Ashley Woodyard, PharmD Candidate

The COVID-19 pandemic has accelerated the prominence of pharmacies in public health by providing pharmacists the legal authority to perform Clinical Laboratory Improvement Amendment (CLIA)-waived testing, which enables greater access to diagnostic testing.

Community pharmacies have experienced a 45% growth in CLIA-waived testing in the past 5 years, making pharmacies the second largest provider of CLIA-waived tests.

 This change is largely due to state and federal action clarifying the authority of pharmacists to provide CLIA-waived SARS-CoV-2 testing during the pandemic.

 There are a wide variety of CLIA-waived tests being performed, including tests for COVID-19, HbA1c, HIV, Hepatitis C, international normalized ration (INR), cholesterol, and pharmacogenetics. These tests can be both convenient and cost-effective for the patient because individuals with a high deductible may be more reluctant to pay the high cost of a physician’s office visit and would be more likely to visit a community pharmacy for testing.

A pilot project examining the feasibility of CLIA-waived point of care testing (POCT) detailed a 3-month trial of hepatitis C antibody (HCV-Ab) testing, in which community pharmacists provided 83 HCV-Ab POC tests.

 Results from this study highlighted that partnering with another organization—in this case, San Francisco Department of Health’s Hepatitis Division—to provide assistance and training was key to success. Two major barriers were found in implementing HCV-AB testing in a community pharmacy setting: patient recruitment for testing and time for pharmacists to administer the tests and provide the results.

To implement these services, there are several considerations for a pharmacy manager to take into account. Most important is to be familiar with the CLIA and federal regulations governing pharmacy and collaborative drug therapy management because the scope of practice available to pharmacists varies among states. If a state does not address POCT explicitly, collaborative drug therapy management provisions may allow for POCT through collaborative practice agreements with physicians. To make POCT more feasible, consider partnering with other organizations to assist in providing services such as state professional organizations, state agencies, or non-profits. These partners can direct patients to your pharmacy, donate supplies, or even provide funding.

Training staff on how to perform POCT is essential prior to providing these services. Dong 

 reported that further training on communication skills needed to discuss positive test results is vital to success.

 This is especially important with diseases such as Hepatitis C or HIV to alleviate the stigma of discussing how infection may have been acquired. When choosing which testing to provide, evaluate the patient population that visits your pharmacy in order to maximize the benefit of these services. For example, if you serve an elderly population, consider cholesterol or blood glucose testing as your initial offerings.

A survey of community pharmacies to investigate the implementation of POCT found that 74% of pharmacy managers agreed that testing would increase stress levels and result in higher workload burdens.

 Consider staffing, workflow adjustments, and space requirements needed to incorporate POCT compliant with logistics and Health Insurance Portability and Accountability Act (HIPPA) regulations.

Pharmacists from Pennsylvania shared their experience in providing point of care services and Steltenpohl 

reported that utilizing pharmacist overlap with 2 or more pharmacists working at the same time eased the burden of workflow.

 If pharmacist overlap is not possible, consider an appointment-based model targeting appointment times for the slower points in the workday.

POCT is already being implemented in community pharmacies across the nation during the pandemic.This has opened the door for pharmacists to widen their scope of practice and increase access to care. Adding POCT as an additional pharmacy service is beneficial to the pharmacy by generating revenue and adding to our repertoire in the name of public health.

Implementing Value-Added Pharmacy Services

Pharmacy Management: Essentials for All Practice Settings, 5e.

 is a PharmD candidate at Touro University California.

, is a professor of social and behavioral pharmacy at Touro University California.

1. Klepser NS, Klepser DG, Adams JL, Adams AJ, Klepser ME. Impact of COVID-19 on prevalence of community pharmacies as CLIA-Waived facilities. 

2. Dong BJ, Lopez M, Cocohoba J. Pharmacists performing hepatitis C antibody point-of-care screening in a community pharmacy: A pilot project. 

3. Gallimore CE, Porter AL, Barnett SG, Portillo E, Zorek JA. A state-level needs analysis of community pharmacy point-of-care testing. 

4. Steltenpohl EA, Barry BK, Coley KC, McGivney MS, Olenak JL, Berenbrok LA. Point-of-care testing in community pharmacies: Keys to success from Pennsylvania pharmacists. 

Articles

The COVID-19 pandemic has accelerated the prominence of pharmacies in public health by providing pharmacists the legal authority to perform CLIA-waived testing.

Tip of the Week: Point of Care Testing Positions Pharmacy for Future Care

Although telemedicine has existed for years, the COVID-19 pandemic has certainly proliferated its use and has brought on more innovative uses of telemedicine to safely provide optimal care.

Telemedicine visits with a clinical pharmacist offer many advantages, such as social distancing, flexible scheduling, and the ability to use nonverbal cues to convey understanding—a major limitation of phone visits. Telemedicine also has the ability to help narrow current gaps in health disparities among various populations, including those most financially vulnerable.

However, certain phenomena such as digital health literacy must be taken into account. Digital health literacy is similar in concept to health literacy; that is, the ability of a patient to access and comprehend health information or services.

 Digital health literacy encompasses a number of skills, including computer literacy. As such, if telemedicine is not properly arranged, it can actually end up exacerbating gaps in health disparities.

A recent cohort study examined 148,402 patients who had scheduled telemedicine visits.

 The study found that older age, Asian race, and a primary language that is not English were associated with fewer completed telemedicine visits (both phone and video). Other studies have shown lower video use associated with lower household income, Latinx ethnicity, Black race, and older age.

Reasons for these results might be explained by lower digital health literacy. For those in older age groups, less frequent use of technology in general, impaired eyesight, and diminished hearing and motor skills make telemedicine a challenge.

 Additionally, families with a median household income below $50,000 had a lower utilization rate of video telemedicine use.

 These findings may be attributed to availability of internet access or devices. COVID-19 has placed further financial strain on lower income families, and this may further widen the digital inequality divide among lower income families and minorities.

Now that telemedicine is so prevalent and is becoming a standard of care, it is important to address disparities in access to telemedicine. The most important factor to increase telemedicine access among older adults is to improve the usability and ease of us for websites and technology platforms. It would be beneficial for patients to be provided with well-designed websites that are simple to access and developed in a literacy appropriate method. It should be functional across a variety of populations in order to be easily accessible for those who have low digital literacy.

Many of the lessons learned regarding telemedicine also apply to telepharmacy. Telemedicine and telepharmacy have the potential to expand the reach of health care, especially for those in rural areas. However, some issues have to be addressed in our health care systems in order for telemedicine to reach its full potential.

In order to address these issues, pharmacists and pharmacy managers can learn from these and other study results. First and foremost, training all staff to be aware of health access issues is paramount. Additionally, pharmacies looking to expand telepharmacy services should consider digital health literacy and other factors that would impede optimal outcomes. Pharmacy managers should also look to collaborate with physician providers to combine or bundle telemedicine and telepharmacy services that even further optimize care and generate revenues for both practices.

Additional information about Managing Technology that Supports the Medication Use Process and Creating and Managing Value can be found in 

Pharmacy Management: Essentials for All Practice Settings, 5e

 is a professor of social and behavioral pharmacy at Touro University California.

 is a PharmD Candidate at Touro University California.

1. Smith B, Magnani JW. New technologies, new disparities: The intersection of electronic health and digital health literacy. 

. 2019;292:280-282. doi:10.1016/j.ijcard.2019.05.066

2. Eberly LA, Kallan MJ, Julien HM, et al. Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic [published correction appears in JAMA Netw Open. 2021 Feb 1;4(2):e211913]. 

. 2020;3(12):e2031640. Published 2020 Dec 1. doi:10.1001/jamanetworkopen.2020.31640

Telemedicine visits with a clinical pharmacist offer many advantages, such as social distancing, flexible scheduling, and the ability to use nonverbal cues to convey understanding.