for 
ambulatory patients would be enhanced by the level of therapeutic drg monitoring 
made possible with more complete patient data. Dr. Juni notes that some lab 
information could be collected by finger stick tests, and, in fact, he is currently 
parcipating in a project (funded by Syntex) in which community pharacists use 
drg 
finger stick tests to monitor  therapy. 
DUR/Patient Counseling

Each patient is interviewed by a pharacist prior to receiving a new prescription and a 
computer screening and pharacist review is conducted each time a drg is dispensed. 
After reviewing the drg regimen, pharacists provide al patients receiving a new 
drg with information on the name of the drg, its purpose, strength of dosage, how it 
should be taken and potential interactions and side effects. Capitol's computer system 
is able to print these instrctions on hard copy, which is given to patients with each 
new prescription. Follow-up counseling is provided by the pharacist whenever a 
patient requests it and in cases when the pharacist feels the patient or drug warant  close monitoring. Dr. Juni believes that, ideally, patients should be counseled by a 
pharacist each time a drug is dispensed. 
Physician Consultation 
Beyond occasions when physicians phone pharacists to order a prescription , the most 
frequent contact with physicians occurs when a Capitol pharacist calls a physician 
with a question or concern about a paricular prescription. Dr. Juni places a strong 
emphasis on the importance of cultivating successful collaborative relationships with 
the physicians who treat his patients and reports that, in most cases, physicians are 
open to questions or suggestions he raises. On some occasions, physicians call Dr. 
Juni before prescrbing to seek his advice on a parcular drg. As mentioned 
previously, Capitol is located adjacent to a family practice office and, in cases when 
common patients are being treated, the physician and pharacist have an opportunity 
to consult with one another in person. In managing the clinical staff at Capitol, Dr. 
Juni also emphasizes the importance of pharacists keeping abreast of the most 
drg 
current scientific information on  therapy; he believes that physicians ' knowledge 
of such expertise among his staff encourages them to use pharacists in an advisory 
capacity. 
EDUCATIONAL AND ASSOCIATION ACTIVITIES 
Dr. J uni is the immediate past president of the Minnesota State Pharaceutical Association 
and is a member of the American Pharaceutical Association. In his capacity as offcer of the 
State Association, Dr. Juni spearheaded a number of community education efforts geared to 
increasing patient demand for clinical pharacy services. He is a strong proponent of 
educating patients about the benefits and risks of drug therapy and encouraging them to seek 
consultation services from their pharacists. 
His long association with the University of Minnesota has enabled Capitol to serve as a site 
for internships, externships and residencies. Dr. Juni believes that this constat stram of 
students has been highly beneficial for Capitol's clinical sta; students brig new questions 
and perspectives with them that encourage the clinical sta to continually improve their own 
skils and knowledge.  --_u._-
CASE STUDY No. 
Linda Garrelts and Jones Pharmacy 
GENERAL BACKGROUND 
Jones Pharacy is located in Spokane, WA. It is a full-scale drgstore, with a walk-
pharmacy and a large shopping area that includes both over-the-counter (OTC) drugs and 
numerous non-pharacy items, located in the same building. The pharacy and 
non-pharacy sections of the business are not separated by a wall or by any other structure. 
However, the two pars of the business are managed separately. 
The client base is of mixed social and economic status. Approximately 25 percent of 
prescriptions are Medicaid-reimbursed, and the percentage is growing. Another 10 percent are 
paid for by private third party insurers; most of these prescriptions are for nursing home 
patients. The remaining 65 percent of prescriptions are paid for in cash. Jones Pharacy 
competes with approximately ten other pharacies within a one- ile radius. 
The pharacy has three main components: the walk-in pharacy for ambulatOry patients; 
nursing home drug provider and consultant; and durable medical supply sales, which are 
usually made to home-bound patients. In addition, Jones Pharacy serves as the provider to 
the county jail. The pharacy fills approximately 900 prescrptions per week: approximately 
75 percent of these prescriptions are for wal-in patients, and 17 percent are for nursing home 
patients. The pharacy provides drgs for 105 nursing home beds. Additionally, Jones also 
provides cholesterol screening tests on a regular basis for ambulatory patients. 
Jones Pharacy has a branch pharacy 30 miles away in Deer Park, a smaler, more rural 
community. The Deer Park pharacy fills prescriptions alost exclusively for walk-
patients. 
PHARMACIST' S BACKGROUND 
The pharacy is managed by Linda Garelts. She graduated from the Washington State 
University College of Pharacy in 1978, imd immediately went to work at Jones Pharacy. 
Soon thereafter she became a parner in the business. For the last ten year, she has 
increasingly emphasized clinical services in her pharacy. .  has been continually 
She  also
involved in national and local pharacy and health car organizations, including the Red 
Cross, but especially the American Pharaceutical Association (APhA). She lectures and 
organizes community education sessions for these groups, and is a past president of APhA' 
practice management section. Through these activities, Garelts has established a nationwide 
reputation in the pharacy community as a practitioner and exponent of clinical pharacy in 
the community setting.  STAFF 
The pharacy staff.includes four full-time pharacists working at the main store, and one 
full-time pharacist and one half-time pharacist working at the other store. In addition, one 
Class A" pharacy technician works full-time at the main store. A Class A technician has 
gone through a training program accredited by the Washington State Board of Pharacy, and 
has passed tests devised by the Board of Pharacy. She can fill prescriptions and take orders 
for prescriptions over the phone. Jones  serves as an internship site for
Pharacy  also 
Washington State University College of Pharacy. 
PHYSICAL SETTING 
There is no space maintained especially for communication betWeen the pharacist and the 
pharacy 
. patient. This communication occurs at the single window in the  section of the 
facility. According to Garlts, this arangement generally allow  enough privacy for the 
patient to convey whatever information she/he nees to; in her view, the proper atttude on the 
pharacist s par wil make the patient feel comfortable discussing her/his drg therapy 
such a conventional physical setting. 
CLINICAL ACTIVITIES

Data Collected 
When a new patient first has a prescription filled at Jones Pharacy, the pharacist 
obtains some basic information concerning the patient s drg regimen that wil form 
the basis of a patient profile, to be used as a guide for appropriate drg therapy in the 
future. Washington State law requirs the pharacist to collect such information on all 
patients. 
Jones Pharacy asks patients for the names of all prescription drgs taken currently 
and in the past, and for the patient s allergies. (Jones Pharacy typically does not keep 
information on OTC drg use on fie.) This data is not kept on paper; the pharacist 
simply receives the information orally from the patient and types it imediately into 
the pharacy s computer system. 
Unavailable Patient Data 
Garelts said that diagnostic information and data from lab tests concerning patients 
would be useful for her performance of clinical pharacy services. This data would 
enable her to do more thorough drg utilization review (DUR) at the time a drg is 
dispensed, allowing her to identify more potential ADRs and other pO!ential problems.  None of this data is currently available to her for her ambulatOry patients, or to.. 
community pharacists in general. 
perfortng 
Consultant pharacists typically have this data available to them when 
DUR for nursing homes. Garelts acts as a consultant pharacist for some nursing 
homes, and in that capacity, diagnostic and lab information are available to her. In that 
setting, she said that her increased access to data enables her to do a more thorough 
DUR. 
Garelts said that pharacists could perform some of the standard lab tests themselves 
through a fingerstick procedure, and could thus obtan some of the lab data. However 
she said, any attempt to empower pharacists to perform such tests would likely 
encounter strong opposition from physicians. 
DUR/Patient Counseling

Garelts reviews a patient s drg profile in order to consider the appropriateness of 
her/his prescribed drg therapy before the drg has been dispensed. She looks for 
one condition; this is 
duplicate prescriptions (more than one drug prescribed to trat 
the most common problem she discovers), potential drg interactions, and 
inappropriate dosages. If she discovers any of these problems, she contacts the 
prescriber immediately. Aside from those times when new prescriptions ar presented 
individualize DUR only when she observes a negative reaction 
Garlts wil conduct 
of some kind in the patient to her/his 9rg therapy. 
Jones Pharacy wil soon have a new computer system instaled that wil facilitate 
DUR by displaying a patient's last several prescriptions on the screen automatically, 
when the patient s name is entered. The attendig pharacist will not need to access 
this information separately. 
Pharacists at Jones Pharacy do most of their counseling of patients at the initial 
point of sale (POS), that is, for new prescrptions rather than for refills. The amount of 
counseling that a patient receives vares considerably. Patients who are receiving 
maintenance drgs receive less counseling than those who are being treated for acute 
conditions. 
Information typically given to patients includes: the name of the drg they are 
receiving; the strength of the prescribed dosage; how to take the drg (method of 
intake, when to take it, with or without food); and potential interactions and side 
effects of the drug.  Physician Consultation 
The initial contact between the pharacist and the prescriber, in the case of a given 
patient, usually is made by the prescriber. She/he does this when she/he phones the 
prescription in to the pharacist, which is most often the case with new prescriptions 
at Jones Pharacy; this is done for the patient s convenience. At this time, the 
pharacist has the opportunity to ask the physician questions concerning the patient 
condition and therapy, and also to give the physician relevant information concerning 
the patient s clinical history, if the patient has been a patron of the pharacy in the 
past. Physicians wil occasionally consult with the pharacist prior to prescribing a 
new drg for a patient. In these cases the physician may wish to consult with the 
pharacist concerning allergic reactions or other kinds of ADRs that the patient has 
experienced in the past, and may wish to seek the pharacist's opinion concerning the 
most appropriate drug therapy for the patient. In these cases, though they are 
infrequent, the physician displays great confidence in the pharacist s clinical 
expertse, and in the closeness of the pharacist s relationships with her/his patients. 
The pharacist at Jones Pharacy usually wil contact the physician in order to 
This can be a delicate matter, and 
discuss the appropriateness of a prescrption. 
requires the pharacist to exercise a great deal of judgment concerning the physician 
personality. Garelts said that she is famiar with most of her patients ' physicians, and 
tang 
she knows which physicians wil be amenable to  advice from a pharacist and 
which ones wil not be. She wil not contact those who seem to guard their 
professional functions, such as prescrbing, jealously. Most, however, are cooperative 
and wil discuss prescriptions seriously with her, she said, and are wiling to change 
their prescriptions on her advice. The most frequent reason for Garelts to contact a 
physician is that she recognizes an ADR in a patient. Patients who are reacting 
negatively to their medications often seek advice from her, rather than from the 
prescriber. Additionally, she may call the physician because she notices a potential 
ADR, from her reyiew of the patient s profie, before filling the prescrption. A 
call a physician
situation such as this usually arses about once a day. Garelts may 
 also 
concerning the appropriateness of a prescription with the respect to the cost of the 
drg. Some prescription drugs are prohibitively priced, for many patients, and some 
of these drgs have much lower-priced alternatives. However, Garelts usually does 
this only for patients who pay the full cash retail price of a drug, and not for those who 
are covered by a third pary insurer, and who therefore pay the same copayment for 
every drg.

Significantly, Garelts can change a prescription or a dosage level without consulting 
the physician , in some cases. Under Washington State law, a pharacist can establish 
prescriptive authority" with an individual prescriber. The pharacist and the 
physician together develop a protocol for the pharacist to follow, with clear 
parameters for her/his power to change prescriptions. Within those parameters, the 
pharacist may alter the prescriptions of the given prescriber s patients, as she/he sees 
fit. Clearly, this possibility indicates the confidence that State law places in the ability  of pharacists to conduct clinical analysis and to arve at prognoses, and the 
existence of such an arangement indicates similar confidence on the part of the 
prescriber involved. 
In order to gain a physician s perspective on pharacist-patient interaction , we talked 
with a Spokane physician who practices in the community setting, who is well 
acquainted with Jones Pharacy, and who is active in the local medical society. He 
said that pharacists most often initiate this interaction, usually to clarfy a 
prescription or to suggest a change in prescription. Pharacists usually contact 
physicians concerning clinical issues surrounding prescriptions, he said, but 
occasionally they call with respect to the cost of a prescribed drug. 
This physician also told us that physicians sometimes initiate communication with 
pharacists. In these cases, he said, physicians ar often seeking information 
concerning a new drg that they may not receive from drg companies' saJespersons, 
such as potential side effects and cost of the drg. In these cases, physicians clearly 
display respect for the pharacological expertse of pharacists. 
However, this physician said, physicians more often are unaware of the level of 
by pharacists-usualy far more 
pharacological trning and knowledge possessed 
than a physician possesses. He felt that this situation could be aleviated through 
educati.on of physicians concerning pharacists ' trning, and he felt that local medical 
societies and pharacy societies were well situated to perform this education. In fact 
at the time we spoke with him, he sat on a County Committee for 
Pharacist-Physician Communication. 
EDUCATIONAL AND ASSOCIATION ACTIVITIES 
drg 
Garelts is unusually active in group-oriented education around  issues, both with patients 
in the surrounding community and with other health professionals. As noted above, she is a 
former president of the APhA practice management section, and she stil gives speeches for 
APhA to other pharacists on how to manage a pharacy. 
She paricipates in community education primarly through the use of three programs 
developed by APhA, in association with Lederle Laboratories. These programs, designed to 
improve patient understanding of and compliance with drg therapy, are entitled "National 
Medication Awareness Test," "Self-Awareness Test," and "Managing Medication Wisely. 
These presentations combine cassettes, slides and oral presentation. They feature quizzes on 
the topics discussed, with individual answer sheets for all those attending, which are 
eventually graded.

Garelts is involved with the local Red Cross, with the local OstOmy Board , and with the local 
Diabetes Board, on which she currently sits. She helps to get speakers for these organizations.  Her invoJvement with these organizations has helped her to become known to other health 
professionals, and to become respected by them as a health professional herself. 
ECONOMIC ISSUES 
Like most community pharacies, Jones Pharacy is not reimbursed directly for the clinical 
services the staff provide to their patients, such as patient counseling. The cost of providing 
these services-most of which is entailed in the time that must be taken to perform 
them-must be added to the pharacy s drug prices. Jones staff must rely on the quality of 
these services to maintain the loyalty of their patients, in the face of the intense price 
competition Jones faces from nearby independent, chain and deep-discount pharacies. Jones 
Pharacy has managed to stay afloat financially, despite this competition; but its profit margin 
is far from comfortable, reflecting the diffculties encountered by even exemplar pharacists 
in the community setting who make a concerted effort to provide clinical services to their 
patients. 
HOME HEALTH CARE 
Jones Pharacy is involved with home health care through its sale and leasing of durable 
medical equipment. The clientele for this equipment ar mostly recent dischargees from 
hospitals, and the equipment is mostly of the kind one would fmd in hospitals or nursing 
homes: wheelchais, leg supports, hospital beds, trapeze bars, siderals, and seatlift chairs, for 
example. Most of Jones s home health patients are geriatrc. Jones has alost 1 000 home 
health patients. 
Patients hear of Jones s medical equipment services mostly through referrs by physicians 
and discharge personnel in hospitals. Jones Pharacy employs one staf member to work on 
home health care full-time, and he details hospitals, infortng them of Jones s home health 
services. The  runs monthly advertisements concerning their equipment sales
pharacy  also 
on local cable television. The pharacy s management thought TV ads would be an effective 
way of reaching the potential clientele for this equipment, since many of them are 
home-bound; they report that the ads have brought in a noticeable amount of new business. In 
addition, the pharacy s home health supervisor currntly plans to go to local retirement 
communities to give talks on the services he provides. 
He interacts both with patients and with their caregivers, giving instrction to both in the 
proper means of using the medical equipment, though he is neither a pharacist nor a nurse. 
He also makes follow-up visits to patients ' homes to make sure that the equipment is being 
used properly. If patients have questions about the equipment, they can call him directly.  Virtually none of Jones Pharacy s home health patients have the n:sources to pay for this 
equipment themselves. Approximately 70 percent receive some assistance from Medicare in 
paying for the equipment, and approximately 30 percent receive assistance from Medicaid. 
However, Jones s home health supervisor told us that Medicare reimbursement for home 
health equipment is quite incomplete and seems arbitrar. For example, Medicare covers

equipment used to treat renal conditions, but does not cover equipment used to treat liver 
ailments; and Medicare does nO! cover bathroom items, which form an essential part of home 
health care. Overall , it does not seem that Medicare has yet recognized home health care as a 
distinct sectOr of health care, and has not yet developed any systematic method of reimbursing 
home health care costs. Thus, reimbursement gained for these costs is generally incomplete 
and piecemeal.  CASE STUDY No. 
Nancy Culberson and Lexington Family Practice Pharmacy 
GENERAL BACKGROUND 
Nancy Culberson is the owner and chief pharacist of Lexington Family Practice Pharmacy, 
in Lexington, South Carolina. This is an independent, walk-in community pharacy that 
located in the same building with five physicians ' offces , which make up Lexington Family 
Practice. All of the physicians ' patients who receive prescriptions receive drug counseling at 
this pharacy, but they have the choice of having these prescriptions filled there or elsewhere. 
The pharacy and the family practice are, however, separte businesses with entirely separate 
finances. 
Lexington is a suburban/exurban area, about ten miles outside Columbia. Ms. Culberson 
pharmacy competes with six other pharacies within a three-mile radius, two of which are 
chain pharacies. Despite this competition, the pharacy does a healthy business: 
approximately 18,000 families are on file as patients; the pharacy sees approximately 120 
patiems per day, and fills betWeen 140 and 200 prescrptions a day. Approximately 80 percent 
of those patients who come to the pharacy from the physicians ' offces have their 
prescriptions filled there. 
Since it was founded, Lexington Famly Practice Pharacy has emphasized clinical services. 
Robert Davis, the pharacy s founder, had gone through school with the physicians who 
stared the family practice. They all worked together as residents in the Medical University of 
South Carolina (MUSC) teaching hospita, as a clinical team. This experience inspired them 
to set up their practices together, so that they could replicate some of the collaboration 
between physicians and pharacists that appears in hospitas more often than in a 
non-institutionalized setting. This kind of collaboration is a basic component of clinical 
pharacy practice; thus the atmosphere at Lexington Family Prctice was probably conducive 
to clinical pharacy practice when Ms. Culberson arved there. 
PHARMACIST'S BACKGROUND 
Ms. Culberson received her B. S. in Pharacy from MUSC in 1976. After completing a 
3-month unpaid internship at Lexington Family Pharacy, she was hired as a full-time staff 
pharacist. She has been at the pharacy since, and bought the pharacy three year ago 
when the pharacy s founder, Robert Davis, left the practice to pursue other interests. She 
and the physicians in the family practice have recently purchased and moved into a new 
bigger building for their practices. 
Ms. Culberson told us that she received little training in clinical pharacy in school. She got 
such training on the job. She had a family member who was a community pharacist when  she was growing up; perhaps it was this exposure that left her with the idea that, as she told 
, emphasizing clinical services is simply the way that pharacy should be practiced. 
STAFF 
Ms. Culberson herself is the only full-time pharacist on staff; in addition, two par-time 
pharacists and two full-time pharacy technicians are employed in the pharacy. (Under 
South. Carolina State law, technicians can dispense drugs under the supervision of a 
pharacist, and a ratio of one technician: one pharacist must be rnaintained. 
LexingtOn Family Practice serves as an extern ship site for MUSC and typically has two 
pharmacy students on staff at one time. In addition, Lexington is a placement site for students 
enrolled in a local college pharacy technician program. 
There are four physicians practicing in the building, with plans for two more; and one nurse 
practitioner practices there as well.

PHYSICAL SETTING 
The pharacy seems designed to convey the sense of a health professional' s offices, similar to 
a physician s offces in many ways. A waiting area, with chairs and reading material , is 
located in front of the broad pharacy counter (this waiting ara is centrally located among 
the physicians' offices and the pharacy). 
The pharacy is technically an apothecar: nothing besides drgs is for sale. There is not 
drg 
even an open over-the-counter (OTC)  section; a smal OTC section is located behind the 
pharacy counter, and a pharacist wil sell the patient something from this section if it is 
recommended by a physician, or if the patient asks for it. 
Two private counseling rooms are located on either side of the dispensing area. The 
these rooms to counsel a patient if privacy is desired, or to meet 
pharacist wil use one of 
drg 
with a physician or  detailer. 
A drve-through window is a new feature of the recently constructed Lexington Family 
Practice building. A patient can call ahead for a prescription-usually a refill-and pick it up 
here. One of the two computer terminals in the pharacy is located next to this window, so 
that the pharacist can call up the patient s computer profile and screen for potential problems 
during a drve-through pick-up.  .,-_.._  .--
CLINICAL ACTIVITIES

Data Gathered 
The pharacy generally has extremely complete data on patients, because of the easy 
information flow from the physicians' offices. When a patient comes to the pharmacy 
from one of the physician s offices, the pharacist gets the physician s file on the 
patient. (The carer of the file vares. ) This fie, on paper, contains: allergies; 
medical history; drug history; vital signs; a list of the patient s chief complaints; 
test results; and insurance 
report of physical examinations; diagnoses; basic lab 
s offce generally goes back only to 
information. This information from the physician 
the point when the patient first visited that physician. 
The patient also brings an "encounter form" with her or him to the pharacy, from the 
physician s offce. This is a sort of "superbil " tellng the pharacist what treatment 
the patient has received, and for what condition, and also allowing for easy tabulation 
of the costs of a patient s visits to all the health care professionals she or he sees in one 
a special pharacy section containing the most 
trp. This encounter form also includes 
important few pieces of information for the pharacist, concerning the patient 
current physician s visit: namely, the drgs prescribed and the reasons why: 
When a new patient comes to the pharacy, if the physician s file is far less extensive 
than those of old patients, the pharacist wil ask the patient for some basic 
allergies and past adverse drg reactions. 
drg-related information, such as 
DUR/Patient Counselirig 
The pharacy s computer system accommodates basic information on patients such 
as: name of physician; drg history, including refill dictions and dosage information 
on current prescriptions; insurance information; and alergies. (Allergy information 
s fie 
generally is not kept on the computer files, since it is included in the physician 
on the patient, which is reviewed when a new prescrption is made, and which can be 
consulted readily at other times when needed.) This information is reviewed whenever 
a prescription is filled, and each new prescrption or refill that is dispensed is entered. 
When a patient receives a new prescription , the pharacist gives the patient 
information including: the name of the drug; the purpose of the prescription; dosage 
information, including the exact meaning and the importance of following these 
instrctions; the length of the fill; how to coordinate the drug therapy with eating 
habits and what foods to avoid; exactly when and how to tae the drg; how to store 
the drug; the potential side effects of the drg, and how to spot them; and when the 
patient can expect relief. The  gives the patient information on how the 
pharacist  also 
prescription can be refilled. Lexington Family Prctice Pharacy provides a two-page 
summar of its services to patients (attached) that informs the patient that when  receiving medication-from anyone-she or he should receive all the information 
listed here. 
More extensive counseling sessions are deemed necessar by the pharacist if the 
drug therapy prescribed is especially complex , if it cares unusual potential dangers 
or if the patient requires special attention. In these cases, such a consultation wil take 
place, either over the pharacy counter or in one of the private counseling rooms, 
revolving around the issues enumerated above, and involving more extensive 
questions and answers between the pharacist and the patient than is usual. Such a 
consultation will usually last between five and ten minutes. There is an additional 
charge for this consultation, which vares with the time spent by the pharacist. 
Economic Issues
(Sometimes this charge is waived; for more on this fee, see the 

section , below. 
A great deal of written material is available to patients at the pharacy, in addition to 
all the verbal information. Culberson maintains a libra of pamphlets and leaflets 
from pharaceutical companies, the United States Pharacopoeial Convention CUSP), 
and other health organizations, on specific drgs and on different health conditions or 
risks. In addition, she prepares her own pamphlets on certn parcularly serious 
drgs, such as coumadin, and prednisone, that ar not available from any outside 
source. She regularly gives this information to patients, though not every patient 
receives this kind of wrtten information. 
When patients come in for refills, they receive basic counseling. The pharacist asks 
the patient whether any problems have arsen since starng the drg treatment. If the 
pharacist can detect no problems, the refill is dispensed and the transaction is 
recorded on the patient s computer fie. 
Phy  Consultation 
ician
The ease and extent of physician-pharacist interaction in Lexington Famly Practice 
Pharacy is perhaps, more than anything else, what sets this pharacy apar from 
most community pharacies. Almost all of the pharacy s patients are referred there 
by the physicians on the premises. With the co-location of the pharacy and the 
medical practices, the inter-professional collaboration usually confined to an 
institutionalized setting can be, to a great extent, replicated. We have aleady seen 
how this arangement provides for ease and completeness of information flow from the 
physicians to the pharacist. Occasionally a physician in the practice wil contact 
Culberson prior to prescribing, to ask her about a patient s past reactions to drgs, or to 
ask about a drg s effects generally. Usually, however, discussion between Culberson 
and the physicians in the practice occurs after the physician has prescribed a drg. The 
procedures for such discussion seem very informal and flexible: discussion can occur 
either after a patient has left the premises, or while the patient is stil there, if the  pharacist thinks this is necessar; the physicians and pharacists do not schedule 
regular patient care conferences. 
In addition to discussing patients , the pharacists and physicians are able to discuss 
other matters, such as the merits of new drgs being detailed or of various health 
insurance plans, very easily in this setting. Drug detailers usually meet with Culberson 
and with the physicians on the same visit, although not with all of them at the same 
time. 
Under South Carolina law, a pharacist may not substitute one drug for another that a 
physician has prescribed, at all, and may not change the dosage of a prescription 
without the express permission of the physician. However, the proximity of 
Culberson s pharacy to most of the prescribers with whom she deals, and the 
collegiality that has developed between her and these physicians, keep this legal 
restrction from functioning as a very substantial barer to substitution. The 
physicians at the practice with whom we spoke told us that they generally allow the 
substitutions that Culberson suggests. Generic substitution for a brand-name 
prescription does not occur very frequently, simply because the physicians 
tr to 
prescribe generics in the first place whenever they can. 
EDUCATIONAL AND ASSOCIATION ACTIVITIES 
Ms. Culberson ia a member of the APhA, the National Association of Retail Druggists , the 
South Carolina Pharacy Association and the Local 5th Distrct Pharacy Association. She 
has been a speaker at national pharacy association conferences and is an instructor in clinical 
pharacy at MUSe. Ms  serves on the Pharacy and Therapeutics Committee 
Culberson  also
of a local health maintenance organization. 
ECONOMIC ISSUES 
Only 30% of the pharacy s patients are covered by third-pary insurers, and approximately 
70% are cash patients. Approximately 5 percent of patients are Medicaid patients, and 15 
, many of whom receive Medicare benefits. 
percent are geriatrc patients
Culberson charges a fee for some of her patient counseling services, in addition to the price of 
the drug. She does this rather than add the cost of the time she spends counseling patients 
drg 
onto the  charges. The fee vares, from $1 to $5, according to the time spent in 
consultation. She charges this fee only if unusually extensive counseling is required. This fee 
is not reimbursed by any third-pary insurers. For this reason, Culberson sometimes waives 
the fee; she is more likely to do so if the patient has the prescription filled at her pharacy.  . ..-
The pharacy requests that cash patients pay for the drugs and services they receive at the 
rime service is rendered. Insurance cards are presented to the pharacist before the 
prescription is filled.  CASE STUDY No. 
iI/lee Alexander alld Lifesource, Inc. 
GENERAL BACKGROUND 
Lifesource is a home infusion pharacy in Larkspur, CA, just north of San Francisco. It 
prepares medications for use by home-bound patients; almost all of these medications are IV 
preparations. Lifesource delivers all its products to its patients; this service, Lifesource 
personnel told us , -is drven by patient demand. It is a licensed retail pharacy, but it has no 
walk-in facilities. 
PHARMACIST'S BACKGROUND 
Julee Alexander is the manager of Lifesource s main offce (it has two other, smaller 
branches). She graduated from the University of California at San Francisco (UCSF) College 
of Pharacy in 1981. UCSF was an early center of the clinical pharacy movement: 
1966, the "ninth floor project" at the university s hospital brought pharacists and physicians 
together in clinical care teams, and helped launch the hospital pharacy movement that 
spread throughout colleges of pharacy in the early 1970s. A grduate from the UCSF 
College of Pharacy would likely be trained to emphasize the clinical aspects of pharacy 
practice, and this education would, in par, explain Alexander s emphasis on clinical pharacy 
in her own practice. She worked in hospital pharacy for two to three years after graduating 
from school. Then she left hospital pharacy to work for a different home infusion pharacy 
for five years, before coming to Lifesource. 
CLIENT BASE 
This branch of Lifesource (which wil be the subject of this case study) has approximately 100 
patients at anyone time. Approximately one-third of these patients are geriatrc. 
Approximately 50 percent of Lifesource s patients are AIDS patients. This preponderance of 
AIDS patients is not, Alexander said, typical of home infusion pharacies. However, it is not 
so untypical for such pharacies to specialize somehow in the kind of patient condition they 
treat, in response to the competitiveness of the market. 
treats some children , delivering neonatal care to patients at Oakand 
Lifesource  also 
Children s Hospital. 
A key to Lifesource s viability is the general affuence of its clientele. The treatment they 
furnish is costly, and often is protracted, since many of the patients treated are tertnally ill. 
Medicare and Medicaid provide little reimbursement for the products and services involved in  home infu stoynl'erny (see below), and provide scant coverage for long-term care. This 
means that reimbursement must come either from private third pary insurers-who are 
providing a growing share of Lifesource s revenues--r from the private resources of the 
patients. Lifesource screens prospective patients before agreeing to treat them, to determine 
whether reimbursement wil be available through some means. Without this screening 
process, under the present public health system, it seems unlikely that a home infusion 
pharacy like Lifesource could remain economically viable. 
STAFF 
This offce has four full-time pharacists on staff, one on three-fifths time, and all five are on 
, two supervisory pharacists are on staf. Lifesource also employs one 
call. In addition
dtieteicianc , oneh full-ntime wiarchousie waorkenr, thrsee p.ar -time drvers, and one full-time 
pharacy
accountant who handles biling and reimbursement. Lifesource employs no 
Lifesource coordinates the overall health car of its patients, and this includes aranging for 
nursing services. Unlike some other home infusion pharacies, Lifesource does not have 
staff nurses. Healthsource is the name of the nursing agency that contrcts with Lifesource to 
perform most of the direct care of those patients who reuire in-home supervision. Lifesource 
originally owned Healthsource, but the two businesses separated when that arangement 
became unprofitable. Still, however, Lifesource brings its nursing. business to Healthsource 
before any other nursing agency. Thus the relationships and the communication between the 
nurses at Healthsource and the pharacists at Lifesource are well-established. 
BASIC SERVICES 
Lifesource provides some special services that are wort discussing at some length , in order to 
explain the kind of pharacy Lifesource is: 
(1)  Conferences:
Patient  Care 
including all the 
Each Friday morning, most of the Lifesource staf-
pharacists-gather to discuss the treatments of all current patients. Everyone present 
at the meeting has a patient char, contaning lists of every patient s name, address, 
physician, prescribed therapy, and insurer. Dennis Honda, a pharacist who 
coordinates all of Lifesource s operations, facilitates the seminar-type discussion. The 
staff discusses the prescribed therapies, the attending physicians, and the 
reimbursement schemes of all patients. The pharacist who is handling each case 
gives an update on the patient s progress, and suggestions are made concerning 
treatment.  (2)  Nutritionist Services: 
Lifesource employs a fuIJ-time dietician who services most, but not all , of the 
business s clients. She analyzes their diets, their medical conditions and their 
prescribed drg therapies; then she makes recommendations concerning the diets that 
in her judgment, would best facilitate the distrbution and effectiveness of the 
medications the patients are taking. These recommendations usually do not take the 
dieta 
form of a strct dietar regimen, but rather, broad  guidelines. This dietician 
emphasizes personal contact with the patients she trats. She goes to many patients 
homes, in order to develop a better idea of their dietar needs than she would 
otherwise possess, and in order to develop a general rapport with them. She also 
performs follow-up monitoring after making dietar recommendations, to check the 
compliance of patients with these recommendations, and to check their effectiveness. 
Some patients are not able to ingest food orally, so they are placed on a therapy known 
as Total Parenteral Nutrtion (TPN). This therapy involves the intravenous ingestion 
of all necessar nutrents. The staff dietician monitors patients on TPN, checking their 
progrss weekly. If their health progrsses far enough , she and the rest of the 
Lifesource staf tr to replace the TPN with oral ingestion. 
(3)  Enteral Therapy: 
Enteral therapy is instrmantal administered by Lifesource to about 75 nursing home 
patients distrbuted throughout 20 different Skiled Nursing Facilities (SNFs). This 
therapy requires a wide range of paraphernalia and equipment used to administer these 
solutions. This sector of Lifesource s business is kept separate from the home health 
sector, to which a much grater share of the business s resources ar devoted. 
CLINICAL ACTIVITIES 
(a)  Data gathered 
Lifesource has extensive information on all its patients. Virtally no clinical data 
missing from its patient profies and chars. This indicates the attentive and close 
nature of the relationship between Lifesource and its clients, as well as Lifesource 
close professional collaboration with the physicians who treat these patients. 
Lifesource s clinical data base on its patients includes: medication history (OTC as 
well as prescription), including dates, dosages, duration of therapy, purpose of 
treatments, and potential adverse reactions to each drg; history of smoking and 
alcohol intake; allergies; data from laboratory tests; general medical history; and 
summar of most recent hospitalization. Clinical information specifically concerning  the present treatment includes: age, weight and neigfii; diagn6sis;,yp-e of therapy; 
whether the patient is receiving IV treatment; whether the patient is diabetic; whether 
the attending physician has given standard anaphylaxis orders; duration of current 
therapy; and whether patient has taken the first dose of medication without incident. 
Not only is Lifesource s background information on its patients very complete, given 
the close attention Lifesource gives to patients, and given the closed environment of 
these patients, it is highly unlikely that any new clinical information will escape the 
pharacists. In this respect, a home infusion pharacy like Lifesource is similar to a 
hospital or nursing home pharacy. 
DUR/Patient Counseling

Lifesource performs prospective DUR for all its patients. The pharacists there 
examine patients ' basic clinical data, in order to detertne the appropriateness of a 
drug therapy that has been tentatively prescribed. They look for potential side effects 
drug interactions and drg-allergy interactions. As noted above, the data base at 
Lifesource is very extensive, including information on OTC drgs and home remedies. 
Most contact between Lifesource pharacists and patients occurs over the phone. 
This occurs when pharacists call patients to check their compliance and their general 
condition-which they do on a regular basis-and when patients call their attending 
pharacists with questions or problems. 
A fair amount of face-tO-face contact is, nonetheless , an integral part of any patient 
treatment. The attending pharacist makes the initial visit to a patient s home, with a 
nurse. Sometimes, but not always, the pharacist shows the patient how to use the 
medical equipment necessar for the patient s treatment. 
Perhaps the most distinctive aspect of patient-pharacist interaction at Lifesource is 
the frequency and quality of the follow-up contact. Pharacists check on patients at 
least once a week if they are on infusion therapy, and in some cases more than once a 
week. The individualized care plans that the Lifesource staf plan and coordinate for 
. patients are executed with individualized attention. 
As a result, Alexander told us, the relationship between pharacists and their patients 
are generally very positive, despite the emotionally depressed state in which many 
home-bound patients find themselves. The staf at Lifesource ar generally very 
young, and are imbued with the communications training that has been emphasized in 
pharacy school in recent years; furthermore, most of the staf pharacists were 
trained at UCSF, which, as noted above, is a center of clinical pharacy training. 
Staff, including drvers, are given further communications training on the job, through  minicourses" designed to increase sensitivity to the needs and circumstances-of 
patients; these minicourses focus parcularly on AIDS patients. 
Physician Consultation 
The professional relations between Lifesource pharacists and most of the physicians 
attending Lifesource s patients are quite close, and long-standing. The character of 
Lifesource s client population is, in fact, shaped to a 
grat extent by these professional 
relationships. Several of the physicians with which the pharacy has close relations 
specialize in AIDS patients, for example, and many patients come to Lifesource 
through referrals from physicians. 
The Lifesource pharacist is the coordinator for a patient s overall treatment. The 
pharacist may be able to give more individualized attention to the patient than a 
physician can. In any case, the pharacist heads the clinical team that cares for the 
patient. 
One issue that has become controversial in California is that of physician ownership of 
pharacies. Under state law, physicians may oWn only less than 10 percent of a 
pharacy. 
Lifesource personnel told us that physicians someties, through holding 
companies, own more than this 10 percent limit. No physician has any financial 
interest in Lifesource. 
ECONOMIC ISSUES 
Third-pary reimbursement for Lifesource s services and products comes mainly from private 
insurers, whether HMOs or other entities. Medi-Cal (the California Medicaid agency) 
. provides some coverage for less than 25 percent of Lifesource s clients (Medi-Cal does not 
cover AIDS treatment). Third-pary insurers do not reimburse the cost of the clinical services 
that Lifesource provides. Most of the costs of these services must be added to the price of the 
products provided. 
Medicare pays a small shar of the cost of therapy known as "pain management " usually 
given to terminal patients: Medicar pays for the pump used in IV treatment in these cases, 
and for a smal porton of the morphine  management is becoming increasingly 
reuired. Pain 
expensive, and may soon become costly beyond any available means of payment. 
Another economic issue that looms large in Lifesource s sights is drug pricing. Hospitals, and 
sometimes other pharacies, may buy drgs at preferential prices from drg manufacturers, if 
this brings enough business to the manufacturer. Lifesource s owners have just helped 
organize their own "buying group" of pharacies (the Parnteral Alimentation Providers  Association) that wil negotiate collectively with the manufacturers, Lifesource hopes, for a 
competitive "contract price. " This, of course, would be a stabilizing factor in the fees that 
Lifesource charges its patients. 
The use of generic drgs reduces Lifesource s costs, as it does for any pharacy. Lifesource 
uses generics whenever possible. Pharacists in California can substitute generics for 
brand-name drugs without the prescriber s express permission. (However, they cannot use 
therapeutic substitutes, or change dosages, without such permission. 
LEGISLATIVE ISSUES 
At least two legislative issues concerning pharacy ar currently under discussion in 
California. One bil pending in the state legislature is a patient counseling requirement for 
pharmacists. California currently has no such legal requirement. 
Another bil would allow much wider use of pharacy technicians than is now perttted. 
Currently, technicians may only work in hospita pharacies. Under the proposed law 
technicians could work in community pharacies in a varety of capacities, so long as a ratio 
of I: 1 : 1, among pharacists, technicians and clerks was maintaned in a given pharacy. 
This is the bil that has engendered the most serious opposition from pharacy groups, though 
pharacy 
onl y some  groups have lobbied against it. The national Association of Retail 
Druggists, for example, has lobbied against it, Lifesource personnel told us. Such a position 
may seem irrational, for the judicious use of technicians could free pharacists to perform the 
clinical services in which technicians are not trained, and that pharacists now often have no 
time to perform. However, Alexander told us, such opposition may make sense to those 
pharacists who in fact do little more than a skiled technician could, and who envision 
themselves doing little more if given the opportunity.  CASE STUDY No. 
Madeline Feinberg a1ld Accredited Surgical Company 
GENERAL BACKGROUND 
Accredited Surgical Company (ASCO) is one of the countr s largest compliance packaging 
providers, as well as nursing home pharacy provider and medical equipment company. The 
nursing home and medical equipment components of ASCO have been in existence since 
1954. The home care component, specializing in the provision of compliance packaging for 
the non-institutionalized patient, has been in existence for only three years; this component is 
the subject of this case study.

ASCO personnel refer to their home care service as "residential care services" or "assisted 
" This seems apt since this component of ASCO does not service patients who 
living services.
are confined to their individual homes. Rather, it services group homes, and domiciliar care 
settings whose residents require supervision and some assistance with the Independent 
Activities of Daily Living (IADLs). Most residents ar able to perform their own Activities of 
Daily Living (ADLs), except perhaps for bathing. In other words, although these residents 
can no longer live independently, they are not and need not be institutionalized. ASCO 
packages and delivers prescribed medications for these patients using its compliance 
packaging system. 
ASCO fills approximately 1 800 prescriptions per month (both prescription and 
nonprescription drgs) in its assisted living component; this amounts to 8-9 percent of its total 
of 40 000 prescriptions per month , or 2 000 per day. In its assisted living component, ASCO 
services approximately 550 beds in 13 homes, the smalest of which contains six beds, and the 
largest of which contains 174 beds. ASCO' s assisted living patients receive an average of 5. 
drugs each.

PHARMACIST'S BACKGROUND 
Madeline Feinberg is the pharacist in charge of ASCO' s assisted living program. She 
received her B. S. from the University of Marland School of Pharacy in 1979, at which time 
she began seven years of work in a small community pharacy located in an affluent suburb 
of Washington D. 
Also in 1979, Professor Peter Lamy, then Chairman of the Pharacy Practice Deparment, U. 
drg 
M. School of Pharacy, approached her with an invitation to help develop a community 
education program for elderly focusing on the appropriate use of medications, self care, and 
wellness issues. This program, initially funded by the Administration on Aging, is now 
entirely funded by pharaceutical industr, notably the Parke-Davis Company. As part of her 
effort in working with elderly and the aging provider network for the past 10 years , Feinberg  has recognized the need to develop packaging.systems for elderly at high risk to medication 
mismanagement. She focused on the assisted living sector, which services the frail elderly, 
and whose providers are medically untrained. 
Feinberg told us she enjoyed the interaction with her patients while working in the community 
pharmacy, but overall felt that more needs to be done for those elderly who are at risk of to 
making serious medication errors. Moreover, she had been asked by several county agencies 
to assist in developing a system to assure appropriate medication administration in group 
homes. 
The alternative care site, or assisted living program, grew out of these efforts. Three years 
ago, Feinberg approached Milton Moskowitz, President of ASCO, with the idea of branching 
into this emerging marketplace. She convinced Moskowitz to hire her to develop such a 
component to the business and has been there ever since. 
STAFF 
ASCO employs more than 100 people in its entire operation. Only a small group, however 
work exclusively in the assisted living component. Feinberg, who heads this section, works 
half-time for ASCO, while continuing her diectorship of the Elder-Health Program at the 
University of Marland School of Pharacy. She has the exclusive use of two full time 
pharacy technicians who fill all the medication orders for the assisted living residents. This 
packaging system is more complicated and intrcate to use when compared to the standad 
nursing home blister card or unit dose systems. It requires special skills and concentration, as 
each card is customized for each patient, and must contain exactly the correct doses in the 
appropriate blister. More important, it requires special communication skills in dealing with 
residential care sta, who are medically unsophisticated, and often need help in sortng out the 
regimen as prescribed by the. physician. Both pharacist and technicians devote a 
considerable portion of time to talking with providers, and in addition, visit the homes for 
in-service education on the system periodically. (See section on compliance packaging under 
" below). 
basic services
PATIENT POPULATION 
As remarked above, the assisted living population, in terms of self-suffciency and need for 
supervision, lies somewhere between the nursing home population and the unassisted 
population living in the community. The most importnt and most uniform characteristic of 
this population is its advanced age. Chronic ilnesses are common among this group, as are 
polymedicine and multiple prescribers. Many, though by no means all, members of this 
population also suffer from mild cognitive impairment. Thus, an easy-to-use method of drug 
self-administration is highly necessar in this setting.  . --- g. " , " 
SERVICES 
sAsrc 
ASCO is an institutional pharacy with no retail services, except for their medical equipment 
store which is located 15 miles from the pharacy. The bulk of the pharacy operation is 
devoted to taing medication orders from nursing homes, and other institutions which they 
service, including jails, intermediate care facilities for the mentally retarded, homes for the 
emotionally impaired, a psychiatrc hospital, and assisted living homes. Drugs are prepared 
for their patients using a varety of systems as noted previous1y, including the compliance 
package. 
(1)  Compliance Packaging System 
The compliance packaging system is one aspect of ASCO' s service. It is intended to 
allow patients to self-administer medications according to a prescribed daily regimen. 
In many of the homes, staff take the responsibility to help the resident with this task 
since most states do not pertt unlicensed personnel to administer medication. The 
compliance packag  facilitates assistance and assures that the untrained staff person 
wil readily identify the correct blister for the patient. 
This package involves a small, hand-held boar with clear plastic bubbles, inside of 
which tablets or capsules are enclosed. Each bubble represents the doses to be taen 
on that day. Each card is labeled with the time of day, e.  morning  evening  , or a 
special time, and contains the month's supply of medicatioI) for that time. The blisters 
on each board come in several sizes to accommodate several pils, as well as to 
accommodate very large pils. The bubbles may be labeled by day of the week, if 
requested by the administrator of the home. The board iUways contains one month' 
supply of medications. As needed medications ar packaged separately, per card, and 
must be reordered when running low. Likewise, eye drops, ointments, liquids and 
other preparations are refilled as needed. But the compliance package contaning the 
month' s supply of medications is automatically refilled each month, thus assuring that 
a medication wil not run out or be forgotten. The medication orders are updated by 
the physicians, and at the time of medication changes, the card may be re-packaged 
and sent to the home within a matter of hours. 
This packaging system facilitates review of the patient s ability to self-medicate by the 
caregiver who may not be giving close supervision to a parcular resident. The 
caregiver need only glance at the card to determine if the medication is being taen 
corrct! y.

Feinberg told us that these systems force pharacists to communicate with their 
patients, or in this case, with their caregivers, i.e., those who manage the group homes. 
It provides an opportunity to tal about the therapeutic use of the drg, its side effects, 
and its proper administration. Feinberg parcularly emphasizes the monitoring  " " " "
ctohmpeone npt ofh they carsegiivcer is dautines, .an d insists that observed changes be reported to
(2)  Patient Education 
Although the pharacists at ASCO do not counsel individual patients as a rule, they 
do conduct in-service staff education in nursing homes and in the assisted living sites 
that they service. Some of the tOpics on which Feinberg speaks are " Depression in the 
Elderly - Medications Used for Treatment,  Psychiatrc Side Effects of Commonly 
Used Medications,  Drug Interactions" and others. ASCO consultant pharacists 
offer talks on Parkinson s Disease , antianxiety drgs, 
dilanti dosing, constipation 
gastrointestinal disease and treatment, AIDS, arhritis, OTC cough and cold remedies 
and other topics on request. 
CLINICAL ACTIVITIES

(1)  Data Collected 
ASCO collects extensive data on its patients, which it can use in perfortng DUR 
car 
since the  sites where these patients ar living have very complete data. ASCO 
collects data concerning prescrption drg use, allergies, diseases and conditions, as 
well as diagnostic data on patients. In addition, ASCO collects complete information 
on OTC drg use. 
(2)  DUR 
ASCO performs prospective DUR when fillng new prescriptions, but only though the 
use of an automated computer program. ASCO' s computers screen for allergic 
reactions and only for the most severe drg interaction. (They are currently in the 
process of acquirng a new computer which wil permit a more comprehensive screen 
for drg/drg interactions. 
ASCO presently does not perform retrospective DUR in its assisted living sites. 
However, Feinberg told us, substantial therapeutic value could be gained through this 
type of DUR; she thinks it would serve to protect a population at risk from potential 
misutilization of prescribed medications. This kind of DUR, unfortunately, is rarely 
reimbursable in this setting. However, some states have considered the need for 
pharacist conducted reviews in domiciliar car, and have mandated this service, for 
example, in North Carolina. Florida recently passed legislation requiring consultant 
pharacy service when the home is inspected and found to be deficient with regard to 
medication management. In therapeutic terms, such a requirement is a step forward.  "---"-'
NATIONAL ISSUES

We discussed the policy context of our study with Feinberg and Moskowitz, and in response 
they offered ideas concerning some national issue aras. 
(1)  Definition of Patient Counseling 
Feinberg and Moskowitz are of the opinion that a wide range of counseling practices 
exist, reflecting great varations in quality of patient care, and that these varations 
should be recognized in government policy. . They questioned whether contact over the 
telephone-which is central to the counseling activities of, for example, mail-service 
pharacies--an provide adequate patient counseling. Furthermore, Feinberg raised 
the issue offollow-up counseling activities, saying that these are crucial to the 
effectiveness of counseling. 
(2)  Demonstration Projects 
Feinberg had some ideas for general topics on which it would be informative for the 
Deparent to fund demonstration projects. One idea was a project involving 
compliance packaging, to determine whether the use of such a drg delivery system 
tends to increase the level of patient counseling and physician consulting that 
pharacists conduct.

pharacy 
. Another suggested project would involve consumer demand for clinical 
services, and possible ways to stimulate such demand. Feinberg believes strongly that 
educated consumers , who demand such services, are more likely than anyone else to 
ensure that such services are provided. Thus detertning how to stimulate consumer 
demand is essential, in her view, to any effective progrm design to stimulate clinical 
pharacy practice.  APPENDIX I 
CASE STUDY METHODOLOGY 
The purpose of conducting the case study was two-fold: 
to observe and document activities that comprise clinical pharacy practice; and 
to identify (in the case of clinical pharmacists who practice in traditional 
community settings) the barers they face in providing pharaceutical care 
their patients and to determine the methods they use to overcome those barers. 
Given that objective, we made a purposive selection of pharacists who were identified by 
members of professional and research organizations as practitioners who provide an unusual1y 
broad range of clinical services to their patients. A number of organizations and individuals 
were helpful to us in identifying a candidate pool, including the American Pharaceutical 
Association, the American Association of Colleges of Pharacy, the University of Florida 
College of Pharacy, and the University of Marland College of Pharacy. We made 
selections from an initial pool of 35 candidates based on telephone interviews during which 
we solicited information about the nature of the pharacist s practice, the population served, 
the pharacist s therapeutic specialty, and her/his wilingness to 
paricipate in the case study. 
Our final selection was based in par on geogrphical diversity; urban, rural and suburban 
practices ar represented. Although we sought candidates who practice in chain, independent 
and apothecar settings , only the latter two are represented. None of the candidates 
nominated practice in chain pharacies. 
The pharacists selected for our study are listed below: 
Julee Alexander 
Lifesource, Inc. 
900 Larkspur Landing Circle, Suite 250 
Larkspur, CA 94939 
Nancy Culberson 
Lexington Famly Practice Pharacy 
O. Box 460
Lexington, SC 29072 
Madeline Feinberg

Accredited Surgical Company 
9515 Gerwig Lane, Suite 131 
Columbia, MD 21046 
1- 1
 Linda Garrelts 
Jones Pharacy 
S. 906 Monroe
Spokane , WA 99204 
Howard Juni 
Capitol Drug Center 
2007 E. County Rd. E 
White Bear Lake, MN 5511 0 
Calvin Knowlron 
Amherst Pharacy 
332 Lumberton Rd.

O. Box 56
Lumberton, NJ 08048 
In each case, we made site visits to observe the pharacist s practice over a 2- to 3-day 
period. In the case of the four pharacists who practice in traditional community settings 
(Knowlton, Juni , Garelts, and Culberson), we conducted extensive interviews with the 
pharacist and other sta on site, physicians who were famliar with the pharacist 
practice, and patients served by the  observed the pharacist in practice
pharacist. We  also 
and reviewed the information systems they use to support clinical activities.