Offline pharmacies protest online sale of

drugs; to remain closed on Wednesday

While online cab aggregators and self drive cars have already faced the heat along withecommerce players when it comes to offline retail and businesses, the All India Organisation of
Chemists and Druggists(AIOCD), has called for a one day nationwide strike on Wednesday,
October 14 to protest against the online sale of pharmacy, reports NDTV. Hospital pharmacies will
remain open.
AIOCD states that the strike has been called to protect its interests as well as that of the consumers
and opposes the governments move to regularise the sale of medicines through the internet,
citing that it is illegal to do so under the Drugs and Cosmetics Act, 1940. It also added that epharmacy would hamper the interest of 800,000 chemists and 8 million workers and their families.
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The Mid Day reports that chemists in Faridabad will also be joining in the strike, along with Goas
chemists, as reported by ET, Karnataka Organisation of Chemists and Druggists as reported
by Daijiworld and All Kerala Chemists and Druggists Association, asreported by The Hindu.
While some websites might allow users to upload prescriptions from doctors, the website would
have no way to verify its authenticity, said Prasad Tamba, the president of the Goa pharmacists
association. Note that every doctor in the country needs to register with the Medical Council of
Indiain order to practice medicine. The websites which allow users to upload prescriptions can
cross check with the Councils database in order to verify the prescription.
About 4 months ago, the Indian Pharmacists Association (IPA) had written a letter to theDrugs
Controller General of India (DCGI) for not allowing ecommerce companies and online pharmacies
to sell medicine and drugs in India. Abhay Kumar, national president of the IPA told MediaNama
that DCGIs moves were in contravention of the Drugs and Cosmetics Act which says that drugs can
be dispensed in registered pharmacies only and cannot be sold online. Even when it comes to the
over the counter (OTC) drugs they must be sold in pharmacies only even though you do not need a
physicians prescription for it, Kumar said.
US FDA advisory: In the same month, the DCGI appointed industry body FICCI to as the nodal
agency to consolidate and frame guidelines for online sales of medicines through e-commerce
channels. IPA which sent a letter to DGCI also cited an advisory(pdf) from the US Food and Drugs

Administration warning consumers of the possible dangers of buying medicine over the Internet.
The letter also mentioned that the National Association of Boards of Pharmacy (NABP), the
professional organization that represents the state boards of pharmacy in the United
States, found that only 4% of online websites reviewed appear to meet state and federal pharmacy
laws.
The Drug and Cosmetics Act, 1940 (pdf) defines drugs as a variety of substances, diagnostic and
medical devices, while cosmetics is defined as any product meant to be applied to the human body
for beautifying or cleansing (excluding soaps). Note that in 1964, the act was amended to include
Ayurveda and Unani drugs as well.
MediaNamas take: While the issue seems a mix of protecting the pharmacists livelihoods along
with consumer protection, India does need a regulation for buying medicines online, given the
potential for drug abuse/illegal sale of prescription medicines. However, just to point out, an offline
prescription can also be used at different pharmacies to procure lots of drugs since prescriptions
in India are not marked as used by the pharmacy which originally supplied the prescribed drugs.
Likewise, neither do doctors direct patients to buy from specific pharmacies (not for generic drugs
anyway). Another issues is that of drug handling: certain medicines need to be temperature
controlled, not exposed to sunlight etc, which may not be possible for online pharmacies to ensure
once the drug leaves their warehouse.
In related news, were not even talking about the responsibility, accountability and liability of
platforms, marketplaces and aggregators or of the Drugs and Magic Remedies (Objectionable
Advertising) Act, 1954. We will highlight that the battle between traditional and online businesses
will only intensify as regulatory intervention will be required when the shift to online happens
(and is already happening).
Also read: Maharashtra FDA lodges FIR against Snapdeal CEO Kunal Bahl for selling
prescription drugs

Related

#Internet

#Online pharmacy

#online vs offline

#Regulation

The battle between traditional and online businesses will only intensify
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FIR filed against Shopclues for selling drugs without prescriptions
mChemist launches online pharmacy in India
Uber cars damaged in Mumbai and Pune; Offline is protesting

Eight lakh chemists plan to protest online medicine

retailers by shutting their own shops

Chemists claim that ePharmacists are exploiting regulatory loopholes to sell prescription drugs freely.

If you or someone close to you is suffering from an ailment, it might be a good idea to
stock up on medicines before Tuesday night. Eight lakh chemists across the country are
planning to shut their shops on Wednesday to protest against the proliferation of online
pharmacies. Brick and mortar stores claim these web retailers are operating illegally and
potentially causing health hazards.

As with so many other things, it is now possible to fulfill the vast majority of your healthcare needs online. From
consulting a doctor to having prescription medicines delivered at home, everything is accessible through the internet. But
these conveniences aren't without their problems.

An investigation by the Maharashtra Food and Drug Administration in May against e-tailer Snapdeal found it selling as
many as 45 prescription drugs that only a licensed pharmacist can retail.

Regulatory loopholes

Pharmacists across the country, facing competition from the sites and apps, are insisting that this regulatory loophole be
shut. The drug distribution industry in India is estimated to be valued at around Rs 83,000 crores, which could more than
triple to cross Rs 300,000 crores by 2020, according to reports. Even though online medicine retailers dont have much of
a share of this pie, their numbers are growing steadily. For instance, the online medicine retailer 1mg.com claims to receive
more than 5 million visits each month and says that its app has been downloaded more than 3.5 million times since 2012.

Even as the government has set up a committee to look into the online medical sector, chemists around the country have
demanded an immediate ban on these sites until guidelines are in place.

What they [online pharmacies] are doing is completely illegal, alleged JS Shinde, President of the All India Organisation
of Chemists and Druggists, which claims to represent more than 99% of India's chemists. We have submitted proofs to the
government of India about how these e-tailers are selling habit-forming medicines, scheduled drugs and even pregnancy
termination kits online which is in complete violation of the laws of the land.

The chemists' association argues that selling medicines online violates the Drugs and Cosmetics Act as well as the
Information Technology Act. It argues that no person other than a registered pharmacist prepare or dispense a prescription
medicine on the prescription of a medical practitioner.

However, people who run online pharmacies claim that they are aren't violating any rules and have checks in place to
counter illegal sales of medicine. For instance, 1mg.com said that it dispatches prescription medicines only after the buyer
uploads a prescription by a certified doctor on the site and its team has a chance to go through it.

Prashant Tandon the founder of 1mg.com, insists that his business model is "fully compliant with the law" since their web
platform passes on the customer's order for fulfillment to a real-world pharmacy that meets all the regulatory pre-requisites.

Stringent norms

"The offline store operates like any pharmacy store, and must have a pharmacy license and a registered pharmacist
dispensing medicines," he said. "Responsible ePharmacies like ours also ensure that no request is forwarded without a
prescription, no order is dispatched without a legitimate bill and batch number [to ensure tracking and authenticity] and we
provide a system that is better than the prevailing model in almost all respects."

Tandon also criticised Wednesday's planned strike by the brick and mortar stores.

"It is unfortunate that they are resorting to such moves, given that the regulator is already providing a proper platform for
all parties to voice their concerns and put their point forth," he said. "This move will just cause a lot of inconvenience to

patients and their relatives, who are really not the entity who should be inconvenienced for such a socially responsible
service."

Protesting the protest

Meanwhile, Indian Pharmacists Association, which maintains that it is opposed to online pharmacies, said that it doesn't
support the chemists' strike because this could result in a great deal of inconvenience to sick people.

This is no way to protest, said Abhay Kumar, president of the association. What is between the government and us
should not harm consumers. A shut-shop protest is not only unethical but it is dangerous too. Where will those go who
need medicines urgently if all shops are closed?

Kumar reiterated that his organisation is working to force the government to rein in the online sale of medicines but wont
participate in such protests.

We should give time to the government to think about their policies before taking such measures, he said. There is an
outbreak of dengue and H1N1 in many parts of the country and shutting shops will be irresponsible on the part of
chemists.

But the chemists' association says that it has put into place safeguards to protect against anything untoward.

We want to ensure that there is no harm to anyone because the pharmacies are closed, said Organisation of Chemists and
Druggists President JS Shinde. We will try to provide emergency counters in each area so that medicines can be reached
to the ones in need quickly and contacts will also be placed with police stations and authorities.

We welcome your comments at letters@scroll.in

If you or someone close to you is suffering from an ailment, it might be a good idea to
stock up on medicines before Tuesday night. Eight lakh chemists across the country are
planning to shut their shops on Wednesday to protest against the proliferation of online

pharmacies. Brick and mortar stores claim these web retailers are operating illegally and
potentially causing health hazards.

As with so many other things, it is now possible to fulfill the vast majority of your healthcare needs online. From
consulting a doctor to having prescription medicines delivered at home, everything is accessible through the internet. But
these conveniences aren't without their problems.

An investigation by the Maharashtra Food and Drug Administration in May against e-tailer Snapdeal found it selling as
many as 45 prescription drugs that only a licensed pharmacist can retail.

Regulatory loopholes

Pharmacists across the country, facing competition from the sites and apps, are insisting that this regulatory loophole be
shut. The drug distribution industry in India is estimated to be valued at around Rs 83,000 crores, which could more than
triple to cross Rs 300,000 crores by 2020, according to reports. Even though online medicine retailers dont have much of
a share of this pie, their numbers are growing steadily. For instance, the online medicine retailer 1mg.com claims to receive
more than 5 million visits each month and says that its app has been downloaded more than 3.5 million times since 2012.

Even as the government has set up a committee to look into the online medical sector, chemists around the country have
demanded an immediate ban on these sites until guidelines are in place.

What they [online pharmacies] are doing is completely illegal, alleged JS Shinde, President of the All India Organisation
of Chemists and Druggists, which claims to represent more than 99% of India's chemists. We have submitted proofs to the
government of India about how these e-tailers are selling habit-forming medicines, scheduled drugs and even pregnancy
termination kits online which is in complete violation of the laws of the land.

The chemists' association argues that selling medicines online violates the Drugs and Cosmetics Act as well as the
Information Technology Act. It argues that no person other than a registered pharmacist prepare or dispense a prescription
medicine on the prescription of a medical practitioner.

However, people who run online pharmacies claim that they are aren't violating any rules and have checks in place to
counter illegal sales of medicine. For instance, 1mg.com said that it dispatches prescription medicines only after the buyer
uploads a prescription by a certified doctor on the site and its team has a chance to go through it.

Prashant Tandon the founder of 1mg.com, insists that his business model is "fully compliant with the law" since their web
platform passes on the customer's order for fulfillment to a real-world pharmacy that meets all the regulatory pre-requisites.

Stringent norms

"The offline store operates like any pharmacy store, and must have a pharmacy license and a registered pharmacist
dispensing medicines," he said. "Responsible ePharmacies like ours also ensure that no request is forwarded without a
prescription, no order is dispatched without a legitimate bill and batch number [to ensure tracking and authenticity] and we
provide a system that is better than the prevailing model in almost all respects."

Tandon also criticised Wednesday's planned strike by the brick and mortar stores.

"It is unfortunate that they are resorting to such moves, given that the regulator is already providing a proper platform for
all parties to voice their concerns and put their point forth," he said. "This move will just cause a lot of inconvenience to
patients and their relatives, who are really not the entity who should be inconvenienced for such a socially responsible
service."

Protesting the protest

Meanwhile, Indian Pharmacists Association, which maintains that it is opposed to online pharmacies, said that it doesn't
support the chemists' strike because this could result in a great deal of inconvenience to sick people.

This is no way to protest, said Abhay Kumar, president of the association. What is between the government and us
should not harm consumers. A shut-shop protest is not only unethical but it is dangerous too. Where will those go who
need medicines urgently if all shops are closed?

Kumar reiterated that his organisation is working to force the government to rein in the online sale of medicines but wont
participate in such protests.

We should give time to the government to think about their policies before taking such measures, he said. There is an
outbreak of dengue and H1N1 in many parts of the country and shutting shops will be irresponsible on the part of
chemists.

But the chemists' association says that it has put into place safeguards to protect against anything untoward.

We want to ensure that there is no harm to anyone because the pharmacies are closed, said Organisation of Chemists and
Druggists President JS Shinde. We will try to provide emergency counters in each area so that medicines can be reached
to the ones in need quickly and contacts will also be placed with police stations and authorities.

We welcome your comments at letters@scroll.in

Drug stores to down shutters today in protest

KOCHI, OCTOBER 13:

With e-pharmacies raring to go and the government working on a regulatory framework for online sale of medicines,
the eight lakh conventional retail medical shops in the country are alarmed.
Threatened by the government move to legalise online sale, the All-India Organisation of Chemists and Druggists has
called a one-day shutdown on October 14 in protest.
If the Union government does not take note of our protest, we will think of longer-term actions, AN Mohan, national
vice-president of AIOCD, told BusinessLine.

Threat to public health

Mohan, who is also president of the All-Kerala Chemists and Druggists Association, said that if the online sale of
medicines is legalised, the livelihood of nearly 60 lakh people employed by the medical shops will be at risk. He
claimed that in a country where more than half the population is illiterate and where abuse and misuse of even
prescription drugs are rampant, online sale of medicines would play havoc with public health.
While online sale is the norm in many advanced countries, Mohan noted, there are very effective checks and balances
in place in those countries and the patients are well-informed. In the US, where drug bills are paid by the insurers
who keep a watch on drug purchases so that misuse of drugs is minimal.
India is several years away from such a situation, Mohan claimed.
Panel formed
Following the increase in illegal online sale of drugs, the Drugs Consultative Committee had set up a five-member
sub-committee headed by Harshadeep Kamble, Commissioner of Maharashtras Food and Drugs Administration, to
go into legalising the online sale.
The committee, which is said to be in favour of the sale, has invited public views on the issue. The chemists and
druggists believe that online sale will be legalised in a few months and that their livelihood will be threatened.
Lower prices
The biggest advantage of online sale is the highly reduced prices: the profit margins of distributors and retailers could
be eliminated and the benefits could be passed on to the patients. The reduced prices are the main attraction of online
retailing of consumer goods too.

But, unlike in the online sale of retail consumer goods, which is fast growing in India, patients do not have many
choices, Mohan said. Before buying medicines, the patient has to be diagnosed by a doctor, who in turn should
prescribe the medicines.
He feared that prescription-less purchase would shoot up and misuse of drugs would increase. Another risk was that
multinational companies would take over the drugs trade in the country and, ultimately, patients would end up paying
much higher prices.
Our country is too premature for online sale of drugs , Mohan said.

(This article was published on October 13, 2015)

IMA White Paper on Online Pharmacy

Why should the Indian Govt. not allow online pharmacies in India?
An online pharmacy sounds convenient; no waiting in queues, no rushing to the pharmacy before it shuts shop for the
day, placing the order is easy, moreover, the order can be placed any time of the day and the medicines are
conveniently delivered via courier at your doorstep. Yet, this convenience comes at a price. Not only there may be
financial implications for the patients, their safety may even be endangered at times.
The online pharmacy may have its own cancellation policy and may not refund or only partly refund the amount paid
upon cancellation of the order or even non-delivery of an order. Unlike the local neighborhood pharmacy or the
hospital pharmacy, the patient does not have access to a pharmacist if he/she has any questions about a medicine.

There are no well-defined dedicated laws for online pharmacies. Pharmacies in India are governed by the
Drug and Cosmetics Act 1940, Drugs and Cosmetic Rules 1945, Pharmacy Act 1948 and Indian Medical Act 1956.

Laws related to ecommerce are defined under the Information Technology Act, 2000.
According to Indian laws, a chemist can dispense prescription drugs only on the prescription of doctor. A prescription
requires the name of the doctor, his /her address and registration number besides the name/s of the drug/s, their
potency, dosage, and duration for which the drugs are to be supplied. The chemist cannot dispense quantity in excess
of what has been prescribed by the doctor. Before dispensing the drugs, the pharmacist is expected to verify the
completeness, authenticity and legality of the prescription.
Even over-the-counter (OTC) drugs can be sold only by licensed retailers.

The major issue of concern is that prescription drugs cannot be sold online. There are provisions in the
various acts mentioned above regarding the same.

According to Subsection 1 of section 42 of Indian Pharmacy Act 1948, .no person other than a registered
pharmacist shall compound, prepare, mix, or dispense any medicine on the prescription of a medical practitioner.
Section 42 (2) also states, whoever contravenes the provisions of sub-section (1) shall be punishable with
imprisonment for a term which may extend to six months, or with fine not exceeding one thousand rupees or with
both.

Online availability of prescription drugs will violate provisions of various acts like Pharmacy Act, Drugs &
Cosmetics Act.

Section 10 of the Drugs & Cosmetics Act prohibits import of any drug that is not of standard quality, any
misbranded, adulterated or spurious drug or any drug for requires a license for import. It also does not permit

import of any drug which by means of any statement, design or device accompanying it or by any other means, purports
or claims to cure or alleviate any disease. Imported medicines may be fake, mislabeled and unsafe.
o

Likewise, Section 18c of the Drugs & Cosmetics Act prohibits manufacture and sale of any drug without a
license.

Section 27 of Drugs and Cosmetics Act has provisions for penalty for manufacture, sale, etc., of drugs in the
form of imprisonment and monetary fine. It very clearly states in subsectionb(ii) without a valid licence as required
under clause (c) of section 18.

Recently, an FIR was filed against Snapdeal.com by Maharashtra FDA for allegedly selling drugs, including prescription
drugs, online for violating provisions of the Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954 and
directly contravening Section 18 (c) of the Drugs and Cosmetics Act, 1940, which prohibits manufacture and sale of
certain drugs.
o

The Drugs and Cosmetics Act, 1940, and the Drugs and Cosmetics Rules, 1945, have clear guidelines on the sale
of Schedule H and Schedule X drugs, which are restrictive drugs and can be sold only on the prescription of a
registered medication practitioner. Schedule X drugs include narcotics and psychotropic substances. Chances of
drug abuse and addiction are higher with these drugs. They also require meticulous storage and dispensing
records. The prescription has to be in duplicate, one copy of which is to be retained by the licensed pharmacist for
2 years.

Schedule H1 of the Drugs & Cosmetic Act 1945 mandates a licensed pharmacist to maintain a separate register
for sale of drugs that are specified in Schedule H1 with details of the patient, doctor and the name of the drug/s
including quantity; it is to be kept for three years and is open to inspection by regulatory authorities. Schedule H1
mainly includes potent antibiotics (like anti-tuberculosis drugs), habit forming painkillers like Tramadol and antianxiety drugs that induce sleep.

Schedule H1 drugs are also required to have special labeling, with symbol Rx in red to be clearly displayed on the left
top corner of the label and a box warning with a red border - It is dangerous to take this preparation except in
accordance with the medical advice. Not to be sold by retail without the prescription of a registered medical
practitioner.
Online pharmacies may not abide by these regulations and bypass them.
The objective of Schedule H1 was primarily to check the indiscriminate use of antibiotics in India, in view of the rising
incidence of multi-drug resistant bacteria, a serious public health issue worldwide. Easy access to antibiotics via online
pharmacies will defeat this very purpose.
o

The Drugs and Cosmetics Act has no provisions for online sale of medicines, or home delivery of medicines.
Hence, online sale of medicines cannot be legally permitted.

The prescriptions submitted via fax/email may be fake and it could be difficult to verify their authenticity.
Online correspondence and/or scanned copies are legally not permitted.

Online pharmacies will promote drug abuse, drug misuse, self-medication etc. Any mediation taken without
the supervision of doctors may be dangerous and even potentially life-threatening.

Pharmacists are not allowed to accept and dispense prescriptions that are brought in by children. Online
pharmacies will provide easy access to controlled drugs or even street drugs to this vulnerable group.

Regulation 5.3 of MCI Code of Ethics stipulates that pharmacists and doctors should work together. If online
pharmacies are allowed, then this relationship will be lost.

Many online pharmacies may be operating without the appropriate license. This increases the chances that
drugs sold by such unlicensed pharmacies maybe counterfeit, substandard, or adulterated and therefore risky
to the patient. There are no checks in place to make sure that the drugs sold by online pharmacies are not
spurious.

If online pharmacies are allowed, the National Pharmacovigilance Program, initiated by Central Drugs Standard
Control Organisation (CDSCO) under the Ministry of Health and Family Welfare, will become a futile exercise. This
program is not only meant for doctors but also for pharmacists. In March this year, the Health Ministry approved a
Materio Vigilance Programme of India to monitor adverse events associated with medical devices. If there is no
system in place to monitor and analyze adverse drug reactions, this will directly affect the health of the
patients.

Medicines have to be stored properly as recommended by the manufacture. Exposure of medicines to high
temperatures in storage or in transit could diminish their efficacy and are a potential health risk. There is no way to
check the storage conditions of the drugs sold by the online pharmacies.

Regulatory authorities continue to monitor a drug for any adverse effect even after it has been on the market. If
the safety/quality of the medicine comes under question or, if it is potentially contaminated, mislabeled or is
improperly packaged, then they may recall or withdraw a prescription or OTC drug from the market even after
it has been approved. Sometimes, the manufacturer may voluntarily recall a drug. If online pharmacies are
permitted, the drug recalls become very, very difficult, almost next to impossible.

Breach of confidentiality is another major concern. Online pharmacies may misuse personal and financial
information of the patient as well as of doctors leading to cases of identity thefts and fraud.

The WMA 2005 Declaration of Lisbon on the Rights of the Patient gives them the right to confidentiality, which states that all
identifiable patient data must be protected. Regulation 7.14 of MCI Code of Ethics 2002, also does not allow a registered
medical practitioner to disclose the secrets of a patient that he/she may have been learnt in the exercise of his / her
profession. Declaration (g) given to doctors at the time of registration states: I will respect the secrets which are
confined in me.
There is no legislation specific to data privacy in India as yet. The laws that deal with data protection or privacy in India
are Section 43A of the Information Technology Act, 2000 and theInformation Technology (Reasonable Security
Practices and Procedures and Sensitive Personal Data or Information) Rules 2011.
There is a proposed Privacy (Protection) Bill, 2013 (Bill), which focuses on the protection of personal and sensitive
personal data of persons. If passed and enacted, it will override all existing provisions directly or remotely related to
privacy under section 3, which provides that no person shall collect, store, process, disclose or otherwise handle any
personal data of another person except in accordance with the provisions of this Act and any rules made thereunder.

Online pharmacies offer drugs at low cost or at discounted prices to lure customers. If the online pharmacy
gives cheaper alternatives of drug/s prescribed, this violates the doctor-patient-pharmacist relationship, which is
based on trust.

Pharmacy laws in India do not allow a pharmacist to substitute a brand written by a doctor.

Pharmacists are also not authorized to change potency of the prescribed drug, even if the patient asks for it.

Refilling of a prescription is not allowed by pharmacists unless authorized by the doctor. If the doctor has
prescribed a drug, e.g., 3 days, the pharmacist cannot dispense drugs for more than this duration.

Online pharmacies may provide rebates and commissions to doctors to provide prescriptions on the basis of
online information that has been filled by the patient. This way doctors will be vulnerable to malpractice
suits. Regulation 6.4 of MCI Code of Ethics prohibits doctors from giving or receiving any rebates or commissions.

Similar to the online search service Justdial.com, online pharmacies may also promote doctor
substitution, which is unethical.

Ultimately online pharmacies will be taken over by MNCs and Indian laws are not applicable to MNCs.

Indian Medical Association is against online pharmacies in India. This will encourage substitution of cheaper and
spurious drugs by the online stores and the doctor-patient confidentiality will be affected. And, will be a violation of all
the laws quoted above. It will deny the patient the supervision of the Doctors in the use of medicines. This will
encourage patient to use one prescription repeatedly without the supervision of the Doctor. This can cause many
adverse drug related reactions, it will encourage drug abuse and overuse of habit-forming drugs. The medicolegal
liability will still fall on the doctor, when a patient misuses this facility. The service of online pharmacy will be utilized by
affluent and educated people. Hence online pharmacy has no public health benefits or implications; but at the same
time it is loaded with scope for misuse, drug abuse, dependence and adverse reactions.
http://www.ima-india.org/ima/left-side-bar.php?scid=324
Prof Dr A Marthanda Pillai

Dr KK Aggarwal

National President, IMA

Honorary Secretary General, IMA

Effects of Computer-based Prescribing on Pharmacist Work Patterns

Michael D. Murray, PharmD, MPH, Bonnie Loos, MBA, Wanzhu Tu, PhD, George J. Eckert, MAS,Xiao-Hua Zhou, PhD, and William
M. Tierney, MD
Author information Article notes Copyright and License information

This article has been cited by other articles in PMC.

Abstract
Pharmacy has readily accepted computerization, and innovative pharmacy information systems are being
developed.1 Pharmacists must carefully process, store, and track a large volume of paper, mainly in the form of
prescriptions, maintain an inventory of the most commonly prescribed medications, and routinely make quick linkages
between hundreds of prescribers, thousands of patients, and millions of prescriptions. Hence, pharmacists embraced
computerization quickly and pervasively to increase their efficiency.
The paper prescription, although historically effective, has always been a somewhat painful prescribing medium for
physicians, patients, and pharmacists. The biggest problem with paper prescribing for physicians is the amount of time
needed to recall from memory or look up which medication and dosage to prescribe more than 20,000 products. To
further complicate matters, physicians increasingly deal with different formularies for sundry insurance schemes. They
then must legibly write each prescription. Pharmacists deal with hundreds of prescriptions each day and must legally
account for each one, must store them, and must be able to retrieve them for refills. Thus, alternative ways of generating
and maintaining prescriptions with computers are often sought.

Computer-based writing of prescriptions by physicians addresses many of the problems posed by the paper
prescription.2 Many of the advantages of this form of prescribing are obvious. More advanced systems can provide
physicians with the list of medications covered by patients' insurance plans, provide the list of medications obtained in a
specific plan's formulary, and enable the pharmacist to easily determine the right medication and even provide a safety
check on interactions or dosage. When there are links between the physician's office and patient's pharmacy, the
prescription can be sent directly to the pharmacy, be filled while the patient is traveling there from the physician's office,
and be ready for pick-up on arrival. Pharmacists would save much time not having to interpret physician's writing and
save much space storing prescriptions.3 The time needed for retrieval of prescriptions for refills would be greatly
diminished.
There are no studies describing the effect of computer-based outpatient prescription writing by physicians on pharmacist
work patterns. We had an ideal opportunity to learn more about this issue as we extended our inpatient physician orderwriting workstation into our large primary-care general internal medicine practices. We therefore measured the effects
of computer-based outpatient prescription writing by physicians on pharmacist work patterns using multidimensional
work sampling. We previously used this methodology to measure pharmacists' work patterns before a randomized
health services trial began, to provide a baseline with which future system and process changes could be compared. 4 The
purpose of this study was to determine the changes in pharmacist work patterns from this baseline after the introduction
of computer-based writing of outpatient prescriptions. As such, our hypothesis was stated as the null, namely,
implementation of computer-based outpatient prescription writing by physicians would have no effect on pharmacist
work patterns.
Go to:
Methods
Setting

The study was conducted at the general medicine practice (GMP) and the outpatient pharmacy of the Regenstrief Health
Center, the primary outpatient facility of Wishard Health Services, Indianapolis, Indiana. In addition to this outpatient
facility, Wishard Health Services has a 300-bed urban public teaching hospital and the busiest emergency department in
Indiana. The outpatient pharmacy processes 1,000 to 1,500 prescriptions each day, Monday through Friday, as part of
the care of more than 50,000 outpatients who make over 400,000 visits annually to the clinics and emergency
department. More than 100 internists practice at the GMP during any given week, and they write the largest number of
prescriptions for the 11 full-time and 9 part-time pharmacists at the outpatient pharmacy. Pharmacists are assisted by 14
full-time and 4 part-time technicians. Although there are other clinics at the Regenstrief Health Center that are serviced
by the pharmacy, the majority of prescriptions derive from the GMP. Our internal studies have revealed that more than
95 percent of patients who receive their care from the GMP fill their prescriptions at the outpatient pharmacy.
The Regenstrief Medical Record System

For 25 years the GMP and outpatient pharmacy have been served by the Regenstrief Medical Record System
(RMRS).5 The components of the RMRS that are relevant to this study are a VAX-based pharmacy computer module
used by the pharmacists in the pharmacy to process all prescriptions (paper and electronic) and a network of
comprehensive microcomputer workstations used by physicians in the GMP. The pharmacy module is the primary
information system enabling the pharmacy to fill prescriptions. Sixty-four percent of prescriptions derived from GMP
physicians during this study. Before computer-based outpatient prescription writing by physicians became available at

the GMP, physicians wrote paper prescriptions. The patient hand-carried these paper prescriptions from the GMP to the
outpatient pharmacy, where they were then interpreted by pharmacists and technicians who entered the prescription
information into the RMRS at one of the five VAX terminals throughout the pharmacy. The RMRS stored all
prescription data for ready retrieval and then generated a label for the pharmacist to apply to the medication's container.
Computer-based Prescribing

Online prescription entry created major changes in the process of handling prescriptions by physicians and pharmacists.
First, GMP physicians entered their prescriptions directly into microcomputer workstations located throughout the
GMP.5 After a patient's hospital number is entered, a menu of actions is displayed on the monitor. Among selections on
the menu is one for prescription medications. When the prescription order selection is chosen, all active prescription
medications for the patient are shown. The physician can renew or modify an existing medication that has been
previously stored or order a new medication.
Prescription renewal is as simple as highlighting the medication, reviewing the fields corresponding to the medication's
dosage, sig, and quantity to dispense. To prescribe a new medication, the physician can quickly summon a specific order
by typing in a few letters of the medication's name or can peruse a specific formulary class of drugs to look for
alternative treatments. This process can improve practice by removing some of the practical ambiguities physicians
have in writing prescriptions (which drug, strength, dosage, how supplied, and costs) and by reminding physicians how
to effectively monitor patients' drug therapy and avoid important drug interactions.
After the physician enters all medications, an electronic copy of the patient's prescription is sent to the pharmacy and a
paper copy is printed for the patient. The paper copy given to the patient serves two purposes. First, pharmacies in
Indiana are required by law to store a paper copy of the prescription. Second, the paper copy brought to the pharmacy
by the patient serves to notify the pharmacist that the patient is at the pharmacy and their prescriptions have already
been written and stored. To display the patient's prescriptions, the pharmacist enters a prescription access code specific
to the patient, physician, and date. All the patient's prescriptions are then displayed for the pharmacist to accept, modify,
or reject. The paper copy is filed later in the evening after the majority of patients have been served during the day.
Multidimensional Work Sampling

The method used to measure the work patterns of pharmacists has been described previously.4 We briefly describe the
methods here. We used multidimensional work sampling to determine the proportion of pharmacists' time spent in a
variety of predefined work activities (activity), the reason for each activity (function), and the people contacted by the
pharmacists to do their work (contact). Recording the appropriate combination of items from each of these three
dimensions permitted any work-related task to be accurately described. The Appendix contains the definitions
measured. Although we collected data on a variety of specific activities and functions, we condensed into a single
dimension several specific activities and functions that were closely related, to facilitate graphic interpretation.
We measured the work patterns of pharmacists before and after the implementation of computer-based outpatient
prescription writing by GMP physicians. Online entry of prescriptions by physicians at the GMP began on Feb 28, 1994.
Therefore, the first work sampling period was from Dec 13, 1993 through Feb 11, 1994, and the second sampling period
was from Mar 2 through Apr 15, 1994. We scheduled the after-phase of work sampling soon after computer prescribing
began, to avoid confounding our results with other interventions being planned, such as pharmacy renovation.
Multidimensional work sampling requires that pharmacists record a large number of instantaneous observations taken at
random intervals.6,7,8,9,10 Because pharmacists work inside and outside the pharmacy, we conducted the study using self-

reported work sampling (as opposed to direct observation methods) with a random-signal generator that pharmacists
took with them wherever they went during their work day.4, 11 Each day pharmacists were provided with a pager-sized
device (JD-7, Divilbliss Electronics, Champaign, Illinois) that randomly buzzed pharmacists at the rate of four to eight
signals per hour, prompting them to record their activity, function, and contact on a form that exact instant the pager
buzzed. For example, imagine that at 10:15 A.M. a pharmacist was checking a prescription previously filled by a
technician, when she felt the pager buzz. She stopped what she was doing, pulled the recording sheet out of her pocket,
and wrote 2-1-1 under the 10-to-11 time block on the sheet. This notation, when decoded (see Appendix) indicates the
no. 2 activity, Check/Prescription, the no. 1 function, Fill Prescription, and the no. 1 contact, Self. In other words,
at the instant the pharmacist was interrupted, she was checking a prescription to dispense it by herself.
At the end of the day, pharmacists returned their pagers and the completed forms. Because their work was not
characteristic of the other pharmacists, pharmacist supervisors did not participate in the study. Furthermore,
measurement of work performed by technicians also was not an objective of this study. Technical support remained
constant in both the type of work performed and the numbers of full-time and part-time technicians performing the
work. However, the distribution of the type of work done, the reason for that work, and the contacts were likely to shift
in response to the changes in pharmacists' work.
We trained pharmacists on work documentation procedures and pretested them on the sampling method. Pharmacists
getting 90 percent or more of test questions correct were able to participate after being given explanations of any errors
they made. Pharmacists scoring less than 90 percent (n=2) were provided with additional lessons and further time to
study the dimensions being measured. Afterwards, these pharmacists received scores of 100 percent. We conducted a
run-in phase of one week to allow pharmacists to become acquainted with the work-recording process. Run-in data were
discarded.
Validation Study

Multidimensional work sampling has been shown to be an accurate, indirect method of work measurement. 8, 12, 13 To
validate our sampling methodology, we directly observed pharmacists recording their work and determined percentage
agreement with their work-measurement recording. A research assistant, trained in the assessment of pharmacist work
patterns, was introduced to all the pharmacists in the study, and the purpose of the validation study was explained to the
pharmacists. At random times, Monday through Friday, 8:00 A.M. to 7:00 P.M. (the study sampling time frame), the
research assistant visited the pharmacy and observed the pharmacists while they worked. During these visits, the
research assistant stopped the pharmacist during a variety of activities and asked him or her to describe in detail the
activity, function, and contact at that instant. For 103 interruptions, 309 coded entries were assessed by the research
assistant and then by one of us. Of the activities measured, the percentage agreement among pharmacists, the research
assistant, and the investigator was 95 percent (95 percent confidence interval: 89-98 percent), and of the functions and
contacts, the percentage agreements were both 99 percent (95 percent confidence interval: 95-100 percent). We believe
these results validate our data recording method and are in agreement with the findings of other investigators. 13
Statistical Analysis

Using our baseline data, we performed sample size estimates, 14 which indicated that 4,500 observations would provide
us with sufficient power to detect a 0.7 percent absolute change in the advising function (counseling patients and
consulting with physicians). For estimation, the baseline advising function (function 7) accounts for 5.9 percent of all
functions. Based on this sample proportion, 4,500 observations allows us to control the margin of error to less than 0.7

percent with 95 percent confidence. For more general estimates (any activities, contacts, functions), this margin of error
is no more than 1.5 percent.
For tests of significance comparing two proportions, the sample size depends on the significance level of the test as well
as the allocation of sample sizes. At 0.05 significance level, assuming the two samples have equal sizes of 4,500, the
test has the power to detect a 1 percent change in advising function. For more general tests, two sampleseach with a
size of 4,500allow for the detection of changes greater than 2 percent.
To assess whether the computer-based outpatient prescription writing by GMP physicians changed the distributions of
the activity, functions, and contacts of pharmacists' operation, we used chi-squared tests to test the hypothesis that the
distributions of the activities (or functions or contacts) are independent. 15 To identify the specific activities, functions,
and contacts that have changed significantly after computer-based outpatient prescription writing, we compared the
probabilities of each individual category before and after proportions. Since we considered only one particular activity
at a time (for example, discuss versus all others) a binomial model was appropriate. A commonly used test for
comparing two proportions is the t-test.16 In large sample situations, the distribution of the test statistic T can be
approximated by the standard normal distribution. The conclusion from the t-test was confirmed with tests based on
generalized estimation equation models, which take into account the potential intercorrelation among the observations
of the same subject (pharmacist) in the analysis. 17
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Results
Before and after computer-based prescribing, total staff hours and numbers of prescriptions were similar. During both
periods, pharmacists and technicians worked 475 and 660 hours per week, respectively. The total numbers of
prescriptions handled before and after computer-based prescribing were 926 and 1007 prescriptions per day,
respectively. Pharmacists recorded a total of 9,422 observations during the study. Before computer-based outpatient
prescription writing began, 4,687 observations were recorded, and afterward pharmacists recorded 4,735
observations. shows the proportion of time spent on the various activities, functions, and contacts. The overall
distributions before and after computer-based outpatient prescription writing differed significantly for activities,
functions, and contacts (P < 0.001). This indicates that computer-based outpatient prescription writing significantly
affected the type of work pharmacists performed, why they did the work, and who they came in contact with while they
worked. shows the before and after distributions of work activities. After computer-based outpatient prescription
writing, pharmacists spent 12.9 percent more time checking prescriptions. These are activities that might be expected to
increase as pharmacists became more vigilant with regard to physician's electronic orders. Pharmacists spent 3.9 percent
less time waiting for work to do, and 2.2 percent less time meeting.

Table 1

Comparison of Pharmacist Work Patterns (Percentage of Time) Before and After Online Entry of
Prescriptions by Physicians

Figure 1
Pharmacist work activities before and after computer-based outpatient prescription writing by
physicians. The activities are defined in the Appendix. Rx indicates prescription.
Interestingly, pharmacists spent about the same amount of time entering information into the computer after computerbased outpatient prescription writing as they did before (P = 0.299), although this fraction of their activities is small.
Before online entry pharmacists (or technicians) had to hand-enter all the prescription data from the paper copy. After
computer prescribing began, most of the pharmacists' computer time involved the electronic review of previously
entered prescription data, which involves moving through the fields (sig, dosage form, quantity to dispense) to accept or
edit the data entered by physicians. Although this would reduce the amount of time, pharmacists spent more computer
time editing the previously entered physician orders (vide infra).
shows the distributions of work functions or the reason for their work. After computer-based outpatient prescription
writing, pharmacists spent 45.8 percent more of their time problem-solving physician's orders. This undoubtedly had
much to do with physicians' learning more about the various medications stored in the pharmacy inventory and the need
for pharmacists to help them deal with a variety of prescribing issues that were new to them.

Figure 2
Pharmacist work functions before and after computer-based outpatient prescription writing by
physicians. The functions are defined in the Appendix. Rx indicates prescription.
Most of these problems involved the pharmacists' editing or double-entering work, on each individual prescription,
already entered by physicians. Pharmacists were required to inspect each field and accept or correct data entered by the
physician. Before computer-based prescribing, pharmacists were required to conform to a firm syntax when entering the
prescription sig such as 1 tab PO TID. To make entry of prescriptions easy for the physicians, the system was
designed to allow them to enter the sig as free-form text, which then had to be translated back by pharmacists into the
appropriate syntax.
Because physicians' lack familiarity with the strengths and dosage forms available in the pharmacy, pharmacists needed
to edit these entries. For example, a physician may enter a prescription as Take one 100-mg tablet TID when the
pharmacy has 50-mg capsules. The pharmacist would need to change this to read Take two 50-mg capsules TID.
Physicians also have no way of telling when a drug or dosage has been depleted from the pharmacy inventory. When it
has, the pharmacist may need to change the patient's dosage regimen (e.g., from one 100-mg tablet to two 50-mg
tablets) to fill the prescription quickly. Moreover, physicians were not aware that some medications were available in
ready-to-dispense packaging, which was encouraged to reduce counting of individual tablets and capsules for

commonly used medications. Owing largely to this time spent problem solving, the time spent filling prescriptions
decreased by 34 percent. The time pharmacists spent advising physicians about other aspects of patients' treatments and
advising patients decreased by 3.3 percent, a considerably smaller effect than that seen with problem solving and
prescription filling.
shows the distribution of pharmacist contacts during their work. Both before and after computer-based outpatient
prescription writing by physicians, pharmacists spent more than 80 percent of their time working alone. There was a
small increase (4 percent) in the amount of solo work by pharmacists after computer-based outpatient prescription
writing and a complementary small decrease in the amount of time pharmacists spent in direct contact with other
pharmacists. Differences in effects on the amount of time spent with physicians and nurses and with patients were small
and not statistically significant.

Figure 3
Pharmacist work contacts before and after computer-based outpatient prescription writing by
physicians. The contacts are defined in the Appendix.
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Discussion
Our results indicate that the overall effect of computer-based outpatient prescription writing by physicians on
pharmacist work patterns was to increase the percentage of pharmacists' time spent checking prescriptions entered by
physicians and sorting out problems that occurred. Pharmacists were able to perform this work without directly
increasing interactions with physicians and without increasing the number of staff required to handle the workload. In
our previous study of pharmacist work patterns before computer-based outpatient prescription writing, we found that
pharmacists spent most of their time working alone.4 We had some hopes that changes in prescription processing
resulting from computer-based outpatient prescription writing would reduce the time pharmacists spent processing
prescriptions and provide more time for communicating with patients and health professionals. That did not occur.
Assessment of the proportion of pharmacist time spent in work activities, functions, and contacts during this study
provided us with an improved understanding of shifts in pharmacist work with prescription and information processing
changes. This becomes especially relevant when state Boards of Pharmacy permit paperless (electronic) prescribing. As
pharmacy progresses in its delivery of pharmaceutic care in this era of managed care, such systems could become more
common. If so, understanding their influence on pharmacist work patterns will be pivotal.
Pharmaceutic care fosters increased involvement in the process of drug therapy evaluation, problem solving, monitoring
and, when necessary, intervention to increase the beneficial effects of drugs and reduce their adverse effects. 18, 19 The
emphasis of managed care on efficient use of resources and time in the delivery of services makes changes in
prescription management critical.20 Such a focus will increasingly require pharmacists to transfer some aspects of their
prescription management to computers and dispensing activities to technicians. It is hoped that this would increase the
amount of time pharmacists had available to advise patients and interact with physicians. However, we did not find this
expected work shift. Instead, more time was required for solving prescribing problems. Others have reported similar

shifts from one type of dispensing work to another (without an increase in interaction with patients or physicians) after
an outpatient pharmacy had been computerized. 13, 21
There are four limitations to this study. First, it would have been helpful to learn how computer-based outpatient
prescription writing affected the amount of time physicians spent doing their work. Unfortunately, we were unable to
conduct such a study of physicians' work patterns. Second, multidimensional work sampling has its own inherent
deficiencies, which have been recently delineated. 8, 10 Nonetheless, agreement was excellent in our direct-observation
validation study. Third, our work sampling might have begun too soon after computer-based outpatient prescription
writing was introduced and so might differ from a stable estimate made several months later. To address this possibility,
we further examined the effect of time using our data. We split our before and after measurement periods to compare the
results of the early part of the before period (Dec 13, 1993, to Jan 2, 1994; n = 2,286 observations) to the latter part of
the after period (Mar 24 to Apr 15, 1994; n = 2,461 observations). We then compared distributions of activities,
functions, and contacts. We found that the distributions of activities, functions, and contacts are similar to the original
distributions, and the tests of significance lead us to the same fundamental conclusions as our original data. Obviously,
it would have been preferable to have collected data at a later time. However, impending renovations to the pharmacy
precluded a later measurement phase. Finally, our electronic medical record system is unique. Its capabilities are more
advanced than those of most other health care systems, yet those advancements, by their very nature, are more crude
than can be expected when more mature systems became widely adapted.
We conclude that computer-based outpatient prescription writing by physicians has a profound effect on the type of
pharmacist work and reasons for it but little overall effect on the amount of time pharmacists spend with patients and
physicians. This information would be beneficial to managers and planners who are considering the implementation of
computer-based prescribing. We are exploring how other process changes to the delivery of information affect
physicians and pharmacists as they work. It is possible that collectively these process changes will improve the ability
of pharmacists to deliver pharmaceutic care, especially if the electronic medical record can target high-risk patients for
pharmacist interventions. Finally, we believe that work sampling is a valuable tool for measuring the effect of
longitudinal changes within a pharmacy on pharmacist work patterns.
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Acknowledgments
The authors acknowledge the patience and support of the participating pharmacists and physicians. They thank Ms.
Holly Borgers and Ms. Debby Garey for their time and patience entering the work observations made by pharmacists in
this study.
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Appendix
Definitions of Work Dimensions*
Activities
1. Discussion: Any interactions with one or more people, including telephone conversations.
2. Check Prescription: Checking a prescription that has been prepared.
3. Prepare Prescription: Retrieving a drug from the shelf, counting tablets or capsules,
putting the medications into the container, and labeling the container.
4. Idle: Includes traveling from one place to another or waiting for the next activity.

5. Computer Entry: Any time spent entering information into the computer through the
computer keyboard. (Other data input devices were unavailable.)
6. Other: Includes indexing and filing prescriptions, writing notes, and running errands,
taking a break or eating lunch, and miscellaneous activities.
Functions
1. Fill Prescription: Preparing the prescription to dispense it to the patient.
2. Advise/Inform: Includes giving or taking information about the patient, including any
professional consultation or advice given to a patient, patient representative, physician,
or nurse concerning medication use.
3. Problem-solve: Detecting and correcting problems associated with prescription
duplication and other prescription problems, such as no signature, no strength provided
or unavailable strength, nonformulary drug, or a drug interaction.
4. Other: Includes recording financial information, stocking medications, continuing
education, work measurement, and miscellaneous other functions.
Contacts
1. Self: Includes time when pharmacists are not interacting with anyone.
2. Patient: Includes interactions with all patients and the people who are with them.
3. Pharmacy Personnel: Includes interactions with outpatient, inpatient, and administrative
pharmacy personnel.
4. MD/RN: Includes all physicians, residents, and dentists, whether or not they work at the
institution, and licensed registered and practical nurses.
5. Other: Includes interactions with someone not listed above.
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Notes
This work was supported by Pharmaceutical Outcomes Grant R01-HS07763 from the Agency for Health Care Policy
and Research.
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Footnotes
*

Modified from Hadsall et al.8 and Rascati et al.13

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References
1. Nold EG. Trends in health information systems. Am J Health Syst Pharm. 1997;54: 26974. [PubMed]
2. Sittig DF, STead WW. Computer-based physician order entry: The state of the art. J Am Med
Inform Assoc. 1994;1: 108-23. [PMC free article] [PubMed]

3. Tierney WM, Miller, ME, Overhage JM, McDonald CJ. Physician inpatient order writing on
microcomputer workstations: effects on resource utilization. JAMA. 1993;269: 379-83. [PubMed]
4. Murray MD, Rupp MT, Overhage JM, Ebbeler DE, Main JW, Tierney WM. Multidimensional work
sampling in an outpatient pharmacy. Pharm Pract Manage Q. 1995;15: 44-56. [PubMed]
5. McDonald CJ, Tierney WM, Overhage JM, Martin DK, Wilson GA. The Regenstrief Medical
Record System: 20 years of experience in hospitals, clinics, and neighborhood health
centers. MD Comput. 1992;9: 206-17. [PubMed]
6. Roberts M, Kvalseth TO, Jermstad RL. Work measurement in hospital pharmacy. Top Hosp
Pharm Manage. 1982;2: 1-17. [PubMed]
7. Robertsen JA. Multidimensional work sampling: a new tool for pharmacy management.Top
Hosp Pharm Manage. 1982;2: 1824. [PubMed]
8. Hadsall RS, Gourley DR, Haggerty, JA, Yih P, Windle MJ, Ohri L. Work sampling in
contemporary pharmacy practice: a multidimensional approach. Top Hosp Pharm Manage.
1982;2(Nov): 15-26. [PubMed]
9. Rascati KL, Kimberlin CL, McCormick. Work measurement in pharmacy research.Am J Hosp
Pharm. 1986;43: 2445-52. [PubMed]
10. Nickman NA, Guerrero RM, Bair JN. Self-reported work-sampling methods for evaluating
pharmaceutical services. Am J Hosp Pharm. 1990;47: 1611-7. [PubMed]
11. Guerrero RM, Nickman NA, Bair JN. Work activities of pharmacy teams with drug distribution
and clinical responsibilities. Am J Health Syst Pharm. 1995;52: 614-20.[PubMed]
12. Nickman NA, Schneider JK, Knick KA. Work activities at an ambulatory care pharmacy with
an integrated model of pharmacy practice. Am J Health Syst Pharm. 1996;53: 397402. [PubMed]
13. Rascati KL, Kimberlin CL, Foley PT, Williams RB. Multidimensional work sampling to evaluate
the effects of computerization in an outpatient pharmacy. Am J Hosp Pharm. 1987;44: 20607. [PubMed]
14. Hepler CD. Work analysis and time study. In: Smith MC, Brown TR (eds).Handbook of
Institutional Pharmacy Practice. Baltimore, Md.: Williams & Wilkins, 1979: 84-8.
15. Agresti A. Categorical Data Analysis. New York: John Wiley, 1990.
16. Santner, TJ, Duffy DE. The Statistical Analysis of Discrete Data. New York: Springer-Verlag,
1989: 217.
17. Miller ME. (1996) Some techniques for the analysis of work sampling data. Stat Med.
1996;15: 607-18. [PubMed]

18. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am Hosp
Pharm. 1990;47: 533-43. [PubMed]
19. Penna RP. Pharmaceutical care: pharmacy's mission for the 1990s. Am J Hosp Pharm.
1990;47: 543-9. [PubMed]
20. Iglehart JK. Managed care. N Engl J Med. 1992;327: 742-7. [PubMed]
21. Kohout TW, Broekemeier RL, Daniels CE. Work-sampling evaluation of an upgraded
outpatient pharmacy computer system. Am J Hosp Pharm. 1983;40: 606-8.[PubMed]

Articles from Journal of the American Medical Informatics Association : JAMIA are provided here courtesy of American
Medical Informatics Association

Independent research published by the National Bureau of Economic Research demonstrates that online pharmacies, U.S.
and foreign, verified by certain credentialing entities, sell genuine medication and require a prescription. [16] In that study, all
tested prescription drug orders were found to be authentic when ordered from online pharmacies, international and U.S.-only,
approved by PharmacyChecker.com, as well as U.S. online pharmacies approved by the National Association of Boards of
Pharmacy (NABP) Verified Internet Pharmacy Practice Sites (VIPPS) program or LegitScript, and Canadian-based online
pharmacies approved by the Canadian International Pharmacy Association. Nine percent of tested products ordered from noncredentialed online pharmacies were counterfeit. [16] https://en.wikipedia.org/wiki/Online_pharmacy
Information Technology and Drugs & Cosmetics Act.