Clinical Pharmacists in Indian Modern Healthcare: An Underutilized Solution to Medication Errors and Polypharmacy

Future of Pharmacy in Indian Modern Healthcare
In the contemporary healthcare setting, the future of pharmacy is facing a fundamental change across the globe, due to the rapid change in the field of medical technology, the complexity of pharmacotherapy and the growing focus on patient-centered care [1–3,37,38,40,47,57,62]. In India, this revolution is being accompanied by a growing healthcare infrastructure, growing chronic disease burden and massive digital health programs [51,59–63]. Due to the fact that medicines are still at the heart of virtually any therapeutic intervention, the role of pharmacy professionals is gaining significance in terms of the safety, quality, and sustainability of healthcare provision [1–5,37,38,40,47].

The nature of modern Indian healthcare is marked by a high amount of patients, complicated treatment plans, and a high level of usage of various medications in various care environments [22,34,35,49,59–63]. Polypharmacy has increased drastically because of the rising incidence of multimorbidity especially in ageing and chronically sick patients [12–14,31–33,59,62,64–66]. Even though improvement in diagnostics and therapeutic has helped in management of the disease, it has also raised the chances of medication error, drug-drug interactions, and adverse drug reactions [10–13,18,19,31–35,64–66]. The mentioned challenges underscore the importance of the specialized medication knowledge that surpasses the traditional dispensing functions.

Traditionally, the pharmacy practice in India has been mostly product-based and the pharmacist was mainly concerned with the acquisition, storage, and dispensing of drugs [4,5,24–26]. Nevertheless, the future of pharmacy in up-to-date healthcare requires the transition to clinical integration, whereby pharmacists have to be engaged in therapeutic decision making, monitoring, and optimization of drug treatment [7,14,24–29,39–41,44–46,47,58,67]. The pharmacotherapist, pharmacokineticist, and patient-specific pharmacotherapy requirements display the unique ability of clinical pharmacists to respond to these emerging needs [7,14,24,25,27,39–41].

The healthcare systems all over the world are becoming aware of clinical pharmacists as an important part of multidisciplinary care teams especially in the hospitals, intensive care units, and chronic disease management programs [7,8,14,15,39–41,44–46,47,67]. Quite to the contrary, the adoption of this model in the modern healthcare in India has been very slow despite the similarities in the complexities of healthcare provision [24–29,34,49,58,59–63]. The use of clinical pharmacists is still under-used and there is no direct patient care and decision making in regards to medication [24–29,27,28,41,49,58]. This disconnection is a stark impediment on the achievement of safer and more efficient and visionary healthcare systems [1–3,37,38,40,41,47–49,67].

With India still undergoing the process of modernizing its healthcare delivery system with digital health systems, accreditation systems, and other therapeutic modalities, there is a need to have clinical pharmacists integrated, and this is not only preferable, but also mandatory [24–29,36,38,49–51,59–63,67]. The future of modern healthcare systems in India relates to the redefinition of the professional roles, the reinforcement of the clinical interaction and the establishment of pharmacists as the direct contributors of medication safety and treatment outcomes [1–5,24–29,37,38,40,47–49,55].

Medication Errors and Polypharmacy in Indian Modern Healthcare

One of the greatest patient safety risks in contemporary Indian healthcare is medication errors as well as polypharmacy [1,2,10–13,17–22,31–35,37–39,49]. Increasingly more complex is the healthcare delivery in which more than one person can prescribe, there are more advanced medications, and the systems are now technologically driven, the risk of an incorrect use of medication grows [10,17–20,36–38,49,52,53]. These problems are not isolated cases but are structural problems that are indicative of errors in the medication management systems [3,11,19,20,36–38,48,49].

Medication errors can be at any point of the medication-use process; some of them are during prescription, transcribing, dispensing, administration, and monitoring [10,17–20,36–38]. In Indian health care, patient-to-clinician ratios, time, missing patient histories, and inadequate interprofessional coordination are only some of the factors that have led to the occurrence of such errors [21,22,34,35,49,59–63]. In spite of making things easier, electronic prescribing and digital health record have created a new source of error, such as inaccurate data entry, fatigue, and overuse of automated decision-support systems without proper human oversight [18–20,36,52,53].

Polypharmacy has become a characteristic of the modern healthcare, especially in patients with chronic conditions, elderly, and those that are under the care of tertiary and intensive care centers [12–14,31–33,59,62,64–66]. In India, rising trends of diabetes, cardiovascular diseases, neurological, and cancer have led to a situation whereby patients were taking more than one drug at a time [59–63]. Although polypharmacy can be clinically warranted under some situations, inappropriate polypharmacy puts the patient at risk of adverse drug reactions, drug-drug interaction, non-adherence to medication, loss of functional abilities, and preventable hospitalization [12–14,31–33,64–66].

Pharmacy in contemporary healthcare should deal with the challenges in the future in a proactive and not reactive manner [1–3,37,38,40,47,57]. The old paradigms, in which medication-related issues are revealed only once the adverse event has taken place, are ineffective. Rather, contemporary healthcare demands ongoing medication review and therapy optimization, and real-time monitoring, which are the functions, which perfectly fit the skills and knowledge of clinical pharmacists [7,14,16,24–29,39–41,44–46,67].

Without formalized engagement of clinical pharmacists, the burden of determining dealing with intricate medication interventions is usually left to physicians and nurses with limited time and special training in pharmacotherapy [24–29,39–41,44–46,47,55,58]. This divide is further amplified by the fact that treatment guidelines are becoming more complex and patients are becoming divided in care among various healthcare institutions [21,22,37,38,59–63].

With the Indian healthcare systems shifting to value-based and outcome-driven healthcare, minimization of medication errors and optimization of polypharmacy will be essential performance measures [1,2,37,38,56,59–63,66]. These problems cannot be resolved only by enhancing compliance or documentation but should be regarded as the necessity of the fundamental change of the way medicines are handled in the modern healthcare systems [3,11,19,20,36–38,48,49]. Clinical pharmacists, due to their specialized training and their more patient-focused approach are best placed to spearhead this change and will be at the center of the new pharmacy practice in India [7,14,24–29,39–41,44–46,47,58,67].

Role of Clinical Pharmacists in the Future of Indian Modern Healthcare

The situation of pharmacy in Indian modern healthcare is inherently connected with the growing clinical responsibility of pharmacists [4,5,7,14,24–29,40,47,58]. The necessity of particular professionals who would be focused on medication optimization becomes more obvious in the context of the growing complexity and technologization of healthcare systems [1–3,37,38,40,52,53,57]. Clinical pharmacists have a special place in the healthcare market as the sole providers of medication expertise in multidisciplinary teams to provide safe, effective, and rational use of medicines at all levels of care [4,5,7,14,24–29,39–41,44–47,58,67].

Clinical pharmacists in the future-oriented healthcare models will have an active role in medication administration instead of a passive one [7,14,24–29,39–41,44–47,58,67]. They are not only required to detect medication errors but also prevent them by means of providing systemic medication reconciliation, reviewing therapy, and dosing plans [7,14,16,24–29,39–41,44–46,67]. Clinical pharmacists will be able to participate in the decision-making process of therapy and improve patient outcomes by engaging in ward rounds, discussions of clinical cases, and treatment planning [7,14,24–29,39–41,44–46,47,58].

In the contemporary Indian healthcare, electronic health records, e-prescribing systems, and clinical decision support tools are quickly becoming popular as digital health technologies [51–53,59–63]. Within this digital realm, clinical pharmacists are supposed to become the key players in the role of being critical interpreters of medication-related information [7,14,24–29,39–41,44–46,52,53,67]. Their specialization allows them to screen the recommendations made by algorithms, define possible errors, and use clinical judgment to make sure that the decisions made with the help of technologies remain patient-oriented [18–20,36,52,53,67]. Such a human control grows in importance as more and more healthcare systems become dependent on automation [18–20,36,48,52,53].

The role of clinical pharmacists in the future also includes management of polypharmacy especially in the elderly and the chronically ill patients [12–14,31–33,39–41,44–46,64–66,67]. Clinical pharmacists can decrease the use of unnecessary drugs without affecting treatment effect through frequent medicine review and deprescribing programs [12–14,31–33,39–41,44–46,64–66]. This practice is consistent with the current changes in global practice of personalized and precision medicine where the therapy plan is specific to the patient characteristics, comorbidities and treatment response [31–33,39–41,57,62].

Clinical pharmacists will be essential in antimicrobial stewardship programs, pharmacovigilance programs, and medication safety programs in addition to direct patient care [7,14,24–29,39–41,44–46,47,49,58,67]. The issue of antimicrobial resistance in India is a big burden and stewardship programs that involve pharmacists have been shown to be effective in optimizing the use of antibiotics and enhancing clinical outcomes [7,14,39–41,44–46,49,58,67]. In like manner, proactive engagement in medication safety through adverse drug reaction monitoring and reporting enhances healthcare institutions frameworks on medication safety [1–3,14,31–35,37–39,44–46,64–66].

Since Indian healthcare is shifting to integrated, multidisciplinary approaches to care, the scope of clinical pharmacologists is anticipated to widen to encompass outpatient clinics, programs of chronic disease management, and transitional care [24–29,39–41,44–46,47,58,59–63,67]. Their contribution to patient education, patient adherence, and continuity of care further substantiates their worth in the success of long-term therapeutic outcomes [7,14,24–29,39–41,44–46,47,55,58]. The future of pharmacy in the contemporary Indian healthcare thus relies on the identification of clinical pharmacists as key players in the provision of patient safety, quality care and sustainability of the system [1–5,7,14,24–29,37,38,40,41,44–47,49,58,67].

Barriers to Integration of Clinical Pharmacists in Indian Modern Healthcare

Although there is increasing evidence about the clinical and economic advantages of pharmacist-led interventions, the incorporation of the concept of clinical pharmacists in the Indian modern healthcare is still minimal [7,8,14–16,24–29,39–41,44–46,58,67]. These obstacles are multidimensional encompassing regulatory, institutional, professional, and educational aspects [21,22,24–29,36,47–49,55,58,59–63]. These issues need to be tackled to achieve the potential of Indian pharmacy practice in the future [24–29,47–49,58,61–63].

The lack of clearly defined and consistently applied roles of clinical pharmacists in healthcare institutions is one of the major obstacles [24–29,41,47,49,58]. As compared to the physicians and nurses, the scope of practice of clinical pharmacists in India is quite diverse in various hospitals [24–29,58]. In most of the environments, clinical pharmacists are limited to documentation, inventory related tasks or passive advisory services, and they have no opportunity to make any meaningful contribution to patient care and medication management [24–29,27,28,41,58].

There are also regulatory and policy related gaps that make integration difficult [21,24–29,47–49,55,58,61–63]. Even though there has been a transition of pharmacy education in India to a more clinical training, there has not been policy frameworks to limit or promote integration of clinical pharmacist in the care team within the hospitals [24–26,28,47–49,58,61–63]. The absence of national guidance on defining staffing standards, clinical duties, as well as clinical pharmacist responsibility, has led to a lack of uniformity in the implementation of these staffing standards across the public and private healthcare systems [24–29,36,47–49,50,58,61–63].

The problem of institutional resistance and ignorance is also quite important [24–29,47–49,58]. Several clinicians and healthcare administrators are yet to become aware of the entire clinical pharmacy practice and its effect on patient outcomes [24–29,39–41,44–46,47,58,67]. Such a shallow knowledge frequently causes a lack of appreciation about the worth that clinical pharmacists should add in medication safety, polypharmacy management, and therapeutic optimization [7,14,24–29,39–41,44–46,47,58,67]. There are also instances where overlapping of roles is an issue and absence of hierarchical healthcare set ups to facilitate collaborative practice hinders practice [24–29,47–49,55,58].

Underutilization is also brought about by workforce and training related issues [24–29,26,28,58]. Despite the clinical exposure provided, pharmacy graduates have differences in the quality of training and lack opportunities of structured residency or mentorship programs which influence the preparation of graduates in high-level clinical practice [24–26,28,39–41,47,58]. Also, insufficiency of staffing and high workload stresses does not allow clinical pharmacists to participate in more detailed medication review and follow-up processes [24–29,39–41,44–46,58,67].

Another significant obstacle is economic factors. The introduction of clinical pharmacists in healthcare institutions can also be seen as an added expense instead of a long-term investment [15,41–43,66]. The short-term financial view lacks evidence proving that interventions that are led by pharmacists can lower adverse drug events, hospital readmission, and total healthcare spending [7,8,14–16,39–41,42,43,44–46,64–67]. Lack of reimbursement model or even performance-based incentives associated with the result of medication safety also discourages broad adoption [39–41,42,43,47,66].?

Given Indian healthcare is in its modernization stage, the absence of emphasis on the eradication of these institutional obstacles will compromise the capability to curb the level of preventable pharmaceutical-related harm [1–3,21,22,37,38,47–49,59–63]. To overcome these obstacles, it is necessary to combine policy change, institutional investment, professional promotion, and education in relation to future health care requirements [21,24–29,47–49,55,58,61–63]. In the absence of such reforms, the possibility of clinical pharmacists to empower current healthcare structures will not be achieved [7,14,24–29,39–41,44–46,47,58,67].

Future Directions and Policy Implications for Integrating Clinical Pharmacists in Indian Modern Healthcare

Pharmacy in the context of Indian modern healthcare will be able to make its future by means of systematic inclusion of clinical pharmacists in patient-care structures, facilitated by policy reform, institutional commitment, and professional recognition [21,24–29,36,47–49,55,58,61–63,67]. With the rapid progress of India in the direction of the technology-driven, value-based healthcare provision, the issue of drug safety and cost optimization has to be a priority, not a secondary concern [1–3,37,38,51–53,56,59–63,66]. Clinical pharmacists can be an evidence-based approach to scaling to these objectives [7,8,14–16,39–41,44–46,67].

Among the most important future directions is the opportunity to establish the policies on the national level which will formally define and identify the role of clinical pharmacists in a healthcare facility [21,24–29,47–49,58,61–63]. By making clinical pharmacy services integrated into national healthcare programs like Ayushman Bharat, the process of medication management would become an ingredient of care and, especially, to patients with chronic illnesses and complicated therapy [51,59–63]. The stipulated policy frameworks should outline minimum staffing, clinical responsibility, and accountability of clinical pharmacists in both the public and private hospitals [24–29,36,47–50,58,61–63].

The systems of accreditation and quality assurance are also very vital in the future practice . The healthcare accreditation agencies like National Accreditation Board of Hospitals and Healthcare Providers can be influential agents of change by implementing the use of clinical pharmacists in medication safety programs, antimicrobial stewardship, and patient-care committees [36,38,48–50]. The connection between the accreditation standards and the measurable medication-related outcomes would encourage hospitals to implement the pharmacist-led clinical services as the quality standard [36,38,48–50,56,66].

The further development of digital health infrastructure also proves the need in clinical pharmacist integration [51–53,59–63]. Countries are undertaking such national efforts as the Ayushman Bharat Digital Mission to develop interoperable electronic health records and data-driven models of care [51,59–63]. Clinical pharmacists may be very instrumental in clinical pharmaceutical system in terms of interpreting medication-related information, monitoring therapy effects and in ensuring the implementation of digital decision-support systems using clinical judgment [7,14,24–29,39–41,44–46,52,53,67]. They will be crucial in ensuring that they avoid medication errors that come as a result of automation and retain patient care [18–20,36,48,52,53].

The other reforms that are vital towards future preparedness are educational and workforce reforms [24–29,25,26,28,47,55,58]. The pharmacy training programs need to keep changing to competency-based clinical training, with the focus being on real-world patient care, interprofessional collaboration, and the evidence-based decision-making [24–26,28,40,47,55,58]. Additional mechanisms (structured residency, ongoing professional growth, and credentialing) have the ability to increase the readiness of clinical pharmacists to advanced roles in contemporary healthcare systems [24–29,39–41,47,55,58,67].

Economically, the model of healthcare in the future needs to change its perception of clinical pharmacists as the costs to perceive them as value creators [15,41–43,66]. The data always show that pharmacist-led interventions have an adverse drug event reduction, shorter hospital stay, and reduced healthcare spending [7,8,14–16,39–41,42,43,44–46,64–67]. Integrating reimbursement arrangements or performance-based incentives based on the results of medication safety would motivate healthcare facilities to make investments in clinical pharmacy services [39–41,42,43,47,66].

Finally, the future of pharmacy in Indian modern healthcare is to shift fragmentation and prescriber-centered medication management to integrated and team-based care [1–5,37,38,40,47,55,57,59–63]. Clinical pharmacists cannot be considered as an unnecessary addition but rather a mandatory part of safe, efficient and sustainable healthcare provision [7,14,24–29,39–41,44–46,47,58,67]. To overcome medication errors and polypharmacy, as well as enhance patient outcomes in the new Indian healthcare environment, the alignment of policy, education, and institutional practices with this vision is necessary [1–3,12–16,21,22,31–35,37–39,47–49,55,58,61–63,64–67].

Future of Pharmacy in Indian Modern Healthcare: Expanding Clinical, Digital, and System-Level Responsibilities

It is possible to build the future of pharmacy in Indian modern healthcare through the systematic implementation of the role of clinical pharmacist in the patient-care structures with the help of the policy reforms, the institutional commitments, and the professional acknowledgments [21,24–29,36,47–49,55,58,61–63,67]. With India moving towards technology-enhanced, value-based healthcare provision, medication safety and optimization should be considered as the primary objectives, as opposed to the secondary ones [1–3,37,38,51–53,56,59–63,66]. A solution to achieve these goals can be clinical pharmacists who can be scaled and have evidence-based [7,8,14–16,39–41,44–46,67].

The development of national-level policies formally recognizing and defining the position of clinical pharmacists in a healthcare organization is possibly one of the most pressing directions in the future [21,24–29,47–49,58,61–63]. National healthcare initiatives such as Ayushman Bharat ought to include clinical pharmacy services such that prescriptions and medication management may become a standard component of treatment particularly in those patients with chronic conditions and complex treatment regimens [51,59–63]. The policy frameworks should show minimum staffing levels, clinical roles and responsibility of the clinical pharmacists in both non-government and government hospitals [24–29,36,47–50,58,61–63].

It is also imperative to note that the quality assurance systems and accreditation also play crucial roles in shaping the future practice . Medication safety programs, antimicrobial stewardship and patient-care committees can be a potent tool of change because the healthcare accreditation institutions such as National Accreditation Board for Hospitals and Healthcare Providers are required to participate in them [36,38,48–50]. Encouraged hospitals to pursue the pharmacist-led clinical service as a quality indicator would be done through the interplay between accreditation requirements and quantifiable medication-related outcomes [36,38,48–50,56,66].

Another reason, which justifies the integration of clinical pharmacists, is the fact that the digital health infrastructure is still expanding [51–53,59–63]. Ayushman Bharat Digital mission is a national initiative to raise up interoperable electronic health records and care on-data models [51,59–63]. In such systems, the use of digital decision-support systems might involve a critical role of clinical pharmacists to make sense of the information presented by medications, evaluate the effect of therapy, and ensure that clinical discretion is employed when using these systems [7,14,24–29,39–41,44–46,52,53,67]. Their involvement will be required to prevent the occurrence of medication errors due to automation and maintain patient-centered care [18–20,36,48,52,53].

Reforms in education system and workforce are also significant in future preparedness [24–29,25,26,28,47,55,58]. The education of pharmacists needs to keep on developing to competency-based clinical education, with an increased emphasis in patient care in the real world, interprofessional collaboration, as well as decision making [24–26,28,40,47,55,58]. Various types of structured residency programs, lifelong learning, and credentialing processes would further improve the readiness of clinical pharmacists to work in advanced positions in contemporary healthcare settings [24–29,39–41,47,55,58,67].

Economically, the future of healthcare models needs to turn out as a shift in the approach of considering clinical pharmacists as a value adding cost, and instead seeing them as a value creating organization [15,41–43,66]. Data has always shown that pharmacist-based interventions decrease adverse drug events, decrease hospitalization, and decrease overall healthcare spending [7,8,14–16,39–41,42,43,44–46,64–67]. A system of reimbursement or performance-based incentive based on the outcome of medication safety would motivate healthcare facilities to invest in clinical pharmacy services [39–41,42,43,47,66].

Finally, pharmacy in Indian modern healthcare can only progress by shifting away with its fragmentation and prescriber-centric approach towards an integrated and team-based approach to medication management [1–5,37,38,40,47,55,57,59–63]. Clinical pharmacists are not a luxury but they are a must have element of effective, safe and sustainable healthcare provisions [7,14,24–29,39–41,44–46,47,58,67]. The policy, education, and institutional practices in the dynamic healthcare setting in India must be aligned to the vision to reduce medication errors, polypharmacy, and enhance patient outcomes [1–3,12–16,21,22,31–35,37–39,47–49,55,58,61–63,64–67].

CONCLUSION AND FUTURE OUTLOOK

The future of Indian pharmacy in Indian modern healthcare is at the cross fire [59–63]. With the growing complexity, technological nature, and increased focus on medicine, the risks of medication errors and polypharmacy are increasing [1–3,10–13,17–22,31–35,37–39,59–63,64–67]. This review indicates that these challenges are not only clinical problems but system failures that occur based on incomplete medication management and inadequate use of professional pharmaceutical skills [3,11,19,20,36–38,47–49].

Clinical pharmacists are a future-proof remedy which fits perfectly well into the requirements of the contemporary healthcare [4,5,7,14,24–29,39–41,44–47,58,67]. They are uniquely placed to handle preventable harm related to medication as they train on pharmacotherapy optimization, medication safety, and patient-centered care [7,14,24–29,39–41,44–47,55,58,67]. It has always been shown that their incorporation into healthcare teams will result in the minimization of medication errors, inappropriate polypharmacy, adverse drug reactions, and preventable healthcare expenses [7,8,12–16,39–41,42,43,44–46,64–67]. Nevertheless, the role of clinical pharmacists in India has yet to be defined and implemented similarly across the country, which restricts the possible effect [24–29,41,47–49,58].

Going forward, Indian modern healthcare will become dependent on the ability to transition to collaborative and multidisciplinary models of care instead of prescriber-centric models of care [1–5,37,38,40,47,55,57,59–63]. Medical drugs are the foundation of the majority of therapeutic process and their safe use presupposes constant monitoring that is impossible to accomplish with the help of both automation and divided responsibility [1–3,18–20,36–38,48,52,53]. Digital health technologies need human judgment, which clinical pharmacists can bring to deliver the needed human judgment, analyze and interpret complex medication information, and offer individualized patient care [7,14,24–29,39–41,44–46,52,53,67].

Further development of the future of pharmacy in India should therefore be directed towards the structured clinical integration, which will be backed by the clear policy dictates, role definitions, and integration of education with the needs of the healthcare system [21,24–29,47–49,55,58,61–63]. This will require the development of more effective and safer systems of health by positioning clinical pharmacists in the hospital wards, outpatient clinics, chronic disease programs and online health programs [7,14,24–29,39–41,44–46,47,58,67]. Also, their value will be appreciated with institutional support and outcome-based assessment which will be key to long-term adoption [36,38,48–50,56,66].

To sum up, clinical pharmacists must not be perceived as an additional element in the development of Indian modern healthcare but as a necessity of the latter [4,5,7,14,24–29,39–41,44–47,58,67]. The need to reduce medication errors and polypharmacy requires dynamic medicine management through expertise [1–3,10–13,17–22,31–35,37–39,64–67]. Increasing the responsibilities of clinical pharmacists will not merely improve patient safety, but will also determine the future of pharmacy as an essential and supportive element of the contemporary, sustainable healthcare system in India [1–5,7,14,24–29,37–41,44–47,57–59,61–63,67].

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