ETHICAL AND SOCIAL IMPLICATIONS OF E-PHARMACY 28 th Annual Congress of EPSA

PHARMACEUTICAL CARE Focuses the patient's problems to public attention and defines pharmaceutical practice as patient-oriented instead of product-centered (Hepler, Strand, 1990)

INTERNET PHARMACY PRACTICE E-pharmacy could be defined as the use of Internet to facilitate pharmaceutical care. -Provision of service, products (OTC and prescriptions) and information 24- hour- a- day - communication with patients -Patient's education -Confidential advice in response to a user's specific question -Fast and easy delivery (additional free delivery of products)

CAN E-PHARMACY PROVIDE THE SAME QUALITY OF PHARMACEUTICAL CARE ? Cyber pharmacies that combine traditional retail operation with B2C operation is called “BRICK AND CLICK” PHARMACY. - ADVERTISE PHARMACIST'S PRODUCTS AND SERVICES - PROVIDE PRESCRIPTION-ONLY MEDICINES AFTER OBTAINING A VALID PRESCRIPTION - PROVIDE RELIABLE HEALTH-RELATED INFORMATION - ENHANCE PATIENT CARE SERVICES

BUYING MEDICINES ONLINE – IS IT ETHICAL? Online drug shops - “pure play" internet pharmacies Online prescribing-based sites that provide advice and products based on a patients` questionnaires (issuing online prescriptions) - SUPPLING PRESRIPTION-ONLY MEDICINES WITHOUT PRESCIPTION REQUIRED, SIMPLY BY FILLING OUT A QUESTIONAIRE - PROVIDING UNSATISFACTORY CONSELLING - OFFERING DUBIOUS ADVICE - NOT KEEPING PRIVACY AND CONFIDENTIALITY OF CONSUMERS` PERSONAL RECORDS - CLAMING INFRASTRUCTURE AND PROFESSIONAL STAFF THEY DO NOT HAVE

QUALITY OF GLOBAL E-PHARMACIES A survey of 104 global e-pharmacies, identified by using terms ”internet”, “online”, “pharmacy”, “pharmacies” and “medicines” (Bessel et al., 2001) Aim: To examine quality of the services provided by e-pharmacies Results: 67% delivered drugs internationally, 21% had an unidentified country of origin 42% provide pharmacist's advice 19% supply prescription-only medicines without prescription required 12% offer online prescribing

QUALITY OF GLOBAL E-PHARMACIES A survey of 22 e-pharmacies delivering Viagra ® online (Eysenbach, 1999) Aim: To examine quality of the information and service provided by e- pharmacies Results: 67% deliver drug internationally, and 21%deliver Viagra ® in Europe 80% provide incomplete information and unsatisfactory information on contraindications 9,09 % required prescription for online selling Viagra ® 40,9 % supply Viagra ® without prescription required 50 % issued “online prescription” after patients submitted questionnaire on medical information (with 80% no complete medical history taken) 30% offer Viagra ® when it is clearly contraindicated!!!!

BENEFITS OF ETHICAL E-PHARMACY To purchase medications To obtain information To interact with pharmacists and health care professionals. Cyber pharmacies can educate patients, and influence public knowledge, attitudes and behavior in relation to health problems and therapy. That is considered to be an ethical obligation for pharmacists.

ETHICAL IMPLICATIONS OF E-PHARMACY -Prescription requirements -Drug safety -Ensuring the privacy and confidentiality of the patient record -Internet-consumer trustworthy -Range of medicines sold -Availability and quality of online consultation and pharmacy's advice

ETHICAL IMPLICATIONS OF E-PHARMACY Pharmacists offering prescription order service online could save some time to enhance patient care service. The majority of pharmacists are concerned with drug safety when providing internet practice. (Zehnder, 2004) -Possible misuses of drugs -Lack of face-to-face communication with patients -The quality of pharmacist-patient relationship -Internet-consumer trustworthy

INTERNET AND CONSUMER-ORIENTED HEALTH INFORMATION The fourth most common use of the WWW is seeking health-related information. (Consumers International 2002) The number of internet users is increasing as well as the number of they can find online.

- HEALTH RELATED INFORMATION Hard to understand (Many patients are unlikely to comprehend most information they find online) Incomplete, misleading and fraudulent information (Unreliable sources that nevertheless influence public attitudes and behavior in relation to health issues. - DIFFERENT PRESCRIPTION STATUS OF VARIOUS PRODUCTS

SOCIAL IMPLICATIONS OF E-PHARMACY E-pharmacy is well position to help patients distinguish reliable from unreliable internet information. -Credible sites where patients can access high- quality information on particular diseases and health problems (besides information on prescriptions and OTCs) -Protect patients from misleading information (primum non nocere)

CORRESPONDENCE WITH PATIENTS - an opportunity to follow up to some patients after counselling - good way to replace the lack of face –to –face interaction. - always protecting patient's confidentiality concerning the information on drug purchase and medical history do not send personal medical information to patients by e- mails, nor archive all correspondence with patients in the computer but on the security intranet site (Intranet)

DIRECT –TO –CONSUMER ADVERTISING One of the benefits of DTCA was supposed to be the public awareness of the availability of some medicine that are presumable more affective and that can profoundly improve public’s health. The information for the prescription-only medicine should be appropriate and adequately balanced as to provide proper guidance to patients. - Potential misinformation that could lead to injuries and harm the patients. - Patients may not be informed on the correct dosage or special caution measures because of the existing therapy and pre-existing medical conditions.

CODE OF ETHICS - identify specific requirements for the ethical conduct of pharmacists offering online services - include them in national and international code of ethics - update (to redraft) existing code of ethics in the light of future developments of online pharmacy

CODE OF ETHICS FIP CODE OF ETHICS (1960) STATEMENT OF PROFESSIONAL STANDARDS CONCERNING CODE OF ETHICS FOR PHARMACISTS (FIP, 2004) _______________________________________________________ ROYAL PHARMACEUTICAL SOCIETY OF GREAT BRITAIN CODE OF ETHICS (2001, 2004)  to reduce the risk of unregulated medicines and to protect patents, as well as “to strengthen the professional framework for pharmacists providing service online” (2001)  to ensure public confidence in the provision of the internet pharmacy service (2004)

GREAT BRITAIN CODE OF ETHICS (2.9) - Pharmacy websites must clearly display the name of the owner of the business and the address of the pharmacy which the business is conducted, and where applicable the name of the superintendent pharmacist. - Details on how to confirm registration status of the pharmacy and pharmacists must be provided. - Pharmacists offering online services, must ensure that the patient understands how medicines are to be administered and that any appropriate information, advice and counselling is provided.

GREAT BRITAIN CODE OF ETHICS (2.9) - All information related to specific medications must comply with the marketing authorisation and include all relevant details of contraindications and side-effects. In addition, all information and advice must be provided according to the best possible standards of security and confidentiality and pharmacists must be accountable for them. - Record keeping of all products sold via the Internet is a necessity, and it is applied to OTC as well. Products recommendation may only be given in respect of individual patients and a record must be kept of the pharmacists assuming professional responsibility. - Pharmacists providing online services must advise patients to consult a convenient pharmacy whenever they suspect that patients` best interest is better served by face-to-face communication. - Pharmacy's website must contain details of how to make a complaint about the online pharmacy services provided.

CONCLUSION - E-pharmacy has a potential to improve practice of pharmaceutical care or to harm patient care, depending on how these services are being operated. It should be considered more seriously and with high- moral approach that e-pharmacy practice is far more than a chance to expand drug market. - For pharmacists it means new opportunities to expand pharmacy- based patient care services and to influence public knowledge, attitudes and behaviour in relation to health issues. - It is clear that pharmacists worldwide must recognise this valuable social responsibility and apply the Internet as a resource to contribute in that meaningful manner, according to high standards of professional ethics and always in best interests of the patients. - Already some pharmaceutical organisations adopted standards for internet pharmacy and incorporated new ethical considerations in their codes of ethics.