INTRODUCTION:

The General Pharmaceutical Council defines an internet pharmacy as “a registered pharmacy which offers tosell or supply medicines (or other pharmaceutical products) and/or provides other professional services over the internet, or makes arrangements for the supply of such products or provision of such services over the internet”¹.

The new age of Internet pharmacies offers prescriptions without a physical exam or even a visit to the doctor's office. As the amount of information on the Internet grows, so does the access to various forms of health care and now self-medication².The Internet gives consumers and patients access to a large amount of helpful and often accurate health and drug information. It has also opened a doorway to risky online "pharmacies" that sell prescription drugs often at a high cost to the consumer in terms of both their pocketbook and their health. Many community based pharmacies have extended their services online to make it easier to get refills and to provide prescription-filling access to patients who might have trouble getting to a pharmacy³. The online pharmacies of these companies fill prescriptions, provide patient information and dispense prescriptions⁴.

These pharmacy sites also provide valuable drug interaction information and patient prescription education as a part of their commitment to provide effective care to their patients⁵. However, a new breed of online pharmacies has appeared on the Internet that provide prescription medicines to patients based solely on an online questionnaire and NOT on a physical exam or office visit with a health professional⁶. Many of the most popular medicines advertised on the Internet if given to the wrong patient could cause birth defects, dangerous blood pressure increases, strokes, and even heart attacks⁷. These pharmacies may be providing strong medications that could lead to serious illness or death if used without the proper screening and monitoring only provided by a personal physician and pharmacist⁸,⁹,¹⁰.

A DANGEROUS DOSE:

Most online pharmacy questionnaires do not ask the patient about high-risk conditions and without an office visit; there is no way for online pharmacies to monitor for this. For doctors to write such online prescriptions without knowing the patient and their past medical history "is below the acceptable standard of care¹¹.

The typical online questionnaire asks an average of 8 to 10 questions covering a patient's general health. Most often, these questions are about a person's weight, height, and age. Very few questions are even about health conditions that might interfere with taking the prescribed drug. Questions that are specific to the medication, like "Do you have high blood pressure?" have only "yes" or "no" answering options. A person may not even know if they have high blood pressure without being diagnosed by an office visit to a doctor. The consequences of someone with unknown high blood pressure obtaining a drug online that is not for use by persons with high blood pressure could be severe and even fatal.

A 52-year-old Illinois man with a history of chest pain and a family history of heart disease died of a heart attack during sex after purchasing Viagra from an online pharmacy that only required an online consultation¹². Had he visited his physician to obtain this prescription drug, he would have undergone a physical exam that would have likely found his heart problems. His doctor could have then decided whether his heart problems made it too risky for him to take Viagra. Unfortunately, an online consultation cannot perform the type of test necessary to screen a person for such risk factors.

"Anybody who needs to use Viagra obviously has some medical problems, should check with their doctor as to whether it's safe and appropriate¹³.

WEB SITES OVER INTERNET:

There are over 36,000 internet pharmacies on the web and hundreds of others sites offer to sell you a wide variety of drugs with little or no problem. Less than 400 of these pharmacies are certified by the National Association of Boards of Pharmacies and have met stringent guidelines for safety. The Internet makes it possible to compare prices and buy products without ever leaving home. But when it comes to buying medicine online, it is important to be very careful. Some websites sell medicine that may not be safe to use and could put your health at risk¹⁴.

The inviting lines: cheap drugs, no prescription required, confidential overnight delivery may be warning signs that you should investigate the site further before providing any information. Some common indicators that the "Internet Pharmacy" site may not be legitimate and should not be used as a source for controlled substances include the following¹⁵.

· The site does not provide a legitimate address and phone number (is it in the US, Canada, ?)

· The site is not a participant in any insurance plan (check your plan for approved pharmacies)

· The site requires that all payments be made with a credit card.

· The site requires that you waive some rights before they send you the drugs.

· The site advises you about the law and why it is permissible for you to obtain pharmaceutical controlled substances from foreign countries via the Internet.

· The site does not ask the name, address, or phone number of your current physician.

· The site suggests the drugs be sent to PO boxes or other locations to avoid detection by U.S. authorities.

· The site does not require that you provide a bona fide prescription issued by your personal physician or mid-level practitioner."

There is a very large industry around the world (especially China and Russia) specializing in fake drugs. These are pills made to look exactly like the real ones but may contain poisonous materials like lead and no real medicine¹⁶. The packaging may be almost perfect but the pills are phony. Some "internet pharmacy" sites don't even sell drugs. They just take your credit card and identity information and sell that¹⁷.

Some websites that sell medicine aren’t U.S. state-licensed pharmacies or aren’t pharmacies at all, may give a diagnosis that is not correct and sell medicine that is not right for you or your condition and may misuse your personal information¹⁸.

Some medicines sold online are fake, are too strong or too weak, have dangerous ingredients, are out-of-date, aren’t FDA-approved, aren’t made using safe standards, aren’t safe to use with other medicine or products you use or aren’t labeled, stored, or shipped correctly¹⁹. The 2004 GAO report on Internet Pharmacies is stunning in the problems they found with internet pharmacies and drug stores²⁰,^{21 , 22}.

Selecting an Internet Online Pharmacy or Drugstore:

· Make sure the site requires a prescription and has a pharmacist available for questions²³.

· Buy only from state-licensed pharmacies. The National Association of Boards of Pharmacies has more information about licensing and its program to certify online pharmacies. Of the 36,402 pharmacy websites the Board has studied only 338 were found to be legitimate and over 96% or 35,323 did not meet Board standards²⁴,²⁵.

· Don't provide personal information such as credit card numbers unless you are sure the site will protect them.

Future of E-Pharmacy:

As Internet-based technologies continue to evolve, pharmacists need to stay up-to-date with emerging applications that are likely to further impact the profession. For example, electronic prescribing (e-prescribing) is expected to become much more common in the next few years. Other emerging Internet applications, such as tele-pharmacy and the use of electronic medical records (EMRs), also are poised for rapid growth²⁶.

E-Prescribing:

For years, experts in health care have been predicting the arrival of e-prescribing, in which physicians send prescriptions via the Internet or another telecommunications channel directly to the patient's chosen pharmacy. According to the Institute for Safe Medication Practices (ISMP), fewer than 5% of U.S. physicians wrote electronic prescriptions in 2000, but the practice is expected to increase as more physicians begin using PDAs. ISMP has called for complete elimination of handwritten prescriptions by 2003²⁷.

The best e-prescribing products require only three touches on a PDA (or other computer device) to generate and transmit a prescription (see Figure 1). The first touch selects the patient's name from a preloaded database that includes the physician's daily office schedule. A second touch, typically done at the conclusion of the visit, indicates a diagnosis for the patient. With this input, the device assigns the appropriate coding to facilitate claims processing for the visit and screens for appropriate medications on the formulary for the patient's insurance company. With a third and final touch, the physician could select a prescription from a predetermined list and send the order to the patient's preferred pharmacy²⁸.

Figure 1 The e-prescribing, in which physicians send prescriptions via the Internet or another telecommunications channel directly to the patient's chosen pharmacy.

[ CLOSE WINDOW ]

Figure 4

Ideally, a legible prescription would arrive in the pharmacy at least 45 minutes before the patient to allow adequate time for dispensing. The patient's eligibility, physician credentialing, formulary, and drug utilization review considerations would all have been cleaned up in the process.

Advocates of e-prescribing say the technology holds great promise for reducing medication errors, especially those resulting from illegible prescriptions²⁹. For pharmacists, e-prescribing offers several other potential benefits, including greater patient convenience, improved formulary compliance, and fewer disruptive callbacks from the pharmacy to the physician's office to clarify illegible prescriptions. Furthermore, by streamlining the dispensing process, e-prescribing could provide pharmacists with more time to provide counseling and pharmaceutical care³⁰.

However, this innovation also poses some drawbacks, including the potential for prescription dispensing to be directed away from the community pharmacy to Internet sites. Also, dispensing errors may occur with the use of electronic devices, such as those resulting from mistakes in data entry. The technology also poses the risk of compromising patients' confidentiality, if, for example, a physician's PDA is stolen³¹.

A national effort to strengthen the security of Internet-based communications between pharmacists, physicians, and other health care professionals is being implemented by Intel, a leading maker of computer and networking products, and APhA. Through the use of a digital credential created by Intel, pharmacists and technicians will be able to establish secure lines of communication over the Internet with other health care professionals. The digital credential will allow pharmacists to verify their identities online, facilitating communication with other members of the health care team³².

Finally, legitimate use of e-prescribing should not be confused with the recent alarming trend in which patients can visit various "rogue" pharmacy Web sites, answer a few questions about their health history, then have a prescription sent to them. These sites, which offer no true physician-patient interaction or dialogue, dispense prescriptions based on often unverified customer information. Physicians who participate in these practices are subject to reprimand by medical boards, loss of licensure, and, potentially, prosecution at the state and federal levels. E-prescribing, as described here, involves interaction and dialogue between the physician and patient, with an electronic prescription resulting from this interaction³³,³⁴.

Telepharmacy:

Telepharmacy, the provision of pharmaceutical care services from a distance, is being practiced on a small scale today, with much broader applications expected in the future. For example, Eckerd Corporation recently teamed up with the Health Hero Network, a Mountain View, Calif., e-health company, to provide telepharmacy services for a small number of chronically ill homebound patients in the Eckerd Patient Care program³⁵,³⁶.

In Eckerd's pilot pharmaceutical care program, homebound patients received a small computer appliance, about the size of an answering machine, called the Health Buddy (see Figure 2). The Health Buddy hooks up to the patient's phone line and has a screen that displays large bold letters for easy readability. When connected to the Internet, the device provides a simple and convenient way for pharmacists to receive and respond to patients' health-related questions, send reminders, and provide education. For example, using the Internet, a pharmacist may ask a patient with diabetes, "Did you check your feet today?" If the answer is "No," the patient can be educated as to why daily foot inspections are important and how to perform them³⁷.

Figure 2 The Health Buddy application can be used in telepharmacy applications to connect homebond patients or those in remote locations to a pharmacist or other health care provider.

Increasingly, telepharmacy will be used to directly manage patients who are homebound or living in remote areas, using a combination of live interventions, such as online messaging and videoconferencing, and "store and forward" interventions. Store and forward interventions involve sending stored electronic information from a central computer to patients (or to other health care providers) in a just-in-time manner. For example, an instructional video on the proper use of a corticosteroid inhaler could be stored on the pharmacy's computer, then forwarded to an asthma patient who has received a new prescription for this medication, ideally as an adjunct to direct patient counseling³⁸.

Electronic Medical Records:

Another emerging Internet application is the EMR, in which a patient's medical record is stored in a computer or server for online access by authorized providers. The EMR will provide a complete longitudinal medical document that gives caregivers global access to a patient's entire medical history when making health care decisions³⁹.

In the future, patients will likely sign informed consent releases allowing trusted health care professionals access to their EMRs⁴⁰. People may carry plastic cards with magnetic swipes, similar to those used in automatic teller machines, to access their EMRs. For example, if a person were unconscious in an emergency department, health care providers could insert that individual's EMR card into a computer device and electronically retrieve a complete and up-to-date medical record⁴¹.

A few e-health companies have already begun to offer EMR services. For example, Personal MD. com (www.personalmd.com) allows members to store and retrieve personal medical information, including paper-based records such as electrocardiograms, lab results, and X-ray reports, from a secure file that can be accessed via Internet or fax anywhere in the world⁴².

An important mission for pharmacy is to gain the authority for read and write access to EMRs. That is, pharmacists must be able to access and read a patient's EMR and then write his or her care activities in the record, thus documenting their important role in the health care process⁴³. Without read and write access to EMRs, pharmacy practice could be relegated to a dispensing-only mode in the future^44-48.

CONCLUSION:
Despite authorities’ attempts to protect the public through law enforcement, new websites are showing up daily. It is the consumer's responsibility to use the Internet cautiously and knowledgeably. There are some guidelines for consumers who use the Internet as part of their pharmaceutical care process. These guidelines include using only VIPPS-certified pharmacies and speaking to your doctor before starting any medication.

If you think you have a certain medical condition or you are interested in using a prescribed drug, speak with your doctor or pharmacist. They can provide an invaluable amount of information about medical conditions and medications that will be tailored to your personal medical history and disease state. Not only will they be able to answer your questions, but they will provide care that is in your best interest.

As the Internet makes health and pharmaceutical care more accessible, one thing will remain certain-there is no substitute for speaking with your doctor and pharmacist.

"Order prescription medications from the comfort of your home-without a trip to the doctor's office!"

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Received on 17.02.2011 Accepted on 22.02.2011

Asian J. Pharm. Tech. 1(1): Jan.-Mar. 2011; Page 04-08