the i-tribe community pharmacy practice Model

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The I-Tribe Community Pharmacy Practice Model: Professional pharmacy unshackled Greg L. Alston and Jennifer A. Waitzman

Received October 30, 2012, and in revised form February 8, 2013. Accepted for publication February 9, 2013.

Abstract Objective: To describe a mechanism by which pharmacists could create a disruptive innovation to provide professional primary care services via a Web-based delivery model. Summary: Several obstacles have prevented pharmacists from using available technology to develop business models that capitalize on their clinical skills in primary care. Community practice has experienced multiple sustaining innovations that have improved dispensing productivity but have not stimulated sufficient demand for pharmacy services to disrupt the marketplace and provide new opportunities for pharmacists. Pharmacists are in a unique position to bridge the gap between demand for basic primary medical care and access to a competent medical professional. Building on the historic strengths of community pharmacy practice, modern pharmacists could provide a disruptive innovation in the marketplace for primary care by taking advantage of new technology and implementing the I-Tribe Community Pharmacy Practice Model (I-Tribe). This model would directly connect pharmacists to patients through an interactive, secure Web presence that would liberate the relationship from geographic restrictions.

Greg L. Alston, PharmD, is Assistant Dean for Assessment and Associate Professor of Pharmacy; and Jennifer A. Waitzman, PharmD, BCACP, is Assistant Professor of Pharmacy, School of Pharmacy, Wingate University, Wingate, NC. Correspondence: Greg L. Alston, PharmD, School of Pharmacy, Wingate University, 515 N. Main St., Wingate, NC 28174. Fax: 704-233-8332. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

Conclusion: The I-Tribe is a disruptive innovation that could become the foundation for a vibrant market in pharmacist professional service offerings. The I-Tribe model could benefit society by expanding access to primary medical care while simultaneously providing a new source of revenue for community practice pharmacists. Entrepreneurial innovation through I-Tribe pharmacy would free pharmacists to become the care providers envisioned by the profession’s thought leaders. Keywords: Disruptive innovation, technology, market niche, value. J Am Pharm Assoc. 2013;53:163–171. doi: 10.1331/JAPhA.2013.12199

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n 2004, the Joint Commission of Pharmacy Practitioners adopted the Vision 2015 statement articulating a nondispensing role for pharmacists as primary health care providers.1 In 2008, the Project Destiny report further described this future role for community practice pharmacists.2 This vision has been percolating within the profession since the drive to clinical education reached critical mass in the mid-1970s. It is time to ask the tough question: “What is preventing us from reaching this goal?”

Obstacles to innovation The first obstacle is institutional. Pharmacy school graduates have a tremendous array of clinical skills. However, they do not necessarily have the business skills to monetize their clinical skills creatively. The drive toward better clinical education may have unintentionally deemphasized the role of business skills in career success.3 Svenson et al.4 stated that “too often, our viewpoint in the Academy is to get students to master a relatively narrow set of skills and knowledge that focuses on clinical practices as we currently understand this view-

At a Glance Synopsis: Modern pharmacists could provide a disruptive innovation in the marketplace for primary care by taking advantage of new technology and implementing the I-Tribe Community Pharmacy Practice Model (I-Tribe). This innovation would provide new primary patient care services directly to patients in a cost-effective and profitable manner that could be implemented without third-party payers acting as intermediaries, while simultaneously providing a new source of revenue for community practice pharmacists. The key elements to disrupting the market for professional primary care services would be positioning a new pharmacist-based service at the low end of the market and targeting the service to satisfy simple needs that existing providers have no interest in or inclination to providing. Analysis: Community pharmacy practice has experienced multiple sustaining innovations that have improved dispensing productivity but have not stimulated sufficient demand for pharmacy services to disrupt the marketplace and provide new opportunities for pharmacists. I-Tribe pharmacy could be the disruptive innovation that expands employment opportunity for pharmacists, insulating them from the types of sustaining innovations designed to reduce the costs of providing care and eliminate the need for dispensing pharmacists. Entrepreneurial innovation through I-Tribe pharmacy would free the pharmacist to become the care provider envisioned by the profession’s thought leaders. 164 JAPhA | 5 3 :2 | M AR/AP R 2013


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point tends to minimize the profession’s past history of evolving new and different roles for pharmacists.” Consequently, students receive little instruction on how to create innovative practice models during their pharmacist education. The second obstacle is bias. The pharmacy profession exhibits a fundamental bias toward obtaining knowledge rather than taking action. This bias assumes that revolutionary changes in pharmacists’ professional roles will occur by an orderly linear process and that the primary care role will be awarded to pharmacists after building a body of evidence that proves they are worthy of performing that role. However, waiting for the proof of concept to be validated creates “paralysis by analysis” and suppresses action. Evidence of the economic benefit of pharmacist services has existed for at least the last 12 years.5 This bias toward evidenced-based decisions produces a crippling set of self-limiting beliefs that foster hesitation rather than stimulate the bold actions required to innovate. Many pharmacists are shackled to the selflimiting assumptions that community pharmacists must work for brick-and-mortar pharmacies, patients won’t pay for pharmacist services, pharmacists can only service patients who live in their local area, and merging Internet marketing practices with real patient care is not possible. Before the clinical pharmacy movement, community pharmacists were primarily risk-taking entrepreneurs who provided valuable goods directly to consumers. A new generation of risk takers is needed to create new markets for the expanded array of clinical services that could be assisted by new technology. The third obstacle is economic. Corporate business decisions are frequently based on cost control and productivity rather than on provision of better patient care. The large multisite employers of pharmacists typically attempt to develop innovative practice methods aimed at sustaining existing business models. These sustaining innovations incrementally reduce costs and improve productivity but do not lead to the disruptive products or services that appeal to customers who are unattractive to existing market leaders. Large organizations have difficulty creating disruptive innovation.6 The fourth obstacle is legal. State-specific pharmacy regulations were crafted based on the assumptions that pharmacists dispense drugs and work in brick-andmortar pharmacies. These assumptions are no longer true for all pharmacists, and the current regulations are straining to cope with new practice models. For professional services to reach their maximum potential, pharmacists need to be able to provide services across state lines legally. The fifth obstacle is training. There is a fundamental misunderstanding of the type of innovation necessary to break away from dispensing as the sole source of income. Computers, workflow systems, and robotics have Journal of the American Pharmacists Association

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been touted as innovations that will free the pharmacist to serve rather than dispense. However, they have done little to increase the market for new services. The pharmacy profession requires a disruptive innovation to create new income streams for pharmacists. Therefore, pharmacists need to be trained on the process of innovation.

Disruptive innovation Hwang and Christensen7 posit that disruptive innovations will shift the question from “How do we afford health care?” to “How can we make health care more affordable?” Sustaining innovations, such as computerized records, claims management, and automation, boost profit margins and productivity but don’t create new markets. Disruptive innovations, on the other hand, are typically entry-level market products that bring complicated services down to a level that makes them more broadly available.8 As costs are squeezed from the prescription dispensing process, fewer pharmacists will be required to dispense prescriptions. Therefore, as the health care system becomes more efficient, more pharmacists will be available to perform nondispensing services. The critical question is: What will they do? The disruptive innovation proposed here is the transition from traditional community pharmacy practice to an interactive I-Tribe Community Pharmacy Practice Model (I-Tribe), as either an adjunct to the brick-andmortar practice or a stand-alone alternative. This innovation will create a tool to provide new primary patient care services directly to patients in a cost-effective and profitable manner that can be implemented without third-party payers acting as intermediaries. The key elements to disrupting the market for professional primary care services would be (1) positioning a new pharmacistbased service at the low end of the market and (2) targeting the service to satisfy simple needs that existing providers have no interest in or inclination to providing.8 This would establish a market beachhead for strategic growth into more sophisticated services in the future.

Foundation for the Internet-connected I-Tribe Seth Godin, in his book Tribes: We Need You to Lead Us,9 describes the essential concept of a tribe and explains how the intersection of Internet and software technology makes the creation, nurturing, and growth of tribes possible. In his definition, “A tribe is any group of people, large or small, who are connected to one another, a leader, and an idea.”9 The Internet has eliminated the barriers to geography, cost, and time that previously made forming a tribe difficult. The success of a tribe will depend on a passionate leader who understands how to lead in the digital age. The I-Tribe will thrive when an engaged pharmacist leader identifies a focused topic around which a group of patients will organize, underJournal of the American Pharmacists Association


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stands the key problems the group wishes to solve, develops an appropriate solution for their problems, and delivers that solution to the tribe in a way that is mutually beneficial. The tribe could come together in an interactive virtual Web-based community that allows dissemination of information, two-way communication with the I-Tribe leader as the professional mentor, and access 24 hours a day, 7 days a week, 365 days a year to an energetic group of engaged tribe members willing to help each other. The I-Tribe will be united by a common interest, without the geographical restrictions of a traditional brick-and-mortar practice. A properly constructed interactive Web presence is feasible using the technology available today, at a cost that is within the reach of an individual practitioner. Many of the component tools required to execute this strategy already exist in the form of e-mail autoresponder systems, blog platforms, membership site platforms, social media platforms, Internet marketing technology, virtual assistant technology, electronic payment systems, secure communications portals, video conference services, mobile tablet computers, and electronic publishing platforms. The missing ingredients are enthusiastic, enlightened pharmacists willing to build their own I-Tribe practice and a technology partner willing to develop the platform. The latter is vital to the I-Tribe, so that the pharmacist can focus on patient services and not on tech support.

I-Tribe revenue model Several methods are available to monetize the I-Tribe to produce revenue. These methods include charging for membership in the tribe, selling information products such as e-books, special reports, audios, and videos via digital delivery; charging for live consultation via teleconference or video conference; receiving referral fees for recommending other products and services; increasing dispensing volume, medication therapy management, and immunization revenue for a dispensing pharmacy; and increasing website advertising revenue. ITribes could develop around tightly focused microniche topics, allowing each pharmacist to specialize in what they do best. Networked pharmacists could form alliances with pharmacists in noncompeting niches to refer patients and receive compensation for that referral. Using this network of experts would allow generalist pharmacists to focus attention on a wide range of topics for their patients without having to be the expert in each area. As I-Tribes flourish, this network could share content, strategies, and techniques to provide additional income streams. All tribes could participate in a network system that would track and reward intertribe referrals at mutually agreed upon payment rates. One potential diagram of the I-Tribe model is shown in Figure 1. This free agent nation of pharmacists would thrive based on the pharmacists’ individual ability to successj apha.org

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The I-Tribe leader pharmacist

I-Tribe member patients

Figure 1. Schematic of the I-Tribe patient portal system for the secure provision of basic primary patient care advice, products, and services fully create value for their patients, the tribe members. The typical community pharmacy draws the bulk of its patrons from within a 3- to 5-mile radius of the store and may thrive with as few as 5,000 core customers. I-Tribe members could live anywhere in the world, thus providing access to vast new audiences and adding new incremental revenue for a current brick-and-mortar pharmacy that adds an I-Tribe to its product mix. Estimated costs for operating an I-Tribe were compiled from current commercial websites and are shown in Table 1. The start-up costs for a minimal Web presence would be approximately $747 for a website with basic functionality. The monthly charges for webhosting, video conferencing software, secure e-mail, and telephone could be kept near $174 for providing access 166 JAPhA | 5 3 :2 | M AR/AP R 2013


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service that is available 24 hours a day, 7 days a week, 365 days a year. The monthly break-even revenue required with this minimal iteration would be only nine transactions if each sale produced a $20 profit. Every existing retail customer will not necessarily purchase I-Tribe services, but incremental revenue generated by high-margin information products would add to bottom-line profits with patient conversion rates greater than 2.38% in a basic version of the I-Tribe tool set. For the I-Tribe to become successfully disruptive, it would need to create new revenue streams, be scalable, be user friendly, ensure Health Insurance Portability and Accountability Act compliance, and integrate with existing business practices.



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Table 1. Estimates of cost and break-even point for the basic technology required to operate the I-Tribe Community Pharmacy Practice Model at a profit I-Tribe technology Domain name registrationa Website hostinga HIPPA-compliant e-mailb VOIP telephone service unlimited callingc Audio/videoconferencingd Membership site management software hostede E-mail autoresponder servicef WordPress custom theme purchaseg WordPress custom theme setup and customizationh Site maintenanceh Total No. of transactions with a $20 net profit required to break even Percentage of 5,000 patient/customer base required to break even

Start-up cost $ 10 7 20 10 0 0 0 100 500 100 747 38 0.76

Monthly cost $ 0 7 3 30 24 25 10 0 0 100 174 9 0.18

Annual recurring cost $ 10 84 36 360 288 270 120 0 0 1,200 2,368 119 2.38

Abbreviation used: HIPAA, Health Insurance Portability and Accountability Act. a GoDaddy.com. b MDOffice.com. c Vonage.com. d Webex.com. e WildApricot.com. f MailChimp.com. g Themeforest.com. h Elance.com.

Process for creating an I-Tribe The key to fully capitalizing on this model is for pharmacists to stop waiting for permission to provide primary care and to begin using their business skills to develop an I-Tribe practice. The only way to prove it works is to start doing it. Trying involves very little downside risk. The start-up investment required is so low that the reward-to-risk ratio approaches infinity. Although a proven business process has not been established, the process needed to create a professional business I-Tribe niche market involves four intuitive steps (Figure 2): (1) identify a market niche, (2) develop a business plan to thrive within that niche, (3) make an irresistible offer to potential I-Tribe members, and (4) lead the tribe. Step 1: Identify a market niche For a niche market to be profitable, it must be large enough to support the business plan and the target market must be willing to spend money on the service. The health care system is undergoing a paradigm shift as a result of the Affordable Care Act.10 Access to primary care medical services is a concern. A 2011 survey indicated that 57% of sick patients could not obtain access to care promptly.11 After implementation of the Massachusetts law, on which the federal legislation was modeled, wait times for medical appointments averaged 36 days for family medicine and 48 days for internal medicine. Less than 50% of primary care physicians were accepting new patients.12 Medical schools graduate specialJournal of the American Pharmacists Association


ists and subspecialists with extraordinary clinical skills. However, this training is expensive and places considerable financial pressure on the new physician to generate enough income to pay off school loans and build a profitable practice. In addition, the vast majority of the typical patient’s entry-level health issues are relatively mundane diagnoses and treatments that do not require a fraction of this training.13 The use of expensive specialist physicians to provide basic primary care creates a competitive advantage for a lower-cost solution to be provided by pharmacists. Determining whether primary patient care is a suitable target market niche around which to create an innovation such as an I-Tribe practice is possible by reviewing the three tests for creating a new market base for disruption of Christensen et al.14: 1. Does the innovation target customers who in the past have not been able to do it themselves for lack of money or skills? Are entry-level customers avoiding consulting a medical professional as a result of a market barrier such as price or accessibility? A study concluding that 57% of sick patients could not obtain prompt access to a physician suggests that barriers exist.11 2. Is the innovation aimed at customers who will welcome a simple product? Are people seeking answers to basic health care questions? The volume of Google searches on health care topics each month would suggest that individuals are not getting the j apha.org

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Identify a market niche What problem can I solve for a group of people?

Develop a business plan

Make an irresistible offer to the market How can I maximize the perceived value of my offer to potential tribe members?

Professional I-Tribe niche strategy

How can I provide valuable services to the market via a scalable strategy?

Lead the tribe How often and in what manner will I communicate with the tribe?

Figure 2. The four steps to developing an I-Tribe pharmacy practice niche answers they want from their health care providers (Table 2). 3. Will the innovation help customers to do more easily and effectively what they are already trying to do? The current options for basic primary care are to figure out what you need from public information sources or travel to a physician’s office and wait for a few hours to spend 3 minutes with a physician. It is reasonable to believe that a need for better access to primary care exists and that a source that is medically competent, but provides customized care plans, would fill a gap in the current marketplace. Step 2: Develop a business plan to thrive within that niche After identifying a market base, two tests can be used to determine whether the business model could result in a disruptive innovation14: Are the prevailing products more than good enough? Is the existing health care system meeting the information needs of the modern Internet-savvy health care consumer? As the knowledge of diseases and specialty treatments for increasingly personal health care issues expand, do health care consumers have a reliable 168 JAPhA | 5 3 :2 | M AR/AP R 2013


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source of accurate peer-reviewed information targeted to their comprehension level? Many Internet resources provide good quality general information, but it remains to be proven whether the non–medically trained consumer can analyze, evaluate, and make good medical choices based on this information without the assistance of a professional. With universal access to information via the Internet, patients now fall into one of three categories. They are highly informed people who know more about their conditions than their primary care practitioner, highly misinformed people who think they know more but actually misunderstand key issues, or highly confused people who become overwhelmed with the amount of information and thus procrastinate. The I-Tribe pharmacist could build a practice on diagnosing these information states and offering the right solution to the right audience. Many patients already visit community pharmacies to answer the ultimate primary care question: Should I self-treat or do I need to pay to see a physician? Therefore, pharmacists already benefit their communities by helping patients decide when and how to use the health care system safely and effectively. That is the essence of basic primary patient Journal of the American Pharmacists Association


Table 2. Sample list of Google keyword searches for January 2013 Search term Cancer Acne Birth control Diabetes GERD Heart disease Pain Side effects of Symptoms of Treatment of Weight loss Total Number of Community Pharmacies Searches per pharmacy per month Data from Google Keyword Tool Search conducted February 5, 2013

Global English searches 30,400,000 9,140,000 2,740,000 13,600,000 2,240,000 2,240,000 37,200,000 9,140,000 24,900,000 37,200,000 11,100,000 179,900,000 64,000 2,811 Represents total global searches for the month of January 2013

care. This article suggests extending this triage role to providing entry-level treatment advice through an ITribe practice. Can a different business model be created? Can the business model provide a high enough rate of return on investment to profit at a low entry-level price? Web 2.0 technology has reduced the start-up costs of interactive online applications to historically low levels. Blogs, social networks, content communities, forums/ bulletin boards, and content aggregators support the creation of informal user networks that facilitate the efficient sharing and dissemination of information.15 Patients are increasingly comfortable with online audio and video as a source of education. By crafting wellwritten or recorded answers to common questions, the ITribe leader could provide insightful commentary without any time required other than the initial authoring. The same message could reach thousands of patients at a fractional cost of what a physical face-to-face consultation would cost. Start-up costs would be minimal, and the transactions required to break even would be nominal. Therefore, Web 2.0 technology could be used to provide effective patient–pharmacist communication tools at a reasonable cost. Step 3: Make an irresistible offer In 2005, Joyner16 described the “irresistible offer” as an identity-building offer central to a product, service, or company, where the return on investment is communicated so clearly and efficiently that the potential buyer would be unwise to pass it up. It is not a “special offer” available for a limited time. It is not a statement of fact such as how long you have been in business. It is not a Journal of the American Pharmacists Association


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benefit or a unique selling proposition. The offer must be central to the identity of your business vision, and it must contain three elements: (1) a high return on investment for the buyer; (2) a touchstone theme that is clear, simple, short, and immediate; and (3) believability. One of the powerful attributes of Internet marketing technology is that response rates to offers can be easily tested and refined rapidly using Web analytics. Although most Internet marketers struggle to achieve credibility in the marketplace, the education, training, and historical levels of consumer trust in pharmacists would give pharmacist I-Tribe leaders a sustainable competitive advantage over nonprofessional content providers. Pharmacists are fully capable of learning how to construct these offers and manage the split testing necessary to refine the success of any offer in converting prospects to clients. Step 4: Lead the tribe For the I-Tribe to thrive, the leader must be a passionate advocate for the tribe’s main goals and the leader’s vision must resonate with the tribe. The leader must understand why the tribe exists and communicate often enough to be helpful but not so often as to be annoying. The communication must be honest, forthright, and sincere, because the Internet now makes it a virtual certainty that all untruths will be discovered. The only way to create and maintain a strong professional reputation will be to earn it every day. The individual pharmacist leader’s competitive advantage in his/her chosen I-Tribe niche would be his/her expertise, communication skills, and talent for problem solving within his/her focused niche. Not every pharmacist will be capable of successfully operating an I-Tribe, and even those who are will need additional training in creating a value strategy, building and maintaining a tribe, and managing the I-Tribe business model. Nevertheless, every pharmacist would benefit from the expansion of opportunities created by I-Tribe entrepreneurs.

Who will build it? Three questions need to be explored to determine whether the I-Tribe business model could succeed. The first question is who will step forward to develop this innovation and build the infrastructure needed to make it work? Should the developers be the pharmacy professional associations or private entities? The research of Christensen et al.6 suggests that the change will likely come from outside the entrenched organizations, which have developed their business models around the existing conventions of practice. Smaller organizations focused on the process of innovation have a competitive advantage. Even though they may lack resources, their cost structures can accommodate low profit margins and their business processes allow management to act j apha.org

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intuitively to embrace and initiate disruptive change. The players who emerge in this market space will likely be individuals or small entrepreneurial organizations with existing expertise in computer systems development, Internet marketing, content delivery, strategic business development, and direct patient care. They will join forces to bring their individual expertise to bear on a solution that will not only benefit their individual organizations but also deliver quality health care globally.

Will patients join the tribe? The second critical question concerns patient willingness to use a website to obtain personalized medical care. The reality is that for many people, the provider of choice for health information today already is a Google search. Google tracks all global searches by keyword. The Google Adwords keyword tool can be used to review “how often people everywhere search for a keyword.”17 A review performed in February 2013 found more than 179 million worldwide searches for only 11 selected health care–related search terms. These terms likely represent only a small fraction of actual health care information–related searches (Table 2). However, although a Google search can rapidly provide access to virtually unlimited amounts of information, a patient without specialized knowledge may actually misinterpret and misapply this information to harmful effect. The Google search is lacking a qualified health professional to provide context, relevance, and clinical accuracy to the search. People who visited community pharmacies during January 2013 likely performed many of the Google searches mentioned above and countless others. There are approximately 41,000 chain18 and 23,000 independent19 community pharmacies in the United States, for a total of 64,000 locations. The 179.9 million searches on these 11 terms alone equals 2,811 searches per community pharmacy per month. Therefore, patients are clearly hunting for answers. The I-Tribe pharmacist would practice at the intersection of the demand for instant answers and the need for evidence-based medical care.

Will patients pay? The third question is: Will consumers pay for health information when they can find information online free? An answer can be predicted from reviewing the world of Internet marketing. Clickbank,20 an online contentmarketing platform, sells information products using an affiliate referral model. Members can promote any product in the marketplace and receive commissions for any sale they generate. The tracking and payments are managed automatically. Referral commissions routinely range from 20% to 75% of the sale. In the Clickbank marketplace, more than 2,000 information products are available for purchase under the health and fitness category currently. These typically consist of e-books 170 JAPhA | 5 3 :2 | M AR/AP R 2013


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or Web-based instruction. In the subsection under remedies, the most popular sellers are e-book downloads for tinnitus, vision improvement, diabetes, acne, hemorrhoids, and warts. Each of these e-books sells for more than $20 per download. Few are authored by medical professionals. This evidence strongly suggests that patients will pay for information if they are presented with the right sales process, even if the author of the information has no certification other than their own experience. It should be easier for pharmacists to establish credibility and therefore gain a competitive advantage in the sale of such information. In addition, the National Association of Boards of Pharmacy (NABP) website reported the following: “NABP recently reviewed nearly 10,000 Internet drug outlets selling prescription medications and found nearly 97% to be out of compliance with pharmacy laws and practice standards established in the United States to protect the public health.”21 The fact that many bogus websites are in operation is another indication that patients are spending money online for pharmacy-related products or services. The dubious quality of many of these sites strongly suggests the need for our profession to develop a better system to protect our patients from harm. The public is clearly demanding fast and inexpensive health care information. The I-Tribe model could help meet this demand. The value proposition for the patient feeds directly into the strength of the I-Tribe model. A patient using Google to read hundreds of pages of conflicting information of dubious quality will likely end up being confused or misled. Alternatively, they could connect to a secure Web portal for self-directed knowledge acquisition, combined with the wisdom, personal attention, and advice from a trusted health professional. Pharmacists continue to rank higher than physicians in the Gallup poll of honesty and ethical standards22 and are in a unique market position to capitalize on this trust. However, with every opportunity comes a challenge. Every fact and bit of information that a pharmacist “knows” is readily available free on the Internet. Therefore, the challenge is to add value to the Google information search or risk obsolescence. Value creation is a critical skill in the modern global marketplace. Pharmacists will need to learn how to interact with patients in ways that will assist them in achieving their goals and in ways that the patient perceives to be worth the cost of the service. An I-Tribe leader pharmacist will not be required to find one employer willing to pay $120,000 per year for his/her services. He/she may only need to find a tribe of 120 people willing to pay $1000 per year, 240 people willing to pay $500 per year, or 480 tribe members willing to pay $250 per year to generate the same income level. In addition, an I-Tribe leader could determine where, when, and how he/she works. I-Tribe pharmacy could be the disruptive innovation that exJournal of the American Pharmacists Association


pands employment opportunity for pharmacists, insulating them from the types of sustaining innovations designed to reduce the costs of providing care and eliminate the need for dispensing pharmacists.

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7. Hwang J, Christensen C. Disruptive innovation in health care delivery: a framework for business-model innovation. Health Aff (Millwood). 2008;27(5):1329–35. 8. Christensen CM. The innovator’s dilemma: when new technologies cause great firms to fail. Boston: Harvard Business Press; 1997.

Conclusion

9. Godin S. Tribes: we need you to lead us. London: Penguin; 2008.

Several obstacles have prevented pharmacists from using available technology to develop business models that capitalize on their clinical skills in primary care. Community practice has experienced multiple sustaining innovations that have improved dispensing productivity but have not stimulated sufficient demand for pharmacy services to disrupt the marketplace and provide new opportunities for pharmacists. The I-Tribe is a disruptive innovation that could become the foundation for a vibrant market in pharmacist professional service offerings. The I-Tribe model could benefit society by expanding access to primary medical care while simultaneously providing a new source of revenue for community practice pharmacists. Entrepreneurial innovation through I-Tribe pharmacy would free the pharmacist to become the care provider envisioned by the profession’s thought leaders.

10. Affordable Care Act, PL 111-148, March 23, 2010.

References 1. Joint Commission of Pharmacy Practitioners. Future vision of pharmacy practice statement. www.aacp.org/resources/historicaldocuments/Documents/JCPPFutureVisionofPharmacyPracticeFINAL.pdf. Accessed December 18, 2012. 2. American Pharmacists Association. Project Destiny summary. www. pharmacist.com/project-destiny-summary. Accessed February 15, 2013. 3. DiPiro JT. Preparing our students for the many opportunities in pharmacy. Am J Pharm Educ. 2011;75(9):170. 4. Svensson CK, Ascione FJ, Bauman JL, et al. Are we producing innovators and leaders or change resisters and followers? Am J Pharm Educ. 2012;76(7):124. 5. Schumock GT, Butler MG, Meek PD, et al. Evidence of the economic benefit of clinical pharmacy services: 1996–2000. Pharmacotherapy. 2003;23:113–32. 6. Christensen CM, Overdorf M. Meeting the challenge of disruptive change. Harv Bus Rev. 2000;78(2):66–77.



11. Commonwealth Fund Commission on a High Performance Health System. Why not the best? Results from the National Scorecard on U.S. Health System Performance, 2011. Washington, DC: Commonwealth Fund; 2011. 12. Massachusetts Medical Society. Access to health care in Massachusetts: the implications of health care reform. www.massmed. org/AM/Template.cfm?Section=Research_Reports_and_ Studies2&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=65475. Accessed January 14, 2013. 13. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev. 2000;78(5):102–12, 199. 14. Christensen CM, Johnson MW, Rigby DK. Foundations for growth. MIT Sloan Management Review. 2002;43(3):22–31. 15. Constantinides E, Fountain SJ. Web 2.0: conceptual foundations and marketing issues. J Direct Data Digit Mark Pract. 2008;9(3):231–44. 16. Joyner M. The irresistible offer: how to sell your product or service in 3 seconds or less. Hoboken, NJ: Wiley; 2005. 17. Google. Google Adwords keyword tool. https://adwords.google.com/o/ KeywordTool. Accessed February 15, 2013. 18. National Association of Chain Drug Stores. Industry. www.nacds.org/ aboutus/industry.aspx chains operate 41,000 locations. Accessed January 14, 2013. 19. National Community Pharmacists Association. Introducing NCPA. http://ncpanet.org/index.php/introducing-ncpa. Accessed January 14, 2013. 20. Clickbank. Clickbank affiliate marketplace. www.clickbank.com/marketplace.htm. Accessed December 20, 2012. 21. National Association of Boards of Pharmacy. .PHARMACY and NABP. www.nabp.net/programs/pharmacy/pharmacy-and-nabp. Accessed December 15, 2012. 22. Gallup. Congress retains low honesty rating. www.gallup.com/ poll/159035/congress-retains-low-honesty-rating.aspx. Accessed January 14, 2013.

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