The Fourth Industrial Revolution: Will it change pharmacy practice?

Schwab (2017) argues that society is at the beginning of a Fourth Industrial Revolution
(4IR). This era will radically change the human use of technology, with major
implications for the ways we live and work. The first industrial revolution started after
1760 and led the move from hand production to machines, which created many new
industrial processes including chemical manufacturing. The second revolution occurred
after 1870 and was initially stimulated by new methods for the mass production of steel,
but then spread to the developments in other industries such as chemicals and transport.
The third revolution (the “Digital Age”) began in the 1960s with the development of
electronics, information technology (IT) and automated production. We are now entering
the 4IR, which will create innovative capabilities for people and machines through the
adoption of technologies such as cyber-physical systems, the Internet of Things (IOTs)
and the Internet of Systems (Gatouillat et. al., 2018).

Throughout its history, pharmacy has successfully adopted a range of “general purpose
technologies” (GPTs) that were developed during the first three industrial revolutions.
GPTs are defined as technologies that affect an entire economy and have the potential to
disrupt the economic life of whole societies.(Helpman, 1998) To date, only 24 GPTs have
emerged, including the steam engine, trains, electricity, computing, the internet, artificial
intelligent and blockchain.(Lipsey et. al., 2005). During their history, apothecaries,
chemists and druggists and modern-day pharmacists have all used GPTs to: create the
pharmaceutical industry; invent new processes for making dyes; improve brewing
techniques; advance photography and film-making; introduce robotic and barcode
dispensing; harness sensor technology in dossetts and pill boxes. As this list suggests,
pharmacy evolved because of its industrial-scale adoption of GDPs from the first three
revolutions. The key question, therefore, how can we make this trend continue during the
fourth wave?

For all industrial sectors, the consequences of the 4IR are predicted to be unprecedented.
Schwab (2017, p.2) describes the potential risks and benefits:
 The changes are so profound that, from the perspective of human history, there has
never been a time of greater promise or potential peril. My concern, however, is
that decision-makers are too often caught in traditional, linear (and non-disruptive)
thinking or too absorbed by immediate concerns to think strategically about the
forces of disruption and innovation shaping our future.

Just as these words apply to all industries, Schwab’s message also applies to pharmacy. If
the pharmacy sector is stuck in traditional, linear thinking that assumes the future will be
an extension of the past, then the fourth revolution may be less of a promise and more of a
threat. In consequence, outsiders may take over many activities that have traditionally
been considered to be solely pharmacy work. For instance, online dispensaries may move
business away from local “bricks and mortar” pharmacies. Phone apps may replace the
need for face-to-face pharmaceutical care, with online platforms for patient counselling. In
response, there is a pressing need for the pharmacy sector as a whole to consider how
fourth wave technologies will affect the future of its clinical and commercial activities.

Technology types
Writing about pharmacy, Baines et. al. (2018a) defines “technology’ as the “dynamic
clustering of techniques, methods, skills and processes used in the production of goods or
services or in the achievement of outcomes that deliver desired benefits for consumers”.
This definition suggest the fourth wave technologies could: (i) help pharmacists do what
they currently do better, (ii) extend the range of outcomes the profession is able to
produce, (iii) a combination of both. However, a technology is not just a cultural product,
but in itself a producer of culture (Nørgaard et. al., 2001). This should be taken into
account, when we try to grasp the meaning of the technology as part of the future in
pharmacy.(Baines, 2015a) For instance, dispensing, patient counselling and the delivery of
services could be made more cost-effective by technologies such as mobile phone apps.
Similarly, pharmacy could extend its services into data analytics using Big Data. If no
competition exists, fourth wave technologies may promote a viable future by creating a
more efficient, expansive pharmacy sector. Applying technologies may support pharmacy
as a valid player in the healthcare sector. However, the sector as a whole faces the
“innovator’s dilemma” when responding to 4IR. Should the pharmacy profession disrupt
their current activities in order to: (i) do things better, (ii) do new things, and (iii) deter
competition? We believe that these are pressing issues in need of widespread debate.

Pharmaceutical care
Leading pharmacists are aware that technology can disrupt society and the economics of
pharmacy. Over thirty years ago, Hepler (1988) argued that technology, economics and
social values are the major forces shaping pharmacy's future. Amongst the technological
forces shaping pharmacy practice, Helper cited computers, robotics, communications and
therapeutics as the stimulants of change. Amongst the important economic factors, he
listed managed care, payment for outcomes and the marketing services as the factors most
likely to have the largest effect. Finally, Hepler believed that an aging population, the
weakening of professional authority and a deterioration in pharmacy's public image were
having the biggest social impact on the profession. In response, he argued that pharmacists
should return to their fundamental relationship with society by accepting the ethical
responsibility for drug-use control. To accomplish this goal, pharmacy would need to
undergo a process of occupational reconstruction and self-renewal in order to become
providers of a new societal model of practice, which Hepler and Strand (1990, p.539) refer
to as “pharmaceutical care”. They state:

Pharmaceutical care is the responsible provision of drug therapy for the purpose of
achieving definite outcomes that improve a patient’s quality of life. These
outcomes are: (1) cure of a disease, (2) elimination or reduction of a patient’s
symptomatology, (3) arresting or slowing of a disease process, or (4) preventing a
disease or symptomatology.

Pharmaceutical care was developed during the third industrial revolution. In the last thirty
years, advances in computing, robotics, communications and therapeutics have all been
stimulants of change. For instance, most pharmacies are computerized, just as robotics
dispensing is growing fast in use. The question, therefore, arises: how will pharmacy
respond to the opportunities and challenges offered by the 4IR?

In the healthcare sector, the 4IR revolution is happening much faster outside of pharmacy
than within. Where the targets of innovation are medicines supply or advice, the main
developers and players involved in the 4IR? tend not to be pharmacists. This raises serious
questions about the future development of the pharmacy sector.(Rossing, 2018) For
instance, what will happen to local pharmacies if most dispensing moves online? What is
the professional role of the pharmacy if dispensing disappears? After thirty years of
struggling to establish clinical pharmacy as a viable model of practice, what will happen to
patient counselling if innovative technologies bypass pharmacy and go straight to
consumers? In response to such questions, we believe that stakeholders in pharmacy
should engage in open discussion about the opportunities and threats of the 4IR.

Health technology
The World Health Organization defines “health technology” as the “application of
organized knowledge and skills in the form of devices, medicines, vaccines, procedures
and systems developed to solve a health problem and improve quality of lives”. This
definition goes beyond the everyday definition of “technology” as manufactured objects
such as mobile phones or computing such as Artificial Intelligence (AI) used by human
beings either for their own personal ends or for the production of goods and services for
sale (Feenberg, 1991; Vyas et. al., 2018). Researchers from the science technology society
argue that the term technology contains at least three components, which are to be present
simultaneously in order for a piece of technique to be functioning, namely: (i) hardware
(tools, machines, devices), (ii) knowledge (knowledge and knowledge interest embodied
in the hardware) and (iii) organization (the ensuing systematic procedures or mode of
work which goes with the use of the hardware (Nørgaard 1996; MacKenzie and Wajcman,
1985). These technology definitions all include the wider dynamic surrounding the use of
technologies to include the actions of humans using clinical procedures and health systems
to help create wellbeing and quality of life. In response, pharmacists would benefit from
viewing technologies as embedded in, and inseparable from, the overall production
processes that supply drugs and generate patient wellbeing (Baines et. al., 2018b).

Traditionally, pharmacy has based its operational procedures for dispensing and
pharmaceutical care on the assumption that patients will interact with pharmacists face-to-
face. According to Schwab, fourth wave technologies will advance communications and
connectivity in ways that connect billions of people to the internet in innumerable ways.
Future developments in internet-based technologies could remove pharmacists from the
process of care delivery. In other words, 4IR could disrupt physical, on-the-ground
networks between doctors, patients and pharmacists and create cyber, in-the-cloud
connections that promote “direct-to-consumer pharmacy”. For instance, Big Data and AI
could identify patient needs, track medicines usage and search for pharmaceutical
problems. All of this could happen automatically based upon algorithms and specified
treatment routines, without the input from pharmacists in real time. Moreover, these
services could be provided outside of traditional pharmacy locations (such as community
and hospital pharmacies), existing only in cyberspace with no or only limited face-to-face
contact.

In developing the pharmaceutical care paradigm, Hepler and Strand were exacting in their
analysis of the evolution of pharmacy and forceful in outlining their vision of pharmacy’s
role in society. Whilst the technological, economic and social challenges they described
thirty years ago have moved on, the underlying issue have not really: how should
pharmacy re-professionalise itself to create value and wellbeing for patients in an ever-
evolving society? The 4IR has made this question pertinent again. Online, direct-to-
consumer pharmacy has the power to disrupt the local, face-to-face networks that have
long existed between doctors, patients and pharmacists. In response, we believe that now
is the time for a debate about the opportunities and threats to medication safety that will be
caused by the disruptive 4IR, with a specific focus on what pharmacy can contribute in a
rapidly changing healthcare sector.
Evidence suggests that external parties will be happy to create a new future for an industry
that traditionally has been the monopoly of the profession of pharmacy.(Baines, 2015b) In
this context, pharmacy urgently needs a new roadmap, an innovative blueprint in order to
survive the disruption ahead.

Conclusions
Pharmaceutical care was meant as a philosophy of practice. A method of caring for
medicines treatment and taking responsibility for patient outcome. Pharmacy was meant to
have a supporting role in this process. To uphold this position and take leadership of
pharmaceutical care in the future, pharmacy needs to be curious on how to work with AI,
Big data, augmented reality, and much more. If the new game is understood, the
pharmacist may become the playmaster of tomorrow.
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