Pjne winter 2017

Vol 14 No. 1 Winter 2017

Winter 2017

Pharmacy Journal of New England

Workflow & Conditions in Community Pharmacies: A Special Report The Learned Intermediary Doctrine: Rx and the Law Connecticut Governor Dannel Malloy Takes the Lead on Opioid Abuse: U.S. News

State Association and College Updates Inside

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Pharmacy Journal

Vol 14 No. 1 Pharmacy Journal of New England • Winter 2017

of New England Advocate Against Budget Cuts

Editors

Dear Readers,

Managing Editor

The latter part of winter can be cruelest, especially when your state’s budget writers turn once again - to the cost of purchasing and delivering prescription drugs to the poor, to state employees and their families, and state retirees, as those places where deep cuts can be endured. This is the time of year our policy makers ignore the big picture and look coldly at these costs, desperate to make the numbers work.

That, compounded by the tumultuous activity in Washington, DC and the uncertainty of the Affordable Care Act specifically, makes this time of year especially difficult for those of us who lobby on behalf of pharmacists, which leads us to support for state pharmacy associations. Their value is unquestionable in the policy arena, and yet when we look at our own budgets, we fall into the same short-sighted temptation to make cuts in places that will hurt us in the long run. Support your state association, and urge your colleagues to do the same. If you have the time, in addition to your dues, offer your time and energy. Attend your Pharmacy Day at the Capitol, contact legislators when asked to, and attend the live CE programs that are the lifeblood of the organization.

We are, as you well know, stronger together.

David Johnson Margherita R. Giuliano, R.Ph., CAE Ellen Zoppo CPA

Design & Production Kathy Harvey-Ellis

The Pharmacy Journal of New England is owned and published by the Massachusetts Pharmacists Association and the Connecticut Pharmacists Association.

Opinions expressed by those of the editorial staff and/or contributors do not necessarily reflect the views or policies of the publisher.

Readers are invited to submit their comments and opinions for publication. Letters should be addressed to the Editor and must be signed with a return address.

For rates and deadlines, contact the Journal at (860) 563-4619.

Pharmacy Journal of New England 35 Cold Spring Road, Suite 121 Rocky Hill, CT 06067-3167 members@ctpharmacists.org

Submitting Articles to the Pharmacy Journal of New England™

Sincerely,

The Pharmacy Journal of New England™ is the product of a partnership between the Connecticut Pharmacists Association and the Massachusetts Pharmacists Association. The Journal is a quarterly publication.

Margherita R. Giuliano, RPh David Johnson Executive Vice President Executive Vice President Connecticut Pharmacists Association Massachusetts Pharmacists Association

All submitted articles are subject to peer review. In order to maintain confidentiality, authors’ names are removed during the review process. Article requirements must conform to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (Ann Intern Med 1982;96 (1part1):766-71). We strongly encourage electronic submissions. PJNE does not assume any responsibility for statements made by authors.

Please submit manuscripts to: PJNE 35 Cold Spring Rd., Suite 121 Rocky Hill, CT 06067 or email to: ezoppo@ctpharmacists.org

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US News

Pictured on the cover, L to R: Marghie Giuliano, Executive VP of CPA; Lynn Pezzullo of RIPA; and Susan Holden of MPhA

New England States Feature: Workflow and Conditions in Community Pharmacies Pharmacy Marketing Group: Rx and the Law From the Colleges

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U.S. News Governor Malloy Takes the Lead, Proposes Legislative Package to Combat Opioid Addiction Governor Dannel P. Malloy of Connecticut -- in his first legislative proposals of the 2017 session – unveiled a package of statutory reforms on January 26 that focuses on efforts to reduce the potential for people to become addicted to opioid medications that could cause a life-threatening overdose. The proposals build upon a series of reforms the Governor has signed into law on the issue since 2011.

“Every city and every town in the country has been touched in some way by substance abuse – and in particular the growing prescription pain killer epidemic. Our local communities are no exception. This is a complex crisis that does not have one root cause, nor does it have a simple solution,” Governor Malloy said. “Addiction is a disease, and together we can treat and prevent it. Our work on this front will not be finished until our communities and our families are no longer struggling with the grave costs of this illness.”

This year, the Governor is proposing the following reforms: Requiring Electronic Prescriptions: Currently, prescribers can choose whether to prescribe opioid medication electronically or on paper. The Governor is proposing to require all of these prescriptions be made electronically in order to reduce the potential for fraud and create a system of trackable data.

Facilitating in the Destruction of Unused Medication: Under current law, only the person prescribed medication or their legal caregivers can dispose of unused medication, including after the patient has died. The Governor is proposing to expand this ability to home health care agency registered nurses. This will ensure that unused medication is not sitting in medicine cabinets, and fits well with the “Mind Your Meds” movement promoted by state agencies, which encourages the proper destruction of unused medications through means such as a drop box program.

Allowing Patients to Refuse Opioids through a Directive: The Governor is proposing to allow patients to include in their personal medical files a form indicating that they do not want to be prescribed or receive opioid medication.

Expand the Requirement to Provide Information about the Risk of Addiction to Adults: Currently, prescribers are required 2

to share information on the risk of addiction when prescribing opioids to minors. The Governor is proposing to expand that requirement to include adults in order to increase the communication between prescribers and patients, ensuring that all patients have the information they need when taking potentially addictive medications.

Encourage Data Sharing Among State Agencies: The Governor is proposing to ease statutory restrictions on data sharing between state agencies. This concept was widely discussed in both the Alcohol and Drug Policy Council’s final report and Yale’s report that the Governor commissioned. Increased data sharing across state agencies would better help the state track trends, determine the effectiveness of the current allocation of resources, and create a more comprehensive system for tracking this epidemic.

“Nearly half of all opioid-related deaths in our country involve prescription painkillers. While prescription painkillers have a place in treating patients experiencing pain, it’s important that they are prescribed responsibly and safely stored,” Department of Mental Health and Addiction Services Commissioner Miriam Delphin-Rittmon said. “By taking steps to safeguard access to these medications, we are not only helping to prevent prescription painkillers from falling into the wrong hands, but we’re also helping to prevent addiction.”

“Opioid abuse and addiction is deeply personal for too many families and communities in Connecticut. There’s not one way to fight the opioid crisis, and we can only make progress by enacting common sense remedies that attack the problem from many directions,” Department of Consumer Protection Commissioner Jonathan A. Harris said. “The proposals Governor Malloy is raising this year, like the many efforts he has championed in past legislative sessions, are a priority of the Department of Consumer Protection’s Drug Control Division, and we’re committed to help build support for these new initiatives that will provide more ways to prevent families from suffering.”

Since taking office, Governor Malloy has enacted several policy changes to combat the opioid epidemic. These include: the 2011 adoption of Good Samaritan laws protecting individuals from prosecution for minor drug crimes who seek medical attention for a friend experiencing an overdose (Public Act 11-210);

Pharmacy Journal of New England • Winter 2017

the 2012 adoption of third party prescriber laws allowing the prescription of naloxone to an individual who is not the direct user of the drug (Public Act 12-159); the 2014 expansion of Good Samaritan protections for any person who, in good faith, administers naloxone to save a life. Previously, only licensed health care practitioners were allowed to administer the medication without being civilly or criminally liable for the action. Following the law’s adoption, all Connecticut State Police Troopers completed a training program providing them with the skills to administer the medication. (Public Act 14-61); the 2015 adoption of legislation that expanded prescriber education, made use of the Prescription Monitoring Program (PMP) mandatory for all prescribers of controlled substances, expanded the scope of practice for pharmacists to allow them to directly prescribe naloxone and reconstituted the Alcohol

and Drug Policy Council (ADPC) as a statewide coordinating body to fight the spread of substance abuse and overdose (Public Act 15-198); and the 2016 legislative package that among things, limits the prescribing of opioid drugs to seven days (with certain exceptions), and requires municipalities to update their medical service plans to ensure first responders are equipped with Narcan. (Public Act 16-43).

Governor Malloy’s 2017 legislation on this topic -- along with all of his other legislative proposals for this session -- will be filed in the coming days. The proposals will receive a bill number at that time. http://portal.ct.gov/officeofthegovernor/pressroom/pressreleases

CONNECTICUT SAVE THE DATES Compounding Conference Coming in May

The CPA and CSHP are again working together to produce the 2nd annual Compounding Conference on Friday, May 19, 2017 at the Cromwell Radisson. Stay tuned for details on speakers and topics for this Live, 5 hour credit program, with Exhibitors and Lunch, or check our website www.ctpharmacists.org.

There are also plans underway to do a Pain Management evening Live CE program in June for Pharmacists, Physicians, APRN’s and Nurses.

And Another Save the Date: Pharmacy Day at the Capitol will be held on Tuesday, March 7 from 4:30 - 7:00 p.m. in the Legislative Office Building Atrium. Plan to come and stand up for the profession! Contact your legislators and let them know you will be there and invite them to join you.

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President’s Message The Legislative session is in full swing at the Capitol and the CPA members and staff are hard at work, deciding what bills we hope to have introduced, and waiting to see which bills might affect the practice of pharmacy.

One of the concerns is always the budget, and what types of reductions in dispensing fees and reimbursement rates we might see. This affects all pharmacists as the less money Bahar Matusik, PharmD we get from insurance CPA President, 2016-17 companies, the less money is available to pay salaries for pharmacists and technicians. It becomes a vicious circle, as with less help, it results in more workload for those who are working. This brings up concerns about medication errors.

Another area we are looking at is reintroducing legislation to reimburse credentialed pharmacists for MTM in Medicaid. We have shown that we can save the state money and the CPA is leading the coalition of organizations across our profession and the schools of pharmacy to get this important legislation passed. So I ask you to support our activities. When we ask you to contact your state representatives please do so. We supply talking points; just make it your own. Call. Write. Be pro-active. Be involved!

The CPA has been working with CSHP and CT-ASCAP to collaborate on Pharmacists Day at the Capitol. We plan to spend the day there visiting legislators and explaining issues that affect pharmacy. We hope you can join us on March 7, 2017 from 4:30 - 7 p.m. in the Atrium of the Legislative Office Building.

We are also working with CSHP and CT-ASCAP again to

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present a collaborative CE program this Spring. Stay tuned for more details!

Hope to see many of you at the Connecticut Pharmacists Foundation 7th Annual Wine Tasting on May 20th at the Arrigoni Vineyard in Portland, CT. Watch the Friday Fast Five for more details.

Respectfully, F. Bahar Matusik, PharmD, BCPS CPA President

Student Spotlight: New Standards in Antimicrobial Stewardship

by Meghan Gagnon, PharmD Candidate 2017, University of Connecticut

Each year in the United States, at least two million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die as a direct result of these infections. Use of antibiotics is the single most important factor in the rise of antibiotic resistance as over 50 percent of antibiotics prescribed are neither necessary nor effective. Considering the widespread inappropriate use of antibiotics and the rise of multidrug resistant organisms, the Joint Commission has recently announced a new Medication Management (MM) standard for hospitals, critical access hospitals, and nursing care centers. Standard MM.09.01.01 addresses antimicrobial stewardship and becomes effective January 1, 2017. Standard MM.09.01.01 states that all of the aforementioned organizations should have an antimicrobial stewardship program based on current scientific literature and follow eight specified elements of performance.

First, leaders of the antimicrobial stewardship program must establish antimicrobial stewardship as an organizational priority. Commitment to this element may include budget, performance improvements and infections prevention plans.

Secondly hospital’s must educate staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about

Pharmacy Journal of New England • Winter 2017

antimicrobial resistance and antimicrobial stewardship practices, these may occur upon hire or granting of initial privileges and periodically thereafter, based on organizational need.

Next, hospitals must educate patients and their families regarding the appropriate use of antimicrobial medications.

Appropriate education materials can include informational videos, infection prevention posters or discharge medication information counseling. A helpful aide for pharmacists creating educational materials is the Centers for Disease Controls and Prevention’s Get Smart About Antibiotics campaign. Additionally, although the new standards apply only to in-patient organizations, the majority of antibiotics are prescribed in the outpatient setting and antibiotic-resistant infections primarily occur in the general community. Therefore, new standards may serve as a basis to rejuvenate meaningful antibiotic counseling in the community; community and ambulatory care pharmacists are in a unique position to identify potential interventions, clarify allergies, and encourage adherence.

The antimicrobial stewardship program must consist of an interdisciplinary team including the following members (when possible): an infectious disease physician, infection preventionists, pharmacists, and practitioners. The stewardship must include core elements as defined by the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs - leadership commitment, accountability, drug expertise, action, tracking,

monitoring, reporting, and education.

Hospital antimicrobial stewardship programs must use organization-approved multidisciplinary protocols. These protocols may include, but are not limited to: antibiotic formulary restrictions, guidelines for antibiotic use in various disease states, plans for intravenous to oral conversion, and preauthorization requirements for restricted antibiotics. Hospitals must collect, analyze, and report data on its antimicrobial stewardship program. This data may be used to evaluate the antimicrobial stewardship program, antimicrobial prescribing patterns, or antimicrobial resistance patterns. And finally, hospitals must take action on improvement opportunities identified in its antimicrobial stewardship program.

These standards, supported by the Infectious Diseases Society of America and Centers for Disease Control and Prevention, aim to usher in a new era of conscientious antimicrobial use and ideally delay the onset of widespread multidrug resistant infections.

References: 1. Get Smart about antibiotics week overview. https://www.cdc. gov/getsmart/week/overview.html. Updated 2016. Accessed January 17, 2017.

2. New antimicrobial stewardship standard. The Joint Commission Perspectives. 2016;36(7):1-8.

3. Pakyz AL, Harpe SE. Takin’ it to the streets: Antimicrobial stewardship in the outpatient setting. J Am Pharm Assoc (2003) 2016 Nov - Dec;56(6):608-609.

When First Time Treatment Fails: Navigating New Treatment Paradigms in Relapsed/Refractory Myeloma •

A complimentary online program from the University of Texas MD Anderson Cancer Center and MediCom Worldwide, Inc.

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Adapted from live meeting series

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Gives continuing education credits Visit the full program here.

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Massachusetts President’s Message Dear Colleagues,

Warm greetings to all!

It has been a pleasure of mine to have connected with many of our Association’ members at our MPhA Meet & Greet at the ASHP Midyear in Las Vegas. After playing a little roulette, it was to back to work to connect with more members concerning our efforts to promote

Alicia Mam daCunha

MPhA President, 2016-17

connect student pharmacists with practicing pharmacists in Massachusetts to give the students opportunities to enhance their career development in a more personal manner.

The MPhA Board of Directors has approved an increase in Membership Dues for registered pharmacists to $175 per year. This increase is the first increase in over 15 years and still keeps MPhA as one of the most affordable pharmacy associations in the nation. The extra revenue will help us advance our advocacy efforts and various initiatives to promote and protect pharmacy practice. The increase is scheduled to take effect March 1st.

pharmacists as providers of care, combat the opioid epidemic, and other MPhA initiatives.

Updates I am excited to share that our Demonstration Grant with the Department of Public Health, designed to engage community pharmacies in the effort to improve the care of patients with hypertension, is moving forward. Physicians and nurse practitioners at four health clinics are in the process of incorporating community pharmacists as part of the healthcare team for patients with uncontrolled hypertension. Referrals of patients from the health clinics to community pharmacists will begin shortly.

Drug overdose deaths, including opioid overdose deaths, continue to increase in the United States. MPhA Operation Prevention Committee has been diligently working on various projects including but not limited to safety training, connecting pharmacists to resources through our Operation Prevention webpage at www.masspharmacists.org, and increasing naloxone distribution.

In order to engage more members, our Communications Committee has kicked off a Mentorship Program to 6

Pictured above, meeting at the Community Health Center of Franklin County in Greenfield, MA to discuss the Demonstration Grant with DPH are from L to R: Cris Carl, Maria Heidenreich, Rachel Stoler, Anne Nusbaum, Alicia Mam daCunha

Foundation News With generous donations from our Association members, our MPhA Foundation is launching its first annual Student Travel Stipends. The Foundation will be sponsoring student pharmacists from each of the Schools of Pharmacy in Massachusetts to attend the APhA Annual Meeting in San Francisco in March. Six Students will receive travel stipends of $250.

MPhA Foundation President Cathy Taglieri is stepping down after four years of outstanding service. Cathy’s guidance and hard work has led to the implementation of the Scholarship Program, the APhA Student Travel Stipends, and an

Pharmacy Journal of New England • Winter 2017

significant increase in the Foundation’s financial resources.

We thank her for her service and continued commitment to MPhA!

Legislative Update The 2017-2018 legislative session is underway. Several bills have been filed at the request of MPhA that are of importance to independent pharmacies and pharmacy practice. First, and most encouraging, House Majority Leader Ronald Mariano has filed MAC transparency legislation. The Majority Leader visited Olden’s Pharmacy this past summer and saw firsthand the problems caused by the lack of transparency of PBM MAC lists. He made a commitment to address this issue and has taken the first step by filing a bill to remedy the situation. On the Senate side, Senator Michael Rodrigues filed similar legislation. The support of these two influential legislators does not guarantee success but it is an encouraging start to the session.

Senator James Eldridge refiled a bill to stop the practice of getting around the state’s “any willing provider” law by labeling a drug a “specialty drug” and limiting its distribution through the PBM’s specialty pharmacy or closed specialty network.

To further support the involvement of independent pharmacies in the political process and help with the final passage of these important bills, the MPhA, with the help of our MIPA members, have engaged Dennis Lyons, a pharmacist and lobbyist with many years of experience as an advocate for pharmacy issues at the state house. Mr. Lyons will help bolster our grassroots efforts and enhance our influence with lawmakers. If we all pull together, we can make this a productive and profitable legislative session!

Upcoming Events The MPhA Foundation will be holding a Wine Tasting Fundraiser at the Boston Winery at 6:00 p.m. on April 6, 2017.

Last year’s event allowed many pharmacists to reconnect and also formed new connections!

Registration is now open for our MPhA Spring Conference, which will be held on April 28, 2017. Special guest, Attorney General Maura Healey, headlines a number of excellent speakers. Visit www.masspharmacists.org and register today!

I look forward to meeting you at one of our events!

Sincerely, Alicia Mam daCunha, PharmD, BCACP, AE-C

An Act Recognizing Pharmacists as Healthcare Providers was refiled by Representative Angelo Puppolo this session, and Senator Michael Moore filed the same language on the senate side. Last session this bill was reported favorably from the Joint Committee on Public Health but made it no further in the process. Two developments provide us with optimism for this bill. First, the legislature requested a report on the bill from the Center for Health Information and Analysis (CHIA), which is tasked with assessing the costs of implementing a bill under consideration. That report came back very favorably.

Recently CMS issued a letter endorsing pharmacists’ involvement in public health efforts such as smoking cessation and contraception, suggesting that these are services pharmacist can provide the community without prescriptions. You can access this letter and the CHIA report by visiting www.masspharmacists.org under the Advocacy tab for state legislative efforts.

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MPhA Spring Conference

Featuring:

April 28, 2017 Four Points by Sheraton

1125 Boston-Providence Turnpike, Norwood, MA

Attorney General Maura Healey Register online at: www.masspharmacists.org

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Also featuring: Pipeline Preview 2017

by Maria Lowe, PharmD, Clinical Pharmacist, PatientsLikeMe Operation Prevention: Pharmacy Safety and Substance Abuse Prevention Presented by Karen Hobrowicz, Pharm.D., Inman's Pharmacy, Cambridge, MA Oral and emergency contraceptives- A review for the pharmacist

by Jennifer Goldman, PharmD, CDE, BC ADM, FCCP Professor of Pharmacy Practice, MCPHS University The combination of basal insulin plus GLP-1RAs for the treatment of type 2 diabetes

by Jennifer Goldman, PharmD, CDE, BC ADM, FCCP Professor of Pharmacy Practice, MCPHS University Hypertension Update: How to give Meaning to your Screening (clinically meaningful interventions for the community pharmacist) Presented by: Courtney Doyle-Campbell, Pharm.D., Clinical Assistant Professor of Ambulatory Care, Western New England University College of Pharmacy Long-Acting Injectables for Behavioral Health: Therapeutic Review and Clinic Practice Implications Presented by: Michael C. Angelini, M.A., Pharm.D., BCPP, Associate Professor, MCPHS University, Boston, MA, Psychiatric Clinical Pharmacist, St Luke’s Hospital, New Bedford, MA

Pharmacy Journal of New England • Winter 2017

New Hampshire New Hampshire Pharmacist Workload Update

by Gabrielle Hill, MCPHS University PharmD Candidate 2018

Pharmacist workload is a growing concern with added responsibilities and ever growing number of prescriptions.

With the rise in workload, there is a greater risk for medication errors as well as added pressure for pharmacists. Globally, the increase in workload has led to a decrease in job satisfaction and increase in job related stress among pharmacists. New Hampshire pharmacists are no exception to this. Last year, the NH Board of Pharmacy (BOP) distributed a survey to community pharmacists in the state asking about pharmacist workload, specifically about the number of prescriptions being filled daily, amount of support staff and quotas. According to the survey results, a majority of community pharmacists are working 12 hour shifts with one pharmacist and one technician on duty and fill between 200 and 300 prescriptions. Pharmacists are being asked to meet quotas for immunizations, MTM, wait times and minimum number of prescription fills with no additional staffing. This information coincides with the Drug Topic’s survey in 2015, which stated that 64.5% of pharmacists are experiencing increased stress levels due to increased workload and inadequate staffing. Pharmacists in NH feel that their biggest barrier to providing quality care is inadequate staffing and too many mandated tasks.

With very limited research found on students’ knowledge of the ever growing workload concerns, a project was completed to assess student pharmacist perceptions of increased workload and to evaluate what is most important to students with regards to job satisfaction as future pharmacists. A twelve question survey was distributed to first and second year students enrolled in the Accelerated PharmD program at MCPHS University-Manchester campus that focused on pharmacist workload demands, adequate staffing and job attributes important to students. Following the survey, a presentation was given by Gabrielle Hill, PharmD Candidate 2018, which discussed the growing concerns associated with increased workload and BOP’s findings.

A total of 51 students completed the survey, with the majority of students being female (53%) and under 25 years of age (61%). Most participants (82%) had pharmacy work experience and of those, (67%) worked in a community chain pharmacy. When asked about appropriate pharmacist to technician ratios when filling between 200 and 300 prescriptions per day, (51%) stated that a ratio of 1:3 is appropriate. The majority of the students (57%) stated that 2 pharmacists are necessary to safely fill between 200-300 prescriptions in a 12 hour day and one pharmacist could safely fill a maximum of 101-200 prescriptions in a 12 hour day when working alone (49%). The majority of students did not believe that quotas should have to be met for immunizations (62%) or minimum number of prescriptions filled (55%).

They did however agree that quotas should be met for MTM services. Students (73%) strongly believe that job satisfaction and work-life balance are important when choosing a pharmacy career. Work environment was also of high importance to 69% of students.

Students recognize the concerns associated with increased workload demands in community settings. The number of prescriptions students felt that pharmacists can safely fill are well below the number of prescriptions that pharmacists are actually filling on a daily basis, and New Hampshire pharmacists have much less support staff than what students feel is necessary. Student agreement with quotas for MTM services, shows the appreciation for taking on more of a clinical role as a pharmacist. Conversely, these increased workload demands can negatively affect pharmacist work-life balance and job satisfaction, which are very important for students when choosing a pharmacy career. This may persuade student pharmacists to pursue careers in clinical settings rather than community pharmacy. An increase in support staff and additional pharmacists, along with mandatory rest breaks could assist in lessening the increase in work demands and result in less job burnout and higher job satisfaction for pharmacists in the future.

New Hampshire Pharmacists are Recognized at Holiday Party The MCPHS University Annual NH Pharmacy Awards Reception was held on Wednesday, December 14, 2016 at the 9

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Manchester Country Club in Bedford, New Hampshire. The celebration was also supported by the NH Pharmacists Association (NHPA), the NH Society of Health-System Pharmacists (NHSHP) and the NH Independent Pharmacy Association (NHiPA).

2016 Gold Certificate Awards Given This year, the NH Board of Pharmacy recognized four New Hampshire Pharmacists who have been licensed in the state for 50 continuous years. The ceremony included the presentation of a framed gold certificate. While the “Gold Certificate” itself has been around for well over 30 years, the presentation only became formal in the past 8 years. The gold certificate is a replica of the recipient’s license that is engraved with his/her name, as well as a signed citation from the Honorable Governor Maggie Hassan. The gold certificate of licensures were presented by Robert Stout President, NH Board of Pharmacy to the following recipients: John B. Robinson, RPh, MCP ‘65 Carl T. Kelly, RPh, MCP ‘65 Everett F. Penney, Jr., RPh, MCP ‘66 Peter A. Grasso, RPh, MCP ‘66

Pictured above from L to R: Jennifer Towle, Marianne Whittaker, Margaret (Peg) Hayes, William Gatchell and John Mini.

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Holiday party attendees above pictured from L to R: Elizabeth Sargent, Senator Donna Soucy, Jay Calabro and Suzanne Gambale.

2016 Pharmacist of the Year - Marianne Whittaker Marianne is a 2006 Doctor of Pharmacy graduate of the Bouvé College of Health Sciences, Northeastern University in Boston. Additionally, in 2014 Marianne earned a Master’s in Health Administration from Simmons College, School of Management in Boston. Marianne is Board Certified in Pharmacotherapy as well as Pediatric Pharmacy.

Marianne is being recognized for the impact on patient care she has made in her practice at Elliot Hospital. She created and served as the Residency Program Director for the PGY2 Pediatric residency program at the Hospital, helping to educate new pharmacists and give them valuable professional experience. She also served as project manager for the construction of the United States Pharmacopeia 797 compliant IV clean room, in order to serve patients in the safest possible manner at the Elliot Hospital. Marianne also assisted in the development of the New Hampshire Hospital for Children (NHHC), which included the writing of all the policies and procedures associated with the NHHC. In 2014, Marianne was promoted to Pharmacy Operations Manager at Elliot Hospital.

Pharmacy Journal of New England • Winter 2017

2016 NH Bowl of Hygeia Award - John Mini This year’s recipient of the Bowl of Hygeia Award is John Mini.

After his graduation from high school in Boston in 1957, John served in the US Air Force for 4 years. In 1961, John went to work at the Naval Shipyard in Charlestown, MA. At the age of 35, John enrolled at MCP and graduated with a baccalaureate in pharmacy in 1979. Initially he went to work at the New England Deaconess Hospital in Boston and later moved to New Hampshire where he practiced at the Dartmouth Hitchcock Hospital and at the Lakes Region General Hospital.

Starting in 1988, John was employed by the New Hampshire Board of Pharmacy as a compliance officer for nine years.

In 1997, John joined the team at Dartmouth Hitchcock Medical Center until its closing. Following that and until his retirement this year, John returned to the LRG Healthcare network and practiced at the Franklin Regional Hospital and the Pharmacy Center at Laconia Clinic.

John has served as youth hockey coach in Abington, MA as well as a science fair judge for the Laconia Christian Academy.

John also volunteered as “Santa Claus” for over 30 years for children at local hospitals, and fire and police departments.

2016 Distinguished Young Pharmacist Award - Jennifer Towle Jennifer Towle is this year’s distinguished young pharmacist.

She is a graduate of MCPHS University-Manchester Campus, receiving her PharmD degree in 2012. Following graduation, she completed a residency program at Elliot Hospital in Manchester. She currently serves as an Assistant Professor of Pharmacy Practice at MCPHS University, School of Pharmacy – Worcester/Manchester where she maintains an ambulatory care practice at Concord Hospital’s Family Health Center. In addition, she works as a per-diem clinical pharmacist at Elliot Hospital.

Jennifer has a strong passion for community and professional service. This passion grew while she was a student at MCPHS where she was a member of and held leadership positions in several student organizations. She has continued to serve as a long-standing, active member of the American Society of

Health-System Pharmacists (ASHP) and the New Hampshire Society of Health-System Pharmacists (NHSHP).

Her involvement with NHSHP began while she was a student at the University, when she served as a student member of the Board of Directors. She has served a 3-year Presidential term from 2014 through 2016. During her time as President she assisted with reorganizing the society by developing committees and streamlining processes to help the organization run more efficiently. This year she also took on the role of Webmaster, working to completely redesign the website to improve functionality. In addition, she also serves on the nomination, education and member relations committees.

On a national level, she has served as an alternative delegate and delegate for ASHP’s House of Delegates representing NH at ASHP national meetings. In addition, she met with state representatives in Washington, D.C. regarding compounding legislation following the New England Compounding Center case in 2013.

Jennifer also participates in the MCPHS University Alumni Cardinal Mentor Program.

Jennifer is also active in the community. She has served as den leader for Cub Scout Pack 86 in Concord, NH for the past 2 years and has taken on the role of assistant Cub Master this past year. She has also volunteered as an adult leader for the Cub Scout’s Camp Carpenter for the past two summers.

2016 Lifetime Achievement Award - Duane ‘Joe’ Clement This year the pharmacy community is honored to recognize Duane “Joe” Clement as the recipient of our 2016 Lifetime Achievement Award. Joe graduated from Henniker High in 1957, and then enrolled at the University of Connecticut College of Pharmacy. Following graduation in 1961 with a BS in pharmacy, Joe returned to NH where he passed the Board’s licensing exam. At the same time, Joe signed a professional baseball contract with the new Houston Astros of the National League. Joe pitched for five seasons in the Houston system, receiving a major league contract in 1962.

In 1965, Joe purchased the Henniker Pharmacy where he continued to practice until 2008 when he sold the pharmacy 11

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but still works there part-time whenever needed.

Even with his busy career, Joe never shied away from community service. In addition to managing his pharmacy, Joe ran a baseball clinic in Henniker for 14 years for boys in grade school and junior high. In November 2013, Joe was inducted in the NH Interscholastic Athletic Association Hall of Fame as an athlete. Joe was instrumental in starting the Henniker Rotary Club in 1984 and having served as past president he is the only charter member remaining. He also served on the Board of Trustees of New England College, in Henniker, from 1983 to 2010 when he was appointed Trustee Emeritus.

Joe also served as a trustee at Concord Hospital, and on the board of directors at the Valley Bank in Hillsborough for 20 years. He was a member of the NH Board of Pharmacy Continuing Education Advisory Council for 28 years (1981 to 2009).

Joe supports The 100 Holes of Golf Tournament run by the Milford Rotary Club. Joe has participated for 18 years and sold almost $13,000 this year alone, bringing the total that he has raised to more than $118,000 and he continues to complete the 100 holes as well.

Joe was recognized by his peers as NH Pharmacist of the Year in 1988 and again in 1999. In 1979, Joe was again recognized with the award of the Bowl of Hygeia.

Douglas Hospital. This program offers rides to and from the Hospital for those who are not capable or fortunate enough to have the means of transportation for their hospital care needs.

Bill is a Certified Pharmacy Technician as awarded by the National Pharmacy Technician Certification Board.

2016 NH Excellence in Innovation Award Margaret (Peg) Hayes

2016 NH Technician of the Year - William Gatchell

The recipient for this year’s Excellence in Innovation Award is Margaret (Peg) Hayes.

This year’s recipient is William Gatchell. Bill has worked as a pharmacy technician for the last 18 years at a variety of practice settings, including community and hospital pharmacy. For the last 5 years he has worked as the Information Services technician at Wentworth-Douglass Hospital and was recently promoted to the Pharmacy Technician Supervisor. In this role, Bill is responsible for the scheduling, orientation, training and supervision of a staff of 17 technicians. Shortly after his promotion, he was tasked with assisting the inpatient pharmacy with a move to a new location within the hospital. This required set up of equip-

A 1981 graduate of the University of Rhode Island College of Pharmacy, Peg has been practicing pharmacy in NH for the past 30 years and since 1986 has been employed at the Elliot

ment, establishment of new workflow, and development of a training manual to complement the hospital’s new USP 797 compliant IV room. Bill also assists in maintaining and running the care-van program at Wentworth12

Pictured above, Joe and Pat Clement

Hospital in Manchester. Since 2007, Peg has been the Clinical Informatics Specialist at Elliot. Peg manages all functions of medication-related databases and documentation of system use and training. She also oversees testing and validating of all new software upgrades, including developing and updating test plans.

Peg has also created electronic tools to support antimicrobial stewardship and venous thromboembolism prophylaxis to aid the hospital’s pharmacists in providing efficient care and improving patient outcomes.

Pharmacy Journal of New England • Winter 2017

Since 2012, Peg has been a Residency PGY-2 preceptor for pharmacy graduates in Informatics rotations.

During her professional career, Peg served a 10-year appointment by the Governor as the hospital pharmacy representative on the NH Board of Pharmacy and served as Board President from 2005 to 2007.

In Memoriam Norman William DeWolfe, 65, died at his residence on August 4th, 2016. He was a graduate of the University of Rhode Island School of Pharmacy. His career as a pharmacist began at Dionne’s Drugs in Somersworth, NH, and then he became the owner of DeWolfe’s Pharmacy in Rochester. He later moved on to be the District Supervisor for Brooks Drugs. He ultimately retired from Rite Aid Pharmacy in Plymouth, NH as a staff pharmacist. He also was a past president of the NH

Rhode Island Hello fellow Rhode Island Pharmacists Association Members!

RIPA has been active with networking events, legislative efforts, educational programs and other initiatives.

In October, RIPA hosted Cheers with Peers at the Dunkin’ Donuts Center in Providence where members, their families and friends enjoyed a fun evening of Providence Bruins hockey, networking, and good times! The Annual Beers with Peers event was hosted in November at the Whaler’s Brewing Company where pharmacists and student pharmacists were able to network and enjoy a flight of the Whaler’s craft brew! In December, RIPA members volunteered their time at the Cumberland Senior Center with the Happy Basket Program which packs and distributes food and toys during the holiday season for families in need in Cumberland RI. Upcoming Events Visit http://www.ripharmacists.org/Events for more information, including links to register for the following events!

Face of Pharmacy We are busy planning the 14th Annual Face of Pharmacy event for early April. Face of Pharmacy brings students, faculty and the associations’ professional and student

Board of Pharmacy.

Upcoming 2017 Continuing Education Conferences Remember to save the dates for upcoming CE programs in 2016 which are as follows:

Saturday, June 3, 2017 Attitash Grand Summit Hotel, Bartlett, NH Sunday, September 10, 2017 Labelle Winery, Bedford, NH Saturday, December 2, 2017 SERESC, Bedford, NH

membership together to allow legislators to “see” pharmacy practice and support legislative changes to permit wider adoption and implementation of clinical pharmacy services, including point of care testing and expansion of collaborative practice. The event is important in helping legislators recognize and understand the collaborative role pharmacists play in health care.

Spring Seminar The Rhode Island Pharmacy Foundation Kimberly McDonough Spring Seminar continuing education program will be held on May 10th at the Radisson Hotel in Warwick. Engaging presenters will focus on current trends in pharmacy.

Registration at Spring Seminar is free to RIPA members – another great benefit to membership!

Gold Outing The 19th Annual Rhode Island Pharmacy Foundation Golf Outing is planned for June 5th at Potowomut Golf Club in Warwick RI. Each year, the Rhode Island Pharmacy Foundation and the Rhode Island Pharmacists Association endeavors to raise funds to enable us to promote the profession of pharmacy, and provide aid to our student pharmacists at the URI College of Pharmacy. We hope to see you out on the links!

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New England States

continued

Maine Spring CE One-Day Program April 1, 2017, Husson University, Bangor, Maine Come join your colleagues in Bangor for a day filled with a wide variety of CE programming and professional networking. All programming is completely ACPE-accredited for both pharmacists and technicians through the University of New England.

PROGRAMMING Completing Assessment of Risk in Community Pharmacy

It’s All About ME - A Tradition of Caring: The Way Pharmacy Should Be! The Maine Pharmacy Association, the first professional state pharmacy association in the nation, will be celebrating the Sesquicentennial Anniversary in 2017. To mark this milestone, we are hosting a three day event with continuing education tracks, social events and a trade show in Portland, ME on October 13- 15, 2017. We are excited to be partnering with the Maine Society of Health System Pharmacists and the meeting will be held in conjunction with the APhA - ASP Region I meeting. Mark your calendars!

Immunization Update 2017 VA Maine Opioid Safety Initiative: Academic Detailing Infectious Diseases Law Update 2017

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14

.

2015 Recipients of the “Bowl of Hygeia” Award

Dan McConaghy Alabama

Tom Van Hassel Arizona

Nicki Hilliard Arkansas

Robert Shmaeff California

Sherman Gershman Connecticut

Kevin Musto Delaware

Fritz Hayes Florida

Ron Stephens Georgia

Kerri Okamura Hawaii

Steven Bandy Illinois

Jane Krause Indiana

Richard Hartig Iowa

Robert Nyquist Kansas

Larry Stovall Kentucky

Lloyd Duplantis Louisiana

Kenneth McCall Maine

Butch Henderson Maryland

Paul Jeffrey Massachusetts

Derek Quinn Michigan

Jenny Houglum Minnesota

Robert Wilbanks Mississippi

Richard Logan Missouri

Gayle Hudgins Montana

Heather Mooney Nevada

Richard Crowe New Hampshire

Edward McGinley New Jersey

Amy Bachyrycz New Mexico

Benjamin Gruda New York

David Moody North Carolina

Kevin Oberlander North Dakota

Danny Bentley Ohio

Gordon Richards, Jr. Oklahoma

Ann Zweber Oregon

Thomas Mattei Pennsylvania

Deborah Newell Rhode Island

Sharm Steadman South Carolina

Renee Sutton South Dakota

Mac Wilhoit Tennessee

Jim Cousineau Texas

Marvin Orrock Utah

John Beckner Virginia

Gregory Hovander Washington

Terri Smith Moore Washington DC

David Flynn West Virginia

Brian Jensen Wisconsin

Randy Harrop Wyoming

The “Bowl of Hygeia”

The Bowl of Hygeia award program was originally developed by the A. H. Robins Company to recognize pharmacists across the nation for outstanding service to their communities. Selected through their respective professional pharmacy associations, each of these dedicated individuals has made uniquely personal contributions to a strong, healthy community. We offer our congratulations and thanks for their high example. The American Pharmacists Association Foundation, the National Alliance of State Pharmacy Associations and the state pharmacy associations have assumed responsibility for continuing this prestigious recognition program. All former recipients are encouraged to maintain their linkage to the Bowl of Hygeia by emailing current contact information to awards@naspa.us. The Bowl of Hygeia is on display in the APhA Awards Gallery located in Washington, DC. Boehringer Ingelheim is proud to be the Premier Supporter of the Bowl of Hygeia program.

15

Feature Workflow and Conditions in Community Pharmacies

by Rebecca Chow, Janet Qian, and Todd Brown Community pharmacists are essential to the management of patient care within the healthcare system. Pharmacists are considered to be the second most trusted healthcare profession by patients and are uniquely accessible providers in the community point of care.1 Patients depend on community pharmacists for counseling, health education, and medication therapy management. As such, pharmacists can create strong relationships with patients and vastly improve healthcare.

Despite the ethical obligations to provide patient care and having the knowledge and skills to perform more clinically oriented duties, places of employment for community pharmacists are not always conducive to such responsibilities. Workflow systems implemented by many retail pharmacies often hinder opportunities to provide optimal patient care. For example, community pharmacies often implement performance-based metrics to assess various elements of the filling process and determine the performance of the store. Examples of such metrics include: prescriptions filled per week, number of errors per day, number of vaccinations administered, prescription turnaround time, and average customer wait time.2,3 Since this system emphasizes the quantity of prescriptions dispensed, it shifts the focus away from another important marker of performance: quality of patient care. When stringent metrics are implemented, pharmacists have less time to ensure a patient’s therapy is optimized. As a result, quality of care is sacrificed for business and short-term results. Furthermore, the added pressure of meeting strict quantity metrics decreases staff morale leading to incoordination, conflicts, and mistakes. The purpose of this manuscript is to advocate for improved community pharmacy systems by exploring the impact of metrics workflow systems 16

in community pharmacy practice on employees and patients and proposing a solution to improve these systems.

Methods A literature search using PubMed, Medline, and reference lists of various articles was conducted to collect research related to the working conditions in community pharmacy settings.

Twenty-four relevant sources were found with the following search terms: workflow pharmacy, community pharmacy, conditions in community pharmacy, chain pharmacy, pharmacy metrics. Sources included systematic reviews, meta-analyses, and opinion papers. Data and arguments were analyzed to generate the findings.

Results Workload & Staff Morale The majority of pharmacists are facing increased pressure as a result of performance metrics. According to a survey of 673 pharmacists conducted by the Institute for Safe Medication Practices (ISMP), 61% of pharmacists feel challenged by the workload generated by time guarantees. 4 Some time guarantees include: time to fill prescription, number filled per hour, number of prescriptions filled per hour.3 Sixty-four percent of those pharmacists say they would not have the support of management if they were not met, with only 30.4% of pharmacies having provisions that allowed pharmacists not to meet a metric.3,4 The most common reasons for not meeting time guarantees include prescription volume exceeding resources and adjudication of insurance issues.3 Moreover, only 17% felt able to handle the workload generated by time guarantees while still having the support

Pharmacy Journal of New England • Winter 2017

of their management if these ‘guarantees’ are not met with only 5.8% who agreed that they could achieve all required metrics safely.3 Common penalities for not achieving time guarantees include poor performance evaluation, no bonus or raise, being written up, and termination.3 Without the support of management, pharmacists may feel that their job security is threatened or feel obligated to cut down on medication checking time in order to fulfill quotas. Increased stress and excessive workload burden on pharmacists, as cited by the USP, results in increased medication errors.5 Another aspect of employee morale comes from the pharmacist’s ethical duty to counsel. The current nature of community practice forces pharmacists to sacrifice patient interactions in order to meet business standards created by performance metrics. However, patient care should be the first priority of all health-oriented services. Pharmacist testimonies have noted the difficulty of “getting work done [even] without attempting to answer extra [patient] questions.” 6 This reflects the impact of workload pressures on the ability to interact with patients. Resnick et. al asserts that pharmacists will inevitably face moral conflicts within the scope of their practice, wherein business performance and sales of products like unnecessary supplements or tobacco are prioritized over patient health. 7 Chui et al found that pharmacists whose work environments enable flexibility, allow the utilization of clinical skills in daily activities, and understand the vast role of the pharmacist are more likely to counsel patients. 8 As a result, pharmacists focused on their dispensing duties in order to fulfill quotas under the pressure of performance metrics are not likely to provide patient consultations.

allergies or interactions.

Unfortunately, due to the volume of medications dispensed and the pressurized environment created within community practice, more medication errors may occur. NEHI cites a figure of around 100 undetected errors per day attributed specifically to a high dispensing volume. In a recent survey of community pharmacists, 63.1% felt that time requirements significantly impacted patient safety.3 Malone et al found that the percentage of dispensed medications with a significant drug interaction increased with more prescriptions filled by the pharmacists.10 In a separate survey, pharmacists reported number of prescriptions and fill-time requirement as metrics that most affected patient safety, with only 5.8% feeling confident that they could safely achieve required metrics. 11 As a result, it important to identify contributing factors to medication errors and implementing methods to prevent them. Szeinbach et al found that pharmacists employed by major chains agreed with the statement that pharmacy design contributes to dispensing errors, decreased efficiency, and communication errors. 12 In an analysis of medication errors reported to the MEDMARX system, the United States Pharmacopeia (USP) notes distractions, excessive workload, and insufficient staffing as major causes (refer to Figure 1.1).4 Pharmacist testimonies state the importance of eliminating multitasking and distractions.5 Studies have shown a positive correlation between distractions and medication errors and suggest that pharmacists should not be

Medication Errors Pharmacy workflows that emphasize business metrics over patient care result in more medication errors. According to the New England Healthcare Institute (NEHI), $21 billion is spent every year on preventable medication errors.9 Of that, outpatient preventable medication errors make up $4.2 billion in spending annually. Pharmacists can make a significant difference in reducing the errors and associated costs by performing reviews of medication dosing and interactions; the NEHI states that 37% of prescription errors are associated with dosing and a further 11% are due to harmful

Figure 1.1: USP-Cited Factors Leading to Medication Errors

17

Feature

continued

interrupted or rushed, especially when performing patient profile reviews and patient consultations.13

Solution Changes need to be implemented to improve workflow systems and maximize patient care in community pharmacies. These changes include: a shift in the pharmacist’s role from dispensing to clinical duties, the revision of performance metrics to include more quality measures, and the use of automation to maximize efficiency and decrease errors.

Pharmacist Duties The expansion of pharmacist responsibilities beyond dispensing duties to more clinical duties has been previously acknowledged. The federal Medicare program introduced MTM services to achieve better health outcomes by decreasing medication-related problems and improving adherence to medications.14 In addition, Douette et al has found that drug therapy for patients with multiple chronic conditions can be optimized with the involvement of the community pharmacist in MTM services. 15 From reviewing medication profiles for 150 patients, 886 medication-related errors were found that prompted 659 recommendations made to physicians. Common issues identified by community pharmacists in this study include inappropriate adherence, adverse drug reaction, and inappropriate dosing. These issues identified by community pharmacists can then be addressed in order to prevent a medication error from reaching the patient. With an increase focus on clinical duties, changes to the staffing structure must be implemented. For example, technicians must take on more dispensing activities. This may require changes in technician hours, including having technicians always on duty when the pharmacy is open and a change in technician:pharmacist ratio. In addition, having two pharmacists on duty with one responsible for verification of prescriptions and the other responsible for clinical duties (e.g. counseling and MTM) may efficiently decrease medication errors.3 Another important pharmacist duty is providing effective patient counseling. The implementation of OBRA ‘90 required

18

that pharmacists offer counseling to Medicaid patients, though patients are allowed to decline. This legislation was a step towards emphasizing the importance of patient counseling; it not only decreased medication-related problems, but also improved patient relationships with pharmacists. Community pharmacies should make changes to their performance metrics including decreased focus on quantitative dispensing measures such as fill quotas in order to integrate more qualitative measurements, e.g. quality of patient consultations. To incentivize community pharmacies to make these changes, further legislation should be enacted to emphasize the pharmacist duty to counsel and the importance of quality care.

Overall, legislation to increase pharmacist clinical responsibilities and emphasize patient counseling is the most effective way to push community pharmacies to revise their workflow to integrate these practices. Revision of current workflow practices to allow for these clinical duties will improve patient outcomes Performance Metrics Though performance metrics should not be completely eliminated, it is important to regulate the metrics used in community retail pharmacies in order to ensure they are effectively maximizing performance instead of creating excessive stress or potential harm. For example, ensuring that pharmacists only work a certain number of hours per shift can decrease medication errors and improve employee satisfaction. Other restrictions can include mandatory, uninterrupted thirty minute lunch breaks and the necessity of two pharmacists per shift in stores with certain prescription volumes. These restrictions will ultimately decrease the pressures and stresses pharmacists experience that increase the risk of medication errors.

In addition, it is important to incorporate the assessment of quality, as it is a major measure of performance by pharmacists. Qualitative measures can include types of interventions initiated by the pharmacist and patient surveys to evaluate their interactions with the pharmacist.

Quantitative measures can include the number of medication --Continued on page 36

Pharmacy Marketing Group

Rx and the Law By: Don R. McGuire Jr., R.Ph, JD

This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

The Learned Intermediary Doctrine It is almost impossible to attend a pharmacy law conference and not have a discussion about the Learned Intermediary Doctrine. The Doctrine was first expressed in a lawsuit against a drug manufacturer in 1966.1 The Doctrine states that a drug manufacturer has no duty to warn a patient about the risks of a drug. The manufacturer’s duty is fulfilled by informing the prescriber (the “Learned Intermediary”) of the drugs risks and benefits. The prescriber then has the responsibility of choosing the appropriate therapy because the prescriber has knowledge of the patient’s medical condition.

Through the years, the Learned Intermediary Doctrine was expanded to include pharmacists. This was done through court decisions, by statute, or other procedural means.

Specifically, courts held that pharmacists had no duty to warn patients of the risks of a particular drug. The Learned Intermediary Doctrine put that responsibility on the physician. There was fear that the pharmacist would somehow interfere in the physician-patient relationship.

Under the Doctrine, the pharmacist discharged their duty by correctly filling the physician’s prescription for the patient.

As the different states have looked at the Learned Intermediary Doctrine, they have taken different approaches to it; some adopted it, some rejected it, and some created exceptions to it. And as things usually go in the law, the different states didn’t agree on the exceptions. So what is a practicing pharmacist supposed to do?

This is where I give you a different answer depending on whether I’m wearing my lawyer hat or my pharmacist hat. A common exception to the Learned Intermediary Doctrine in states that have adopted it is situations where the pharmacist has specific information about the patient’s condition (e.g., she is pregnant or he is allergic to penicillin). My advice as a lawyer in these situations would be to advise my

Pharmacy Journal of New England • Winter 2017

pharmacist clients to know as little about their patients as possible. That way you can fall under the protection of the Learned Intermediary Doctrine. As a pharmacist, this advice is contrary to the direction that the pharmacy profession is headed. We are trying to become more involved in patient care, not less.

At these same conferences, there are also many discussions about gaining provider status. How can pharmacists make a case to be considered health care providers and hide behind the Learned Intermediary Doctrine at the same time? Cases rejecting the Learned Intermediary Doctrine state that pharmacists are not merely order-fillers and want to discourage robotic compliance with the physician’s order.

So what is the pharmacist to do? Relying on the Learned Intermediary Doctrine is not necessarily a good strategy.

The courts have not consistently applied the Learned Intermediary Doctrine. My review of cases leads me to conclude that courts really don’t understand what pharmacists can and are supposed to do. For example, one case reached the right answer for the wrong reason. 2 There are exceptions to it and you don’t want your case to be the one in which the court creates another exception. Many of the cases were decided before OBRA ’903 and its resulting regulations were implemented. Few discussions today talk about OBRA’s impact on the Learned Intermediary Doctrine, but I believe that it is underestimated. It is beyond the scope of this article to recite a detailed history of these decisions.

Suffice it to say that relying on the Doctrine is a risky strategy because it is too difficult to predict the court’s outcome.

The better option is for the pharmacists to use their training, experience, and expertise for the benefit of the patient. Protecting patients from harm is a strategy within the pharmacist’s control. Intervene when you see something that raises a red flag. Protecting your patients ultimately protects you. Additionally, utilizing our expertise and making a positive impact on patient outcomes is a more persuasive way of convincing payers, patients, and regulators that pharmacists are a vital part of the health care team. Let’s move into the 21st Century.

References: 1. Sterling Drug Inc. v. Cornish, 370 F.2d 82 (8th Cir., 1966) 2. Morgan v. WalMart stores, Inc., 30 SW 3d 455 (Tex App.-Austin, Aug. 10, 2000) 3. Omnibus Reconciliation Act of 1990, Pub. L. No. 101-508, 104 Stat. 1388

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From the Colleges University of Connecticut School of Pharmacy UConn Welcomes New Faculty This has been a busy and exciting year so far in the School of Pharmacy. We have welcomed three new faculty between last year and this year. Dr. Nathaniel Rickles was a longtime faculty member at Northeastern University who has moved to UConn to help lead our PRISM initiative. PRISM is a collaborative effort on the part of our faculty to substantiate the value of Dr. Nathaniel Rickles pharmacist-provided cognitive services and to advocate for legislative change to expand the services that patients can be provided. Dr. Rickles’ research is at the intersection of community pharmacy practice and the value of patient access and communication. He has worked closely in the areas of mental health and substance abuse.

Also supporting PRISM is Dr. Christina Pornprasert, a UConn alumnus who completed her PGY1 residency at VACT and PGY2 ambulatory care residency at The Johns Hopkins Hospital.

Her practice site is at Hartford HealthCare Integrated Care Partners where she is showing the impact pharmacists can have within an accountable Dr. Christine Pornprasert care organization by providing direct patient care for high-modifiable risk patients.

Our HOPES group has been bolstered by the hiring of Dr. Adrian V. Hernandez, who is a physician and an international expert in comparative effectiveness research.

His specialty is in systematic reviews and meta-analyses across the spectrum of cardiovascular diseases. Dr. Hernandez also has experience in prognostic modeling and clinical practice guidelines methodology. The HOPES group centers its research on determining the comparative 20

effectiveness of competing interventions in the marketplace, whether drugs, devices, or surgical procedures, and houses an Agency for Healthcare Research and Quality Evidence-based Practice Center, one of only 13 in America and the only one centered in a School of Pharmacy.

Dr. C. Michael White was presented the Award for Sustained Contributions to Literature Award from the American Society of Health-Systems Pharmacists in Las Vegas in December.

This award is given to one individual annually for a lifetime of scholarly success. With over 300 publications including those in JAMA, Annals of Internal Medicine and Circulation and citations in the 99% percentile internationally, this award is well deserved for Dr. White.

Dr. C. Michael White was presented with the Sustained Contributions to Literature Award.

Honors and Publications Dr. Lisa Holle was selected as one of the American Society of Clinical Oncology’s Advocacy Champions based on her advocacy efforts for oncology patients and is spearheading an oral oncology drug takeback program to prevent these drugs from making it into landfills or water supply. Dr. Jill Fitzgerald and Dr. Lisa Holle presented two papers on a revolutionary software program called MyDispense, which

Pharmacy Journal of New England • Winter 2017

has been adapted by UConn and UCSF Schools of Pharmacy.

MyDispense is a simulated community or hospital pharmacy environment in which students can apply their knowledge of therapeutics and drug laws to the prescription and order filling process.

Dr. Kevin Chamberlin is a member of the writing committee for the ACCP Interprofessional Education White Paper for 2016-2017 and Dr. William Baker has joined the Editorial Board of “Diabetes, Obesity and Metabolism” (Impact Factor of 6.198) as the only Pharm.D.. member in the Journal’s history. Dr. Nathaniel Rickles edited a new textbook entitled “Social and Behavioral Aspects of Pharmacy Practice, Third Edition,” while Dr. Robert McCarthy updated his textbook entitled “McCarthy’s Introduction to Health Care Delivery: A Primer for Pharmacists, 6th ed.”

Preceptor Appreciation Dinner Held in October The School of Pharmacy’s Office of Experiential Education held our 15th annual Preceptor Appreciation dinner on October 27. Celebrated during this event held at Saint

Clements Castle were the enormous contributions made by our preceptors towards the development of the next generation of pharmacists. Preceptors’ work in experiential settings prepares students in their transition to practice their future roles as pharmacists. In addition, five preceptors were selected from a large pool of nominations made by the students to be named “Dennis Chapron Preceptor of the Year” in honor of their outstanding work with students.

Honored by Dennis Chapron and our school for their exceptional precepting activities were: Crystal BissonetteGarosshen, (Rite Aid Pharmacy- Canterbury) for her Introductory Practice Experience in Community Pharmacy; Robert Guynn (UConn Correctional Managed Care) for his Introductory Practice Experience in Institutional Pharmacy; John Capuano (Yale Apothecary and Wellness Center) for his Introductory Practice Experience in Service Learning; Marissa Salvo (UConn Health) for her Advanced Pharmacy Practice Experience in Ambulatory Care and James Prota (Connecticut Hospice) for his Advanced Pharmacy Practice Experience in Hospice Care.

Dennis Chapon and the School of Pharmacy recently honored preceptors at the Office of Experiential Education’s Preceptor dinner. Pictured from L to R: Chapron, Marissa Salvo, Peter Tyczkowski, Crystal Bissonette-Garosshen, James Prota, John Capuano and Robert Guynn.

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From the Colleges

continued

Massachusetts College of Pharmacy and Health Sciences – Boston Dear Colleagues, On behalf of President Charles F. Monahan Jr. and Provost George Humphrey, I bring you greetings from the School of Pharmacy-Boston at MCPHS University. As I write to you, the new semester is well underway and our faculty and students are as busy as ever both in the classroom as well as outside of it. I have included some highlights of their notable achievements below.

Best Wishes, Paul DiFrancesco, Dean

Faculty Spotlight Dr. Monica Chuong, Associate Professor of Pharmaceutics, was an invited speaker at two recent conferences: The Formulation and Drug Delivery Congress, held in Boston, Mass., and the 2nd International Conference and Expo on Biopharmaceutics and Biologic Drugs in San Antonio, Texas. She conducts research with undergraduate, PharmD, and graduate students in the area of formulation development and analysis.

Several faculty also presented symposium at the meeting. Dr. Michele Matthews presented two sessions in the area of pain management and chronic opioid use.

Dr. Snehal Bhatt presented two sessions in the area of anticoagulation.

Dr. Mary Amato moderated and presented in a session focused on medication safety.

Dr. Trisha LaPointe facilitated a pharmacy practice experiences section advisory group networking session.

About 60 PharmD students also attended the meeting and MCPHS-Boston students and faculty presented more than 40 posters.

Christopher Fagbote and Yousef Hanna, 6th year PharmD students, represented MCPHS-Boston at the clinical skills competition Saturday afternoon. Their submission included a pharmaceutical plan for a patient case with spontaneous bacterial peritonitis.

The two Schools of Pharmacy at MCPHS University hosted an alumni reception. Approximately 300 alumni, colleagues, faculty, students, fellows, and residents attended the event.

ASHP Midyear Meeting A number of faculty, residents, fellows, and students attended the 51st ASHP Midyear Clinical Meeting this past December in Las Vegas.

22

Pictured at ASHP Midyear are above, L to R, Cal Thomas Murphy, Argeta Dhroso, and Kayla Michelle Najafipour (all class of 2017).

Pharmacy Journal of New England • Winter 2017

Student Success Congratulations to student Nadia Noormohamed who received the Global Clinical Supplies Scholarship and has been invited to attend their Annual Meeting that will be held in April in New Mexico. Nadia will be graduating in May with her PharmD degree.

Honors Program The School of Pharmacy–Boston Doctor of Pharmacy Honors program is an enrichment of the Doctor of Pharmacy curriculum that expands educational opportunities for highly motivated and academically talented students. These students complete four semesters of Honors seminars, an Honors Research project, and additional Honors coursework in two of their courses from the core curriculum of the Doctor of Pharmacy program.

In December, students and alumni of the Honors Program came together at the ASHP Midyear Clinical meeting in Las Vegas. Honors Research projects range from benchtop to clinical trials. The topics presented this year included: an evaluation of an animal model celiac disease for the study of pharmaceutical pharmacokinetics in this population,

the efficacy of a medium chain triglyceride oil for the mild cognitive impairment in Alzheimer’s disease, validation of a medication adherence tool in congestive heart failure, and evaluation of antithrombotic management for atrial fibrillation at a tertiary care center.

All of the students in the Honors Class of 2017 are planning to pursue residencies or graduate school upon their graduation in May. One of the great aspects of the Honors Program for students is the alumni network of graduates from the program that continues to grow. Our alumni now span across the U.S. and planet, and are involved in almost every area of pharmacy, as well as additional graduate education in medicine, pharmacology, and business.

We were pleased to have two of our alumni join students and Honors Program Director, Alissa Segal, for dinner recently in Las Vegas -- Catherine Behret, who is completing her PGY-1 residency at Providence Portland Medical Center, in Portland, Oregon, and Stephanie Lewis, who recently joined the clinical staff at Yale New Haven Hospital.

Massachusetts College of Pharmacy and Health Sciences – Worcester/ Manchester Dear Colleagues, We had a successful Fall 2016 semester and our spring 2017 semester is well underway.

The P1 students are busy with course work and learning about all of the opportunities that the profession of pharmacy offers.

The P2 students are busy with Pharmacotherapeutics and Pharmacology and are looking forward to choosing their APPE sites. The P3 students are more than halfway through their APPE rotations and are exploring residency, fellowship and employment options fol-

lowing graduation in May. Our faculty, our course, have been busy as well! Best wishes for a successful Spring 2017 semester.

Sincerely, Anna K. Morin, PharmD Interim Dean and Professor of Pharmacy Practice

MCPHS University SOP-Worcester/ Manchester Places 2nd during the 9th Annual Pepto Bowl The School of Pharmacy-Worcester/Manchester placed second at the 9th Annual New England Colleges of Pharmacy “Pepto Bowl” at the New England Pharmacists Convention at Foxwoods this past fall. The competition tests student 23

From the Colleges

continued

pharmacists’ knowledge related to self-care and over-thecounter medication. All New England Schools of Pharmacy are invited to send teams of two graduating students to participate in a first round, pre-test. The four teams scoring highest on the pre-test move on to a live Jeopardy style CE event. The schools of pharmacy competing in the first round of competition included Northeastern University, University of Rhode Island, University of New England, University of Saint Joseph, Western New England University, and University of Connecticut. The MCPHS University-School of PharmacyWorcester/Manchester team scored high on the pre-test allowing them to advance in the competition along with University of Saint Joseph, UConn and URI. It was a close competition and congratulations to the URI team that won the Bowl this year. This year’s School of Pharmacy WorcesterManchester team was represented by Stephen Gibson and Andrew Booth from the Manchester campus. Dr. Sheila Seed and Dr. Kaelen Dunican coordinated the team and helped to facilitate the event.

Daya, T, Acquaah-Mensah, GK (October 2016). Similarities between the Alzheimer and Diabetes Hippocampus: A Comparison of Gene Expression Profiles. [also presented at The Northeast Chapter of the Society of Toxicology 2016 Annual Meeting in Boston, Massachusetts] Ennis M, Willett KC, Morrill A, Durand C, Pervanas H. Assessment of an OTC medication safety activity to increase knowledge to consumers.

Clive P, Hauger J, Nguyen S, Carey K, Dietle A. Emergency intranasal naloxone education for addiction healthcare providers.

Daya T, Costantinio K, Bartlett D. The burden Medicare patients face with COPD medications.

Faculty Presentations

ADA StepOut: Walk to Diabetes More than 45 MCPHS University pharmacy, optometry, nursing and physical therapy students, faculty and staff participated in the ADA StepOut: Walk to Diabetes on Saturday, September 24 in Worcester, Mass. The MCPHS contingent provided glucose and blood pressure screenings, foot care and eye exams, and stretching and warm-up exercises before the walk. Worcester campus involvement in StepOut activities was spearheaded by Kayla Bourbonniere (Class of 2018), APhA-ASP Operation Diabetes Chair. She also served as the captain for the MCPHS University – Worcester fundraising/ walking team. She herself is a “Red Strider” (someone living with Type 1, Type 2, or gestational diabetes).

Poster Presentations 34 different students and 21 different faculty worked together to present 28 posters at the 2016 ASHP Midyear Clinical Meeting that took place in Las Vegas, Nevada December 4-8, 2016. A sample of Posters Presented at ASHP: Bautista C, Steinberg M. Evaluation of herbal and nonprescription medication supplement usage in elderly patients.

24

Linda M. Spooner

Linda Spooner presented a session titled “A toolkit for achieving quality antimicrobial stewardship in small and rural hospitals” as part of the Small and Rural Hospital Track at the 2016 ASHP Midyear Clinical Meeting. Dr. Spooner also served as the session chairman and moderator for a session titled “From Admission to Discharge: Optimizing the Management of Hospitalized Patients with New Options for Type 2 Diabetes.”

Timothy Aungst, Kelley Grindrod presented a session titled “Welcome to the E-patient movement: patients becoming more involved in their health through technology” at the 2016 ASHP Midyear Clinical Meeting.

Faculty Grants Matthew Metcalf has received funding from the 20162017 AACP New Investigator Award for his proposal titled “Analgesia with reduced side effects from dual FAAH inhibitoranalgesic ligands”.

Pharmacy Journal of New England • Winter 2017

Faculty Recognition Jen Towle was honored at the University-sponsored Annual Holiday Reception with receipt of the NH Distinguished Young Pharmacist Award on December 13, 2016.

Faculty Publications Gardner A, Lahoz MR, Bond I, Levin L. Assessing the Effectiveness of an Evidence-based Practice Pharmacology Course Using the Fresno Test. American Journal of Pharmaceutical Education. 2016;80(7) Article 123.

Yogaratnam D, Ditch K, Medeiros K, Doyno C, Fong JJ. Idarucizumab for reversal of dabigatran. Annals of Pharmacotherapy.

2016; 50: 847-54.

The Connecticut Pharmacists Foundation Presents the 7th annual Wine-­­Tasting Reception to benefit the Scholarship Fund and other community focused programs sponsored by the Foundation.

Saturday May 20, 2017 6:30 p.m. – 9:00 p.m.

Arrigoni Winery Portland, Connecticut www.arrigoniwinery.com

$50 per person includes wine tasting and appetizers.

Enjoy a summer evening with friends, a variety of wines, musical entertainment, and the opportunity to win a variety of raffle prizes.

Sponsorship Levels Available Platinum Level $1,500 includes 10 guests, a display table, signage at event, and website presence.

Gold Level $1,000 includes 8 guests and signage at event Silver Level $750 includes 4 guests and signage at event Bronze Level (for individual sponsorship only) $500 includes 2 guests and signage at event Please return form and payment by May 13, 2017.

For more information, please call the office at 860-563-4619.

25

From the Colleges

continued

University of New England UNE Pharmacy Students Lead Voter Registration Drive In the weeks leading up to the presidential election, Stephanie Villasis (COP ’18) and fellow students from UNE’s Student National Pharmaceutical Association (SNPhA) organized a voter registration drive and Rock the Vote lecture on the Portland Campus.

Villasis, who is the 2016-17 legislative chair in the UNE branch of the SNPhA, spearheaded Rock the Vote week at UNE. Alongside SNPhA president Christina Fields (COP ’18), she gave a non-partisan lecture on the presidential election and citizen initiatives to members of the Portland community.

Villasis began to take interest in policy and legislation at the 2016 SNPhA National Convention in Atlanta, GA, where she was inspired by student delegates who presented resolutions for SNPhA by-laws. Her passion for volunteerism led her to motivate fellow pharmacy students to become involved with outreach efforts, educating students, faculty and community members about the voting process.

UNE Hosts Fourth Annual LGBT Health Disparities Presentation On October 14, 2016, all third-year students at the UNE College of Pharmacy attended a talk on “LGBT Health Disparities: Social Determinants and the Legacy of Stigma.”

Presented by Benoit Dubé, M.D., Assistant Dean for Diversity and Inclusion, Associate Professor of Clinical Psychiatry at the University of Pennsylvania’s Perelman School of Medicine, the symposium focused on the specific healthcare needs of LGBT youth and adults.

As noted by Dubé, LGBT patients form an ‘invisible minority.’

This invisibility creates a special challenge for healthcare providers, as many of their medical needs are undiagnosed and untreated. Through the symposium, Dubé demonstrated 26

the human consequences of ignoring LGBT health issues, while providing ways that the students can be better, more knowledgeable healthcare providers to this community.

Students attending the presentation said that this was “perhaps the most important three hours spent while attending the College of Pharmacy,” as it deepened their insight into ways that they as healthcare providers can provide compassionate, patient-focused care.

Pharmacy Dean Gayle Brazeau Helps Host 2016 Compass Program for Academic Advancement Gayle Brazeau, Ph.D., dean of the College of Pharmacy, recently participated in the hosting of the Compass Program for Academic Advancement, a program of the Academy for Academic Leadership (AAL). The online program is designed to provide participants (early and mid-career academic faculty) with a better understanding of the culture of higher education.

Nearly 60 people from the U.S. and abroad participated in this year’s Compass Program, which began with an orientation on September 1 and concluded on September 29.

This is the second year that Brazeau, an AAL senior consultant, has been involved in the program. “What’s exciting about being involved with the Compass Program for Academic Advancement is the opportunity to share insights which would have been useful during my early academic career,” she said. “It is a dynamic environment where everyone is learning from each other, all while using the online platform which is interactive and easy to navigate.”

Student Pharmacy Groups Among UNE Community Members Providing Services at Community Health Fair UNE, in partnership with the Portland Public Library, hosted a free Community Health Fair on October 18 at the library.

Pharmacy Journal of New England • Winter 2017

Students and faculty volunteers from the College of Pharmacy, College of Dental Medicine and the Westbrook College of Health Professions provided education on chronic illnesses such as diabetes, cardiovascular disease, balance disorders and depression.

Esidie Epie is pictured above at Two student pharmacy the Community Health Fair. groups participated in the fair. The Student National Pharmaceutical Association (SNPhA), headed by Christina Fields, provided information about key health topics to the public. Members of SNPhA Kayla Harris and Esidie Epie presented posters and other educational tools on HIV testing centers and chronic kidney disease prevention, respectively.

SNPhA Vice President Whitney Sargent sat on a career panel at the fair to answer questions from the public about pharmacy school.

their missions of pharmaceutical education, research and service. It works specifically with interdisciplinary matters of curriculum, course content, education methods, faculty/ administration relations, and national issues of general interest to pharmacy faculties.

Founded in 1900, the AACP is the national organization representing the interests of pharmacy education and educators. This association comprises all accredited colleges and schools with pharmacy degree programs.

UNE College of Pharmacy Students Awarded First Place in MSHP Event Fourth year pharmacy students Erin Kany, Linh Tran, Ashley Woon, and Uju Okoronkwo took home top honors for UNE at this year’s Jeopardy Challenge, held at the Maine Society of Health System Pharmacists (MSHP) Sesquicentennial Event.

UNE’s team defeated competitors from Husson University.

The event comes at the conclusion of the annual MSHP conference, which brings together pharmacy professionals from across the state. This year’s meeting included sessions on collaborative drug therapy, the new opioid law and pharmacy calculations for technicians and students.

SNPhA member Amanda Powers assisted the other student pharmacy group at the event, the National Community Pharmacists Association (NCPA), headed by President Diana Alka, in measuring people’s blood pressure and heart rates.

UNE College of Pharmacy Joins Apothecary

by Design to Launch Specialty Pharmacy Residency Program

UNE’s Daniel Brazeau Elected as AACP Chair

The University of New England College of Pharmacy has partnered with Apothecary By Design (ABD) to create a residency training program in specialty pharmacy. The fastest-growing segment of the pharmacy industry, specialty pharmacy, focuses on high-cost, high-touch medication therapy for patients with complex disease states.

Following national elections, Daniel Alan Brazeau, Ph.D., director of genomics research core, research associate professor in the College of Pharmacy and College of Osteopathic Medicine, has been named Chair of the Council of Faculties for the American Association of Colleges of Pharmacy (AACP).

In this position, Brazeau will represent and support faculty at AACP member colleges and schools while serving on the association’s board of directors. The Council of Faculties is dedicated to the needs of faculty, helping them to carry out

With this partnership, UNE will join a select group of U.S. universities offering this specific program. According to the American Society of Health-System Pharmacists, there are currently more than 1,700 pharmacy residency programs in the country, but it is estimated that fewer than a dozen concentrate in specialty pharmacy.

The first pharmacist is expected to enroll in the new residency program in July 2017. Based in Portland, the one-year residency will provide hands-on management and clinical training around conditions such as infertility, organ 27

From the Colleges

continued

transplant, hepatitis C, HIV and rheumatoid arthritis.

Kenneth McCall, BSPharm, Pharm.D., CGP, associate professor for the Department of Pharmacy Practice, serves as a key preceptor of the program. “With recent advances in science, specialty care is at the forefront of pharmacy, and ABD is at the forefront of specialty,” he stated. “The University of New England College of Pharmacy is thrilled to be partnering with ABD to offer this unique opportunity, which complements the other rich resources we bring to the profession of pharmacy.”

“ABD’s commitment to patients today includes preparing pharmacists to provide specialty care tomorrow,” said Denali Cahoon, ABD chief operating officer and director of the residency program. “The residency is an example of the way ABD is investing in the future of specialty pharmacy, while embracing innovation and new knowledge in our clinical work each day.”

National Media Reports on UNE Professor’s Breast Cancer Detection Marker News of the groundbreaking research by Srinidi Mohan, Ph.D., assistant professor in the College of Pharmacy, has spread across the country, with the Associated Press, Hearst, WCSH, WMTW and the Portland Press Herald reporting on his innovation in the field of breast cancer research. Mohan has received a provisional Srinidi Mohan, PhD patent for his early detection and disease monitoring method, which uses a marker in the blood to detect the presence of highly aggressive tumors and help track cancer growth.

“I was simply in the right place at the right time,” Mohan says, discussing how he stumbled upon this finding in 2014 while studying nutritional supplements. He found that the marker Nw-hydroxy-L-Arginine (NOHA) was both a sensitive and reliable indicator for estrogen receptor-negative (ER–) tumors, found in the most aggressive types of breast cancer.

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According to the American Breast Cancer Foundation, these types of cancers are diagnosed in 50,000 to 60,000 individuals each year in the United States, with young women and African Americans most at risk. As these types of cancers are rarely caught in the early stages, they are often a death sentence when discovered.

Mohan, who had never previously studied breast cancer, began testing the marker on cell lines of African-Americans, Caucasians, Jews, Asians and Hispanics to see if it could detect tumor presence across disparate ethnicities. In each case, he found that the results aligned with his hypothesis: low levels of NOHA in the blood are consistent with ER– tumor presence.

Mohan is now applying for federal grants for this research, and has received funding from the Maine Technology Institute. Subsequently, a clinical trial could be launched, leading to the eventual development of a testing kit to be used by health care providers. This kit could be used not only as a means of cancer detection, but as a tool to track the effectiveness of treatment.

“I find myself humbled. That’s the first thing,” Mohan said, reflecting on his work. “And, I am thankful that I was able to do this, and for the University for supporting it.” He continued, “I am a faithful person. I think about this every day. I have a purpose in my life.”

UNE’s Lauren Payne Invited to Speak at Olympia Snowe Women’s Leadership Institute Summit Lauren Payne, Pharm.D., assistant clinical professor in the University of New England Department of Pharmacy Practice, was chosen by the Olympia Snowe Women’s Leadership Institute to speak at the organization’s Fall Forum.

Held on November 10, 2016, the program brought together high Lauren Payne, PharmD school girls and women from a broad range of occupations.

Payne participated in three rounds of networking with the students, speaking with them about her education at UNE,

Pharmacy Journal of New England • Winter 2017

post-graduate work in critical care pharmacy, and how she chose her career path. The event concluded with a debrief of the day, allowing students and mentors to share their experiences.

Founded by Senator Olympia Snowe, the Women’s Leadership Institute launched in 2015 as a way to create a meaningful leadership experience for 10-12th grade girls. The program has recently expanded to a statewide model and has a total of 155 participants.

UNE pharmacy and dental students team up for first annual Research Day As a way to share the pioneering work taking place at UNE’s College of Dental Medicine and College of Pharmacy, the two colleges collaborated to Pictured above (L to R) are Matt Lacroix, develop the first Max Roberts and Nikki Withrow. annual Research Day. The event took place December 1, 2016 on the Portland Campus.

Pictured above (L to R) are Leslie Ochs and Candace Iba.

In recent years, the quantity of research conducted by students and faculty has increased greatly in

both colleges.

At the College of Pharmacy, students’ involvement in research is now a common practice, leading to the generation of preliminary data for grant applications, poster presentations at national meetings and manuscript publications.

Research and scholarship is also central to the mission of

the College of Dental Medicine. In the summer of 2015, the College implemented a Student Research Program, providing opportunities and funding for both students and faculty.

In 2016, eight faculty members and more than 20 students conducted research that was subsequently presented at Research Day. At the inaugural event, a total of 48 posters were shared by students and faculty. Co-founders Cassia Mizuno, Ph.D., assistant professor in the College of Pharmacy and Curt Cyr, Ph.D., R.Ph., clinical professor in the College of Dental Medicine noted that the day was not only an opportunity to discuss research, but to discover new opportunities for interprofessional scholarship between the Colleges.

UNE’s Ken McCall Presents Webinar on Maine’s New Opioid Prescribing Law Focusing on the legal aspect of opioid regulation, Kenneth McCall, BSPharm, Pharm.D., CGP, associate professor for the Department of Pharmacy Practice, was a featured speaker in a Caring for ME Pharmacy webinar.

Held January 11, 2017, McCall co-presented with Gordon H. Smith, Esq., executive vice president of Maine Medical Association.

The talk addressed Maine’s new opioid prescribing law, Chapter 488. This regulation stipulates that opioid prescriptions be limited to 100 morphine milligram equivalents per patient per day, that prescribers take an opioid prescribing course and that the Prescription Monitoring Program be consulted before any opioid or benzodiazepine prescription is written. McCall and Smith provided an overview of the law and associated rules, discussing the impact on Maine’s pharmacy community and strategies for applying the new regulations in practice. They also explained the implementation timeline as well as the rule-making and exception process.

This webinar was accredited by the College of Pharmacy’s Office of Continuing Education in conjunction with Maine Quality Counts, a regional health improvement collaborative,

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From the Colleges

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Western New England University College of Pharmacy

Message from the Dean Greetings from Western New England University College of Pharmacy!

It is hard to believe we are already into 2017 and all the opportunities and challenges that can result from a new year.

It is hard to believe we have graduated two classes, have an excellent complement of faculty and staff, and a full college of great learners. And yet we are still at the outset of an exciting long journey!

As you read about the great things we’ve accomplished over this past year, this most recent step on our journey, I want to bring your attention to our collaboration, innovation, and entrepreneurship. As I reflect back on the nine years I have been at Western New England University, I am constantly reminded that success results from a collective of the whole.

To paraphrase President Theodore Roosevelt, “The best executive is the one who has sense enough to pick good men to do what he wants done, and self-restraint enough to keep from meddling with them while they do it.” He said it best, hire good people and get out of their way!

Within this issue you will learn about three particular activities linked to collaboration, innovation, and entrepreneurship.

They are but the tip of the iceberg with respect to the wonderful things going on here at the College of Pharmacy.

I look forward to hearing from you and please keep up with our exciting journey visiting www.wne.edu/pharmacy.

All my best!

Evan Robinson, Dean and Associate Provost.

Pictured left to right: Mr. Yongfu Hang, Mrs Fan Zeng, Mrs. Boxia Li, Dr. Shusen Sun, Dr. Evan Robinson, Dr. Xiaoxing Wang, Dr. Wenqian Chen, Dr. Yanting Wang, Dr. Xia Qin

30

College of Pharmacy Establishes Pharmacy Education and Clinical Pharmacy Practice Training Program for Chinese Pharmacists The College of Pharmacy welcomed six Chinese pharmacists to the University on November 7, 2016. This marked the beginning of the Pharmacy Education and Clinical Pharmacy Practice Training Program for Chinese pharmacists. The program is in partnership with Yale New-Haven Hospital and the Chinese Pharmacological Society-Division of Therapeutic Drug Monitoring Research (CPS-TDM). The program allows international pharmacists to spend one month at the College of Pharmacy to learn about pharmacy education, and five months at Yale New-Haven Hospital to learn about the practice of pharmacy the United States. Dr. Shusen Sun, PharmD, Director of International Pharmacy Programs at the College and Board Member of CPS-TDM, oversees the operation of the program, which represents a new and unique opportunity for international collaboration for both the College of Pharmacy and Yale New Haven Hospital.

Six Chinese clinical pharmacists enrolled in the program originating from five major Chinese hospitals: Dr. Xiaoxing Wang and Dr. Wenqian Chen from China-Japan Friendship Hospital, Dr. Yanting Wang from the Cancer Hospital-Chinese Academy of Medical Sciences, Mr. Yongfu Hang from the First Affiliated Hospital of Soochow University, Mrs. Fang Zeng from Tongji Hospital-Tongji Medical College Huazhong University of Science & Technology, and Mrs. Boxia Li from the First Hospital of Lanzhou University.

Pharmacy Journal of New England • Winter 2017

A variety of lectures and topics of discussions were provided to the Chinese pharmacists during their 1-month of academic learning including but not limited to pharmacy school admission process, overview of Doctor of Pharmacy education, pharmacy education accreditation standards and outcome assessment, pharmacy curricular design, creation of the mission and vision of pharmacy education, experiential pharmacy education, pharmacists as educators, and leadership development in pharmacy practice. The program allows pharmacists to attend College of Pharmacy didactic lectures, case discussions, interactions with students on experiential clinical rotations, and faculty development seminars. The visiting pharmacists also had the opportunity to interact with faculty to discuss about research and clinical practice.

Seeking to Innovate Testing for People with Diabetes Dr. Ronny Priefer, PhD, (Professor of Medicinal Chemistry in the Department of Pharmaceutical & Administrative Science and Chair of the University Senate) has developed, in collaboration with Dr. Michael Rust, PhD, (Associate Professor of Biomedical Engineering) a breathalyzer to detect and monitor diabetes. Utilizing multilayer nanotechnology, a sensor was developed and patented that in conjunction with a detector can accurately determine the acetone concentration within the breath of patients with diabetes.

The technology was tested within the clinical site of Dr. Kam Capoccia’s, PharmD, (Clinical Associate Professor of Community Care). A handheld, portable device is under development and has led to a spin-off biotechnology company, New England Breath Technologies, LLC (www.newenglandbreath.com), of which Dr. Priefer is the founder and CEO. Financing has already begun and it is anticipated that an FDA submission will be forthcoming within a few years. The technology is now also being expanded to explore marijuana breathalyzers as well as other disease that may be metabonomically monitored via the breath.

Pictured above, L to R: : Dr. Michael Rust, Associate Professor of Biomedical Engineering and Dr. Ronny Priefer Professor of Medicinal Chemistry in the Department of Pharmaceutical & Administrative Science.

Interprofessional Education (IPE) Winter Session Held January 9th Dr. Linda E. Jones, Provost and Vice President for Academic Affair at Western New England University (WNE), invited administrators from various academic institutions in the Pioneer Valley to a summit on the future of Interprofessional Education in western Massachusetts. This very successful event was organized and coordinated by Dr. Beth Welch, Associate Dean for Academic Affairs within the College of Pharmacy.

The event, held on January 9th at WNE, was highlighted by a panel of national leaders in health professional education, including Dr. Lucinda Maine, Executive VP & CEO American Association of Colleges of Pharmacy, Dr. Geraldine “Polly” Bednash, former CEO, American Association of Colleges of Nursing, and Dr. Steven Shannon, President and CEO, American Association of Colleges of Osteopathic Medicine, who shared their insights and experience with an audience of 30 people representing eight institutions. This event was organized by the Pioneer Valley Interprofessional Education Collaborative (PV-IPEC) in efforts to raise the awareness of the importance of interprofessional education in healthcare professions and to stimulate opportunities for collaboration.

31

From the Colleges

continued

Above, facing forward, pictured left to right: Dr. Linda E. Jones, Provost and Vice President for Academic Affairs, Dr. Beth Welch, Associate Dean for Academic Affairs and Professor of Pharmacy Practice.

Below, Pictured left to right: Dr. Steven Shannon, Dr. Geraldine “Polly� Bednash, Dr. Lucinda Maine, Dr. Beth Welch

32

Pharmacy Journal of New England • Winter 2017

University of St. Joseph Message from the Dean

Four manuscripts from her postdoctoral work are at various

Greetings to All!

recognition from the Mechanism Specialty Section’s (a

stages of publication. Her doctoral research received

We, at University of Saint Joseph School of Pharmacy, continue to cultivate an attitude of gratitude through changing times. The ongoing accomplishments of our faculty not only remain highly recognized by the pharmacy community, but also keep our students excited about their career paths. To our preceptors, thank you for your dedication in transforming our students for future innovative practices. Let us go forth into 2017 with a bright outlook!

specialty section of the Society of Toxicology) Carl C. Smith

Happy New Year!

of Toxicology (SOT). Additionally, she is a licensed veterinary

Dean Joseph R. Ofosu

Society for Veterinary Pharmacology and Toxicology (ISVPT),

New Appointments

Graduate Student Award and Best Poster Award from the Northeast Society of Toxicology regional chapter.

Dr. Rudraiah has served as a reviewer in Toxicology journals, including Toxicology and Applied Pharmacology, and as an editorial board member in journals such as HSOA Journal of Cell Biology and Cell Metabolism, and HSOA Journal of Cytology and Tissue Biology. She is a member of the Society practitioner in India and is a lifetime member of the Indian India.

Dr. Swetha Rudraiah has joined the University of Saint

News

Joseph as an Assistant Professor in the Department of

The Epsilon Alpha Chapter of the Rho Chi Pharmacy Honor

Pharmaceutical Sciences. She earned a Doctor of Veterinary Medicine and MS in Pharmacology and Toxicology from the University of Agricultural Sciences, India and the Karnataka Veterinary, Animal and Fisheries Sciences University, India, respectively. In 2014, she received a Ph.D. in Pharmacology and Toxicology from the University of Connecticut.

Dr. Rudraiah has published fourteen research articles in various peer-reviewed journals and presented her work in professional society annual national/international meetings.

Society at University of Saint Joseph School of Pharmacy inducted 18 new members on October 19, 2016. The ceremony was held at the Pond House Café, Elizabeth Park in West Hartford, CT. Guest speaker was Dr. Amber Castle, BCPS, BCCCP, Supervisor of Residents and Education at Yale New Haven Hospital, where she is responsible for coordinating student pharmacist rotations and pharmacist education and training. Dr. Dora E. Wiskirchen serves as the faculty advisor for the chapter.

Rho Chi Honor Society Induction Ceremony

33

From the Colleges

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The University of Saint Joseph (USJ) School of Pharmacy recently hosted its annual Preceptor of the Year Award, honoring SueGi Kim, Pharm.D., and Venkata Kamal Swami, R.Ph. As experiential education professionals, pharmacist preceptors teach students practice-related skills necessary to provide quality pharmacist care. In addition to serving as teachers, pharmacist preceptors mentor student pharmacists, promoting personal and professional growth.

Dr. Kim is a Clinical Pharmacist at Bristol Hospital in Bristol, CT. In this role, her responsibilities include providing clinical support to physicians and the nursing staff, providing a daily review of the hospital formulary to ensure adherence, and assisting in antibiotic selection, IV to oral medication conversions, and anticoagulation monitoring. Kim has hosted students from the USJ School of Pharmacy since its inception, providing outstanding mentorship and leadership in the area of institutional pharmacy.

Dr. Swami is a community pharmacist at Westown Pharmacy in Manchester, CT., and a graduate of V.L. College of Pharmacy in India. He purchased his local pharmacy in 2010 and became a preceptor for the USJ School of Pharmacy’s inaugural class. Since then, he has hosted dozens of students during their three-year professional programs. He has provided a unique look at independent pharmacy practice, championing the role of the community pharmacist.

Dr. Tamara Malm was inducted as Junior Board Member at Large for CT Society of Health-Systems Pharmacists [2-year term].

Dr. F. Bahar Matusik was installed as the Connecticut Pharmacists Association President [1-year term].

Dr. Steven Lemieux achieved board certification in Critical Care Pharmacy (BCCCP).

Posters and Presentations Francis I, Gimose E, Atembe S, Okwesili P, and Edafiogho IO. “Evaluation of novel enaminones as potential anticonvulsant agents.” Poster was presented at the ASHP Midyear meeting at Las Vegas, Nevada, on December 5, 2016.

Rosa N, Grover O, Maltare A, and Mandela PG. Department of Pharmaceutical Sciences, University of Saint Joseph, Hartford, 34

CT. “Fluoxetine induced behavioral alterations in Drosophila melanogaster.” Poster presentation at Neuroscience 2016 at San Diego, CA on November 12-16, 2016.

Nguyen E, Peacock WF, Fermann GJ, Ashton V, Crivera C, Wildgoose P, Schein JR, Bunz TJ, Coleman C, Kohn CG. “External Validation of a Multivariable ClaimsBased Prediction Rule for In-Hospital Pulmonary Embolism Mortality.” European Society of Cardiology 2016. Rome, Italy, Aug 27-31, 2016 Israel RA, Lemieux SM, Chernova I, Pisani MA. “Lifethreatening amlodipine overdose in an obese male.”

American College of Chest Physicians 2016 Annual Meeting, Los Angeles, CA: October 2016.

Lemieux, SM “Confusions surrounding the confused patient: management of ICU delirium.” Connecticut Society of HealthSystems Pharmacists Catch the Wave Meeting. Cromwell, CT. November 2016 Ross K, Bruneau W, Malm T, Howell BA. “A Survey of Naloxone Access in Community Pharmacies in the Greater New Haven Area.” Connecticut Society of Health-Systems Pharmacists Catch the Wave Meeting. Cromwell, CT. November 2016 Ruggiero G, Wu U, Stock T, Wiskirchen D. “Evaluation of antibiotic utilization in patients with urinary tract infection.”

American Society of Health-Systems Pharmacy Midyear Clinical Meeting. Las Vegas, NV. December 2016 Tran M, Wiskirchen DE, Nadler E, Naut E, Levine AR. “The diagnostic value of procalcitonin in predicting tract infections among adult patients who present to the emergency department tract.” American Society of Health-Systems Pharmacy Midyear Clinical Meeting. Las Vegas, NV. December 2016 Mueller JM, Gimose E, May S, Stock T, Levine AR. “Outcomes of front-loaded diazepam in patients experiencing severe alcohol withdrawal syndrome.” American Society of Health-Systems Pharmacy Midyear Clinical Meeting. Las Vegas, NV. December 2016 Levine AR. “The evolving role of biomarkers in antimicrobial stewardship: is procalcitonin part of the solution?” Connecticut Pharmacists Association Fall

Pharmacy Journal of New England • Winter 2017

Continuing Education Series. Trumbull, CT. December 2016 Kumar N, Weeda ER, Wells PS, Peacock WF, Fermann GJ, Wang L, Baser O, Schein JR, Concetta C, Coleman C, Kohn CG. “External Validation of a Clinical and Claims-Based Approach for Predicting 90-Day Post-Pulmonary Embolism Outcomes among US Veterans.” 58th American Society of Hematology Annual Meeting and Exposition, San Diego, CA, December 3-6, 2016.

Kohn CG, Weeda ER, Wells PS, Peacock WF, Fermann GJ, Baugh CW, Wells PS, Ashton V, Concetta C, Wildgoose P, Schein JR, Coleman C. “Reduced Costs and Length-of-Stay Associated with Rivaroxaban As Compared to Parenteral Bridging and Warfarin in Pulmonary Embolism Patients Managed in Observation Status.” 58th American Society of Hematology Annual Meeting and Exposition, San Diego, CA, December 3-6, 2016.

Difficile Infection in a Tertiary Academic Medical Center: A Retrospective Case-Control Study.” Pharm Pharmacol Int J 2016, 4(5): 00088.

Wiskirchen DE, Summa MA, Perrin A. “Antibiotic stewardship: The FP’s role.” J Fam Prac 2016 65(12): 876-885.

Manoukian OS, Stratton S, Matta R, Letendre J, Arul MR, Rudraiah S*, Kumbar SG*. “Tissue Engineering” in Introduction to Biomaterial Engineering Third Edition. Editors Enderle, Blanchard and Bronzino. Elsevier Academic Press 2016 (In Press). * Corresponding Authors.

Stratton S, Shelke NB, Hoshino K, Rudraiah S, Kumbar SG. “Bioactive Polymeric Scaffolds for Tissue Engineering.”

Bioactive Materials, 2016, 1: 93-108.

Caranfa JT, Zeichner SB, Weeda ER, Kohn CG. “External Validation of Generic and Cancer-Specific Risk Stratification Criteria for Predicting 30-Day Mortality in Patients Presenting with Pulmonary Embolism and Active Cancer.” 58th American Society of Hematology Annual Meeting and Exposition, San Diego, CA, December 3-6, 2016.

Publications Zeichner SB, Kohn CG, Goldstein DA. “Economics of ramucirumab for metastatic colorectal cancer.” Expert Rev Pharmacoecon Outcomes Res. 2016 Nov 9. [Epub ahead of print] Diaby V, Adunlin G, Ali AA, Zeichner SB, de Lima Lopes G, Kohn CG, Montero AJ. “Cost-effectiveness analysis of 1st through 3rd line sequential targeted therapy in HER2-positive metastatic breast cancer in the United States.” Breast Cancer Res Treat. 2016 Sep 21. [Epub ahead of print] Weeda ER, Kohn CG, Peacock WF, Fermann GJ, Crivera C, Schein JR, Coleman CI. “Rivaroxaban versus Heparin Bridging to Warfarin Therapy: Impact on Hospital Length of Stay and Treatment Costs for Low-Risk Patients with Pulmonary Embolism.” Pharmacotherapy. 2016 Aug 22.

Thabit AK, Varughese CA, Levine AR, Hooper DC. “Antibiotic Choice and Duration in Association with Clostridium 35

Feature

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Workflow & Conditions --Continued from page 18

errors that reach the patient, the number of patient consultations performed, and the number of interventions initiated. The incorporation of more quality over quantity measures will improve workflow and patient care.

For example, the Centers for Medicaid & Medicare Services (CMS) provides star ratings for different prescription drug plans, based on certain quality and performance measures.

Quality measures for pharmacies under Medicare Part D are based on adherence and safety needs for patients. They include, for example, Proportion of Days Covered (PDC), Helping Patients Get Needed Medications, and Drug-Drug Interactions. There are also measures for optimal or suboptimal treatment for disease states like hypertension and diabetes, as well as adherence rates to therapies (e.g. oral diabetes, hypertension, & hyperlipidemia medications).

Although these measures are being implemented, they need to be further incorporated into quality improvement initiatives and expanded beyond Medicare patients.

One particular measure, patient adherence, is important because it is a major cause of healthcare waste and avoidable hospitalizations, as around half of patients do not take their medication correctly. 16 Community pharmacists in particular are able to make a significant impact on adherence issues. According to a meta-analysis performed by Al-Jumah Ka and Qureshi NA, pharmacist intervention for those on antidepressants resulted in adherence improvement of up to 27%.17 Kriplani et. al further report 20 studies that show significant improvement in at least one adherence measure after pharmacist intervention, and state that more research is warranted. 18 Pharmacy management should consider including further metrics for counseling rates and incorporate quality measures as a larger portion of their business model. Not only is quality important from a patient health standpoint, but from a public relations standpoint as well. Patients agree that quality criteria are important and are likely to use the measures reported by CMS when choosing pharmacies within Medicare Part D plans, especially those related to medication safety.19 Furthermore, accrediting bodies like the Center for Pharmacy Practice Accreditation are implementing standards 36

that will require community pharmacies to report on quality

and performance metrics. Though accreditation is currently optional, the growth of pharmacy in its role and recognition in the healthcare industry may increase the emphasis and need for accreditation.

State and federal legislation is required in order to regulate the extent and criteria of performance metrics. In a recent survey, 72.7% of pharmacists supported establishment of regulations by state boards to limit the metrics that would negatively affect patient safety.3,11 Automation of Systems Many prescribers have adopted an electronic prescribing system that has helped reduce medication errors.

E-prescribing should be continually promoted, as it can help prevent misinterpreted prescriptions. They also save time when prescriptions and accompanying labels are processed.

Currently, approximately 70% of physicians use e-prescribing, up from 24% when Medicare incentives designed to create electronic health records were approved in 2008. Ninety-six percent of community pharmacies accept e-prescribing routed through Surescripts, the major prescription network, and therefore are equipped to handle input from online networks. Beginning 2015, physicians are penalized for failing to demonstrate use/implementation of EHR as related to Medicare payments. The success of such penalties should be further evaluated to determine whether further legislation is needed.

Hospital institutions often use a barcoding system for medication filling, dispensing, and administration. A unique barcode for each order and medication reduces likelihood of medication errors and ensures patients get the right drugs at the right time. A similar system could be hugely beneficial for community pharmacies that are able to finance the infrastructure. Szeinbach et al found that community pharmacists perceived that automated systems are efficient and help reduce dispensing errors.12 Having a technician scan a bottle to verify the correct medication, for example, may reduce the likelihood that the wrong medications are dispensed to a patient. It may be another opportunity for cost

Pharmacy Journal of New England • Winter 2017

and time savings by standardizing the inventory-related processes to increase ease of tracking and stocking. Some pharmacies also utilize software that shows images for certain medications/brands to visually check the identity of the products. Encouraging wider adoption of such programs would also improve the medication verification process for pharmacists.

Financial Impact Pharmacist interventions such as correcting prescription errors or potential drug interactions, counseling patients, or reporting suboptimal doses can save significant amounts on health care. Munroe et al found that the average cost per prescription was significantly higher with pharmacist interventions in patients with common disease states (hypertension, diabetes, asthma, hyperlipidemia); however, significant overall savings between $143.95 to $293.39 were observed in terms of total monthly medical costs (refer to Figure 1.2).20 The overall monthly savings even with higher average cost per prescription can be attributed to pharmacist interventions such as identifying medication errors that may warrant another physician visit, switching to a more costeffective drug, and discontinuing unnecessary therapy. In addition, more thorough review of patient profiles and proper counseling of patients may be able to optimize therapy that may improve overall health, leading to decrease in amount spent on health services. Furthermore, improving workflow for pharmacists will increase employee morale, leading to better patient care and a more efficient and productive pharmacy.

Limitations Though revision of workflow and working conditions in community pharmacies will ultimately improve the quality of patient care, there are limitations in implementation. Some argue that current metrics are indeed balanced between quantity and quality, and account for customer satisfaction by including measures such as number of errors per day. Though certain measures are quality-oriented, the actual direction of pharmacies is driven more by the quantity measures like time-guarantees. Overall, performance metrics are aimed at shaping behaviors that maximize revenue while keeping customers satisfied (though not necessarily in best health).

Figure 1.2: Cost Savings per Pharmacist-Led Intervention

For example, CVS has eleven categories of report listings for each of its store’s performance metrics.21 Of these eleven categories, only three of the listings can be considered to be aimed at improving patient care while the remainder are focused on revenue and sales. By adding more categories aimed at improving quality of care, business performance metrics can find a balance between quality and revenue.

Though pharmacists are reimbursed for MTM, other clinical services, such as patient counseling and evaluating drug interactions, are not directly paid for. Despite having the ethical duty to provide patient care, critics argue there is no incentive to develop clinically-oriented programs within pharmacies because of limited remuneration. As a result, individual states are now recognizing pharmacists as providers.

Conclusion Pharmacy practice is undergoing transformation in the community setting, as pharmacists gain increased recognition and responsibility. Pharmacists are highly trusted healthcare professionals who have an ethical duty to provide the best patient care possible, including the duty to counsel. However, workflow systems implemented by retail pharmacies often create environments that are suboptimal for patient care and increased stress among employees. Rethinking performance metrics to allow for more clinical responsibilities and more quality-based measures can improve patient outcomes, prevent medication errors, and lead to significant cost savings.

Implementation of workflows that encourage pharmacist-led 37

Feature

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interventions will lead to significant cost savings for patients and decreased wasteful spending in the healthcare industry.

Integration of automated systems also will allow pharmacists to concentrate on clinical duties, including MTM and patient counseling. To incentivize community pharmacy owners and management to implement quality-focused changes, legislation at the state and federal levels is needed. Advocacy and partnership with pharmacy organizations and legislators will help increase community pharmacists’ recognition as healthcare providers with billable status. It is in pharmacy owners’ best interest to reconsider workflow designs to create an equitable environment for their staff and patients alike.

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