**5. Discussion**

The 2019 findings showed that 34% of U.S. pharmacists devoted their time primarily to medication providing (compared to 40% in 2009 and 2014), 52% contributed a significant portion of their time to patient care service provision (compared to 40% in 2009 and 2014), and the remaining 14% contributed most of their time to other health-system improvement activities. This is the first time in the modern pharmacy era that over half of all pharmacists (52%) spend considerable amounts of time in patient care service provision that is separate from patient care that accompanies medication providing. In addition, the segmen<sup>t</sup> of pharmacists who devote almost all of their time to patient care services, separate from medication providing, had doubled from 6% of pharmacists in 2009 to 12% of pharmacists in 2019. It should be noted that the data collection method for 2019 used an electronic survey, which was di fferent than a mailed questionnaire approach that was used for 2009 and 2014. However, non-response bias was checked for each of the three survey years, and respondents were found to be representative of the overall pharmacist population of interest in terms of geographic distribution, gender, age, and year of the first licensure. Our confidence in the representativeness of each sample for each of the years was high, but this variation in the method should be considered when interpreting the findings.

These shifts have significant implications for the work system and process designs that will be needed for new ways of delivering products, managing inventory, and reimbursing for the product cost. At the same time, new ways for recruiting and connecting patients with practitioners, achieving patient outcomes, organizing space for patients to receive services, and being reimbursed for value-based outcomes are needed. We suggested that these significant changes in work systems and processes of care are now the most significant influences on the types of work activities performed by pharmacists and the time they devote to these activities [2]. Distinguishing characteristics of the segments suggested that recent growth in the pharmacist workforce has been in the patient care services, with more being provided through remote means in organizations that are not licensed as pharmacies (see Table 2). This not only has implications for the work system and process designs but also for updates that are needed for scope-of-practice regulations.

One of our goals was to interpret the findings within the context of the future scope of practice changes that could a ffect roles filled by pharmacists and pharmacy workforce support personnel. Whereas transitions in clinical training (PharmD, Residency) had contributed to increased capacity for pharmacist contributions to the U.S. Health Care System [1,2,5], the 2019 data showed that transitions in work systems and processes of care (including updates for regulation and roles for pharmacy support personnel) are likely necessary for increasing pharmacist contributions to the U.S. Health Care System in the next decade. As mentioned in the introduction of this paper, pharmacies are being organized by their capacity to operate as healthcare access points that provide patient care and public health services. Comprehensive integrated care models are being created through horizontal integration with clinics, medical centers, community centers, and even places of employment [8–12]. Vertical integration between insurance companies, wholesalers, manufacturers, integrated delivery networks, pharmacy benefit managemen<sup>t</sup> companies, and health care centers are being formed to coordinate services, improve access, leverage data, and bear financial risk for health outcomes of patient populations [9,14–17]. As these transitions take place, new ideas for (1) tech-check-tech processes [34–36], (2) patient-tailored packaging and delivery [37], and (3) application of new technologies [37] are being applied.

As pharmacist work activities continue to evolve in the future, it is likely that pharmacy support personnel work activities will be impacted as well. A systematic review of pharmacy technician participation in support of medication therapy managemen<sup>t</sup> service provision [42] has shown that they are most commonly provided assistance with medication reconciliation (70%), documentation (41%), and medication therapy review (30%). Actions least likely to be described include personal medication record development (5%), physical assessment (5%), follow-up (2%), and medication action plan development (0%). Another study [43] has shown that pharmacy technicians in the United States are regularly involved in calling prescribers for clarifications of orders, collecting information from patients, documenting pharmacy care in patient records, and calling patients regarding refills. Other tasks that are not regularly performed but for which technicians report that they are very willing to provide include preparing vaccinations for administration, taking orders from physicians over the phone, transferring a prescription to another pharmacy, and conducting medication reconciliation after a patient is discharged from a hospital [43]. That study has identified four work system and process changes that would help facilitate technicians embrace emerging tasks. They are related to adequate staffing, having time to complete additional tasks, classifying technicians based on specialized skills, and helping cope with stress in the work environment [43]. We highlighted these findings to make the suggestion that, as pharmacist work activities change, pharmacy support personnel work activities will change as well. Koehler and Brown reported that pharmacy technicians and other pharmacy support workforce cadres differ globally in terms of supervision, requirements, education systems, and regulations [44]. Similarly, a pharmacy technician stakeholder consensus conference in the United States [45] has shown variation among technicians in the United States and called for more uniform standards for pharmacy support personnel in terms of legal definition/licensing/regulation, education, entry-level competencies, certification, and advanced practice roles.

As such changes are made within the pharmacy profession, it must be noted that the U.S. Health Care System is filled with perverse incentives, financial pressures, documentation burdens, the pressure to meet production metrics, and a constant specter of litigation that are creating intensely competing drivers that are emotionally and morally exhausting for pharmacists and pharmacy support personnel as they try to deliver the care that their patients need [46,47]. Thus, there is also a need for a focus on training and system change related to work conditions for personnel, patient safety, paymen<sup>t</sup> models, organizational designs, wellbeing, and communications within the overall systems of health care. This will take collective action.
