Defining new technologies in pharmacy is central to their configuration as useful or otherwise for everyday working practices. The specificities of this ‘coherence’ work (see May and Finch, 2009) depend upon the sector of pharmacy into which these technologies are being implemented. As such, the ‘scope’ of the technology in question (i.e. whether it focuses on chronically or acutely ill patient bodies or low or high risk medications) affects the process of defining the utility of technologies in different pharmacy settings. Here, again, the differences between hospital and community pharmacy practice become apparent through this process of defining the innovation. Within this, the meaning of the new technology is linked with the particular nature of toxicity management being undertaken in that location. As such, the practices and discourses of medicines management and pharmaceutical care are central to this process of defining new technologies in hospital and community pharmacy respectively.
New technologies are, then, located within formal, codified and bureaucratic strategies of improving pharmaceutical care and medicines management at local and national levels (see Audit Commission, 2001). Chapter Six demonstrated an epistemic distinction between hospital and community pharmacy practice around the notions of medicines management and pharmaceutical care with medicines management being related to an understanding of organisational interests in improved medicines efficacy and pharmaceutical care being more focused on individualised patient-centric efficacy and risk.
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Within this, medicines management in hospital pharmacy is grounded in organisational interests in medicines efficacy, where therapy decisions are based around local policies and financial implications. Moreover, risk management in this practice model is located within legal and corporate responsibilities. In this vein, the implementation of innovative practice technologies in hospital pharmacy is understood as a way of both streamlining dispensing practices in order to improve overall pharmacy efficiency and improving and monitoring dispensing quality, as Hospital Pharmacist 6 says;
“The computer does all that [inputs prescription details such as dates and signatures] for you which means that we’ve been able to focus the pharmacist resource more on safety and appropriateness of drug treatment.” (HP 6- Director of Pharmacy)
“And the way the information can be used in terms of we can do audits that were impossible to do previously” (HP 6- Director of Pharmacy)
Here, the electronic patient record and the computer system on which it depends are defined through bureaucratic policy rhetorics as technological instruments which can make more efficient use of staff resources and assist with better quality audit activities. On the less formalised, more negotiated level of everyday practice, these technologies are central to the discourse of toxicity generated through the hospital pharmacy gaze. In this, toxicity is managed through the application and mobilisation of these technologies, as Hospital Pharmacist 6 highlights in reference to electronic prescribing systems:
“Under electronic prescriptions and administration records... And that’s made a massive difference in terms of the information you can present to prescribers at the point their doing prescriptions about interactions and allergies and all sorts of other things” (HP 6- Director of Pharmacy)
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Another example of this is computerised labelling where medicines are made meaningful and located within a patients’ wider lifeworld through the information (for example, dosage and administration details) provided on these labels. Shrank et
al. (2007b) note that effective labelling is central to toxicity management as, in
contrast to Patient Information Leaflets, medication labels are part of the medication itself given that labels cannot as easily be separated from medications. Although this labelling work has always been a central feature of pharmacy practice, its computerisation represents a new paradigm of medicines management where computer-generated (rather than hand-written) labels are thought to be clearer, thus making medicines easier for patients to engage with and adhere to (Shrank et al., 2007a). The comment from Hospital Pharmacist 4 highlights the impact of electronic medication labelling;
“When I started we had typewriters. From that point of view technology has really improved in terms of…patient labelling” (HP 4)
The implementation of technologies into community pharmacy is centred around two primary concerns: the pharmaceutical care of individual patients vis-à- vis potential drug reactions, and the increase in clinical practice, the latter of which is explored in more detail below.
The discourses and practices of pharmaceutical care are central to the process of defining new technologies in community pharmacy. Similar to the medicines management discourses mobilised in hospital pharmacy, pharmaceutical care processes are central to the operationalisation of new technologies in everyday community practice. As such, the community pharmacy computer is understood as a means to improve pharmaceutical care, patient adherence and outcomes and reduce toxicity through various functions and packages. The data suggests that the most pertinent example of this is the implementation of computer systems into everyday pharmacy work.
The arrival of computer systems in community pharmacy represents a significant departure from traditional experiences of pharmacy work, in which
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manual documentation and procedures played a central role and underpinned much of the GP/pharmacist communication (Motulsky et al., 2008). Writing some years ago, Foster (1992) noted that producing labels, storing patient prescription information, producing patient safety documentation and managing stock were the key areas that applications of computer technology addressed in pharmacy; the data collected here suggest that these work activities are still the primary applications of computer technology in community pharmacy.
Making sense of the meaning and significance of computerisation of community pharmacy is strongly linked with pharmaceutical care processes and discourses through the use of computers to identify potential toxicity. Within this, the pharmacy computer is framed as advantageous in its capacity to store patient medication records and algorithmic information which can help identify potential drug interactions. In doing so, the community pharmacy computer is understood as a way to improve pharmaceutical care by increasing patient and practitioner awareness of potential toxicity (Abarca et al., 2006). This is in addition to the capacity for electronically producing labels and safety information, which is central to patient adherence and outcomes policies.
At the less formalised, policy-bound level of everyday pharmacy practice, the community pharmacy computer is seen to enhance rather than undermine the pharmacy gaze. Patient information on the computer acts as a documentary space for the recording and management of toxicity which at the same time brings the patient body to life through its presence within this toxicity documentary. The community pharmacy computer, then, is used to store patient drug histories which construct a discourse of toxicity through the identification of potential risk-laden drug interactions. Within the documentary space of this drug history the patient body is configured as a complex site of potential toxicity to be managed by the community pharmacist through labelling, advice and counselling. Community Pharmacist 2 highlights the centrality of the computer to toxicity management in contemporary community pharmacy practice;
“I think the computer coming into the pharmacy opened so many doors really. Prior to that we didn’t even have a record of what
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patients had ever had. We’d nothing to help us with drug interactions. We’d no computer to flash up warnings. I mean, I often think - well I worry, to be honest - how much harm we did to patients because of drug interactions that we never even - we may have known about but not to the extent that we do today. And we had nothing to remind us of them at all. We didn’t put particular patient warnings on labels” (CP 2)
Defining the utility and meaning of new technologies in pharmacy is a process which sits within both formalised, codified pharmaceutical care and medicines management practices and less formalised, more negotiated everyday work practices which are enacted through the pharmacy gaze. Within bureaucratic medicines management and pharmaceutical care rhetoric and practices, the integration of new technologies into pharmacy is operationalised as a way to improve the safety and efficacy of pharmacy dispensing. At a more negotiated, pharmacy gaze level, new technologies act as inscription devices to configure the patient body as a set of particular risks and toxicities which are then observed through the pharmacy gaze and managed through the discourse of toxicity. Moreover, in community pharmacy new technologies can also act to configure a more clinically-focused pharmacy gaze. It is to this application of technology that the chapter now turns.