Learning Outcomes

Key Terms

History and Evolution of Community and Ambulatory Care Pharmacy Practice

Practice Sites

Community Pharmacies

Clinic Pharmacies

Managed Care Pharmacies

Mail-Order Pharmacies

Technician Responsibilities in Prescription Processing

Communicating with Patients

Ensuring Patient Privacy

Receiving Prescriptions and Registering Patients

Transferring Prescriptions

History and Evolution of Community and Ambulatory Care Pharmacy Practice

When most people hear the word “pharmacy,” they think of a community or ambulatory care pharmacy. Community pharmacies were the first pharmacies, and although today’s community and ambulatory care pharmacies have significantly evolved from the original “corner drug store,” they still share the common purpose of providing pharmaceuticals and accessible health information in the community setting for ambulatory patients. Ambulatory care pharmacies evolved from community pharmacies. They still meet the needs of outpatients, but are usually located in close proximity to clinics, hospitals, or medical centers. Whereas community pharmacies often sell items not related to pharmacy, ambulatory pharmacies generally provide only prescription services and possibly a limited number of over-the-counter medications.

In the early part of our country’s history, very few medications were manufactured in their final dosage form, as they are today. Pharmaceutical remedies were limited, so pharmacists prepared, or compounded, these remedies, mostly from natural sources and raw chemicals. There were no regulations on drugs and pharmacists were free to prepare and sell almost anything. Physicians would send patients to pharmacists, who would compound remedies based on the patient’s evaluation and diagnosis. Pharmacists would also create remedies based on a patient’s symptoms or requests.

In 1938, the Food, Drug, and Cosmetics Act (FDCA) was passed, which began to loosely regulate drugs, requiring pre-market approval for new drugs based on safety, and prohibiting false therapeutic claims for drugs. The law also allowed for the designation of a drug to be available only by prescription, but lacked specific guidelines and left it mostly up to the manufacturer.¹

In 1951, the Durham-Humphrey Amendment to the Food, Drug, and Cosmetics Act was passed, which more precisely defined the previous guidelines for prescription drugs established in 1938 under the original act. Two categories of drugs were established: legend drugs and over-the-counter (OTC) drugs. Any drug that was determined to be a legend drug, based on safety and potential for addiction, required authorization from a doctor before a pharmacist could prepare and dispense the product. OTC drugs were considered safe enough for patients’ self-administration and could be purchased without a doctor’s authorization. The written or verbal authorization and the dispensed product became known as a prescription.

As the pharmaceutical industry continued to grow and more and more drugs were being manufactured in their final dosage forms, the focus of the pharmacist’s role began to change from making the drug products to repackaging and dispensing them. Information about prescriptions was considered to be limited to doctor-patient relationships and it was mostly considered inappropriate for a pharmacist to discuss drug therapy with a patient.

This philosophy began to change in the 1960s and 1970s, as more and more drugs were developed and patients’ individual drug therapies began to include medications with increased risks of drug interactions and side effects or adverse reactions. Whereas, in the past, pharmacists essentially dispensed prescriptions one by one, many pharmacies began maintaining patient profiles that listed all of the drugs each patient was using. This allowed pharmacists to check for potential problems between drugs when new drugs were prescribed or when patients reported problems. These records became much easier to maintain and utilize as computers began to be used more widely for prescription processing.

By the 1980s, the principle of pharmaceutical care was gaining wider acceptance as a standard model for pharmacy practice, beginning the shift toward a more clinical role for pharmacists. Pharmaceutical care essentially encourages the establishment of the pharmacist as the manager of a patient’s drug therapy. Guidelines for this level of care include assisting in the selection of drugs, educating patients, and monitoring adverse reactions and outcomes of drug therapy.

Another change taking place was the involvement of third-party payers in reimbursement for prescriptions. In the past, most patients paid for their prescriptions with cash, but as the costs of health care and drugs increased, third-party payers began to cover some or all of the costs of patients’ medications. These third-parties include government employers, government programs such as Medicaid, employers’ health insurance policies, and private insurance purchased by individuals. Since then, the most significant influence of third-party payers has been negotiating continually decreasing reimbursement for community and ambulatory pharmacies. To make up for the revenue lost to low reimbursement from third-party payers, pharmacies have had to trim operating costs, which has resulted in such issues as reduced staff, increased prescription volume, and discontinued services, such as free prescription delivery. Third-party payers also play a role in influencing what drugs physicians prescribe for their patients by restricting the drugs they will cover and controlling what portion of the total cost the patient must pay. Today, most prescriptions are covered at least partially by a third-party payer.

In 1990, the U.S. Congress passed the Omnibus Budget Reconciliation Act (OBRA). Part of this law required pharmacists to perform three functions when filling a prescription for a Medicaid recipient:

Under the law, states were required to develop specific standards for patient counseling, such as when counseling must be offered (i.e., new prescriptions and/or refills), who may make the offer to counsel (i.e., pharmacist and/ or technician), and what types of information should be included during counseling (e.g., what a drug is used for, directions for use, and possible adverse reactions).² As these standards were developed, states required them to be applied to all patients’ prescriptions, not just Medicaid recipients. Although many of the OBRA requirements were being followed under the principles of pharmaceutical care, OBRA and the subsequent state regulations now require them, by law, to be applied to every prescription and patient.

The role of the pharmacist in community and ambulatory care pharmacies has generally evolved from preparers of drug products, to dispensers of drug products, and to managers of medication therapies. As the pharmacist’s role has changed, pharmacy technicians have assumed many of the important technical functions of the processing of prescriptions that were formerly performed by pharmacists. As technicians’ roles and responsibilities have increased, so have the professional standards for technician licensure and certification, as described in Chapter 1: Introduction to Pharmacy.

Practice Sites

There are several types of community and ambulatory care pharmacy settings, or practice sites, including community pharmacies, clinic pharmacies, managed care pharmacies, and mail-order pharmacies.

Community Pharmacies

Community pharmacies are generally broken down into two groups: independent and chain pharmacies. Independent pharmacies are generally owned and staffed by one or two individual pharmacists. An independent pharmacy owner may own a small number of pharmacies in a limited geographic area, but they are still generally considered to be independent. Originally, all pharmacies were independent, with chain pharmacies beginning to develop in the 20th century.

Chain pharmacies developed when companies began to own larger and larger numbers of pharmacies that all used the same name and logo and carried similarly branded OTC products. As more pharmaceuticals began to be produced by manufacturers, chain pharmacy companies gained a financial advantage by buying in bulk to supply all of their stores. As financial pressures on the pharmacy business have increased, so have the number of chain pharmacies. In fact, although the number of independent pharmacies has been steadily declining, the number of pharmacy chain stores has been steadily increasing. Many independent pharmacies have been sold to chain pharmacies, some of which have combined to form fewer numbers of bigger chains. Chain pharmacies originally were simply large groups of pharmacies, but today other retail chains, such as grocery chains and “big box” retailers, have added pharmacies inside their stores.

Clinic Pharmacies

Clinic pharmacies are ambulatory care pharmacies that are located in clinics or medical centers to serve the needs of outpatients. These pharmacies may be owned and operated by the facility, or owned independently but located in the facility. Clinic pharmacies typically function similarly to community pharmacies, but there is often more direct contact and communication with prescribers and other health care personnel within the facility. As such, clinic pharmacies may be more involved in managing drug therapies and offering other health screening and immunization services. Clinic pharmacies are generally smaller in size and carry a limited amount of OTC medications and other merchandise.

Managed Care Pharmacies

Managed care pharmacies are ambulatory pharmacies that are owned and operated as part of a managed care system, such as a health maintenance organization (HMO). They usually resemble clinic pharmacies but are operated by the managed care company for the patients they serve. As with clinic pharmacies, they would typically be located in proximity to a medical facility. As part of a managed care system, all of the managed care pharmacies within any one organization would likely look similar and offer similar services. There may be even more coordinated communication between managed care pharmacies and other health care professionals in the organization than there would be in clinic pharmacies.

Mail-Order Pharmacies

Although classified as ambulatory pharmacies because they generally serve ambulatory patients, mail-order pharmacies look and operate differently from other types of community and ambulatory care pharmacies. Mail-order pharmacies generally fill very large volumes of prescriptions and specialize in maintenance medications. Because of their high prescription volume, the prescription filling process is often highly automated and there is generally less direct contact with patients, except by telephone and electronically via Web sites and the Internet. Mail-order pharmacies are really more like warehouses with pharmacists and technicians. They are unlike typical pharmacies, where patients can walk in and pick up prescriptions.

Technician Responsibilities in Prescription Processing

Within community and ambulatory care pharmacies, pharmacy technicians have a variety of responsibilities, including

Communicating with patients

Ensuring patient privacy

Receiving prescriptions and registering patients

Transferring prescriptions

Entering prescriptions in a computer

Handling restricted-use medications

Resolving third-party payer issues

Filling and labeling pharmaceutical products

Compounding prescriptions

Collecting payment and offering patient counseling

Fulfilling miscellaneous responsibilities

Communicating with Patients

Pharmacy technicians spend a larger percentage of their time communicating with patients in community and ambulatory care settings than in any other practice setting, with the exception of mail-order settings. A technician is likely to be the first person to interact with a patient when he or she arrives, and the last before he or she leaves. Technicians also assist patients on the telephone with technical issues regarding their prescriptions. In many cases, patients will actually interact more directly with technicians and other support staff than with pharmacists.