John O. Beckner, RPh

 Liz, maybe you can take a moment and talk to us; we’ve seen many practice changes through waivers of privilege and state boards of pharmacy. We’re hearing that some of these changes will remain a part of our practice, and we’re also hearing the opposite, where some of this privilege that’s been given may not stay within our pharmacists and technicians. Can you talk about those changes? I know in your state, in Idaho, you have a very progressive board of pharmacy and some statutes that we would all love to aspire to. Can you talk about those waivers and the board of pharmacy changes?

 Yes, it’s really exciting. To your point, I live in a fantastic state for practicing pharmacy. I feel very privileged. Our state was among the first for various prescriptive services, as well as starting pharmacy technicians in the process of administering immunizations to our patients. With that, states started to trend that way. We saw Utah, Washington, Rhode Island, and there have been more states that have passed rules allowing pharmacy technicians to administer vaccinations. With the PREP [Public Readiness and Emergency Preparedness] Act, that grew tremendously. We gained a lot of momentum, as a profession, for pharmacists because, obviously, there’s a big range of what pharmacists can do depending on the state you live in. You have some, like my state, which have independent prescriptive authority, so pharmacists can do every immunization out there on their own. Other states allow you to do those immunizations, but under a collaborative practice agreement. Then there are states that require a collaborative practice agreement, but the ability to administer all those vaccines is very limited. You might be able to do 4 or 5 vaccinations. Then, consider pediatric and adolescent immunizations. That’s a whole other scenario, where in some states, you can go down to 6 months of age, and in other states, we can’t immunize anybody under 18 years old.

With the PREP Act, we were allowed, first of all, pharmacists could administer any ACIP [Advisory Committee on Immunization Practices]-approved vaccinations to anybody down to 3 years old. That helped grow our opportunities for immunizing adolescents and children who hadn’t been immunized during the COVID-19 pandemic and to try to catch people up. Secondarily, it allowed technicians across the country to administer immunizations under supervision. With that, we can obviously immunize more of our population, because it removed the constraints limiting the ability to just pharmacists, or just medical assistants, or just doctors, or whatever. We grew the number of immunized patients astronomically. Now, with that came boards of pharmacy that were more restrictive. Some states say, “OK, a technician can only do COVID-19 vaccinations and nothing else.” There are definitely some constraints. We’re starting to see states end emergency declarations, and with that, they are reversing many of the things that pharmacists have been allowed to do under the PREP Act, which is unfortunate.

To your point, there are some states that we see these changes sticking, where pharmacists will continue to have expanded roles in administering and/or prescribing immunizations that they hadn’t previously been able to prescribe. It’s exciting in a lot of ways because I think we’re seeing more growth than anything. Most people, if they’re going back, they are going back to the status quo, but as a profession, as pharmacists, as individuals, we’ve been able to grow and expand our comfort with administering immunizations to all age groups when we hadn’t previously had that opportunity.

Videos

Liz Oler, PharmD, discusses the short- and long-term impact of the PREP ACT on expanded privileges and practice changes within the pharmacy profession.

PREP Act: Short and Long Term Impact on Pharmacy Practice

 webcast “Community Pharmacy: Center of Immunization Services.” I’m Ed Cohen. I’m from 

, and I’ll be your moderator today. Joining me in this virtual discussion are my colleagues, Dr Jennifer Adams, associate dean for academic affairs and associate professor at Idaho State University in Meridian, Idaho; John Beckner, senior director of strategic initiatives at the National Community Pharmacists Association in Richmond, Virginia; Dr Liz Oler, patient care services coordinator of immunizations and advanced clinical services at Albertsons Companies in Boise, Idaho; and Dr Susie Soliman, founder of Pharmacist Moms, and chief academic officer for the Accreditation Council of Medical Affairs in New York, New York. Today, we’re going to discuss the role of the pharmacy as the center of immunization services. We know COVID-19 remains a threat, and we have made tremendous progress returning to what we call our new normal. The vaccine and the involvement of pharmacy are key contributors to returning to a new normal. We have come off a nonexistent flu season, and we know this coming season may not be the same. I’d like to begin our discussion focusing on COVID-19 immunizations, the opportunity to vaccinate adolescents age 12 and older, and then move to the flu, how teams will embrace the responsibility and step up to continue to immunize. Let’s get started.

Pharmacy has been providing immunization services for over 20 years. We’ve had increased recognition over the last few months from many levels of government and other agencies. We know seniors embrace pharmacy as the No. 1 and strongest audience for our service. With this new recognition, I think we have some notoriety from the 18- to 64-year-old group—those who are well and possibly have mild disease. There’s a quote that we took out of the literature. It states that it’s clear the American people feel comfortable relying on their local pharmacy for vaccines. I will start today’s conversation with Susie and John. Let’s talk about pharmacy as a center of immunization services

 I echo some of the data that you mentioned. Pharmacy is definitely the center for immunizations, and there have been surveys done, related to the COVID-19 vaccine, that showed that 40% of patients prefer to get their vaccine at the pharmacy and prefer to have a pharmacist administer their vaccination. Only 4% wanted a big site, where I had to go. I think it’s very clear that pharmacy is on the trajectory to become the center of this space. I think pharmacists have been embracing this new role and are taking it on. We have been working with schools as well, in a different way that I’ve seen. Pharmacies are expanding outside of their pharmacy, taking the show on the road and doing a lot more in different places. John, I don’t know if you want to add to that.

Thanks, Susie. Thanks for including me on the panel. I’m excited about being part of this. As you mentioned, immunizations have been a passion of mine for a long time. I think, certainly, what we’ve seen during the COVID-19 epidemic supports the fact that people like coming to the pharmacy to get their vaccine. Pharmacists are knowledgeable, accessible, and trusted. Probably the last word, trust, is what is helping people decide where to go for immunizations. That’s the pharmacy. Pharmacies have long been the center of health care in many of the communities that they serve. I think that trust factor plays a big role. People feel safe coming to the pharmacy. That’s been important with COVID-19. Not only has it tried to allay people’s fears about the vaccine, but it allays their fears about coming to a provider and coming to a pharmacy to be immunized. Again, pharmacists have been administering immunizations since the mid-1990s, so people are used to coming into the pharmacy to get their vaccines. The other thing with pharmacists taking care of the entire family is that they’re adept at understanding and knowing who needs what immunizations, not just COVID-19. They’re going to know whether a senior citizen needs a pneumococcal vaccine in addition to their seasonal flu shot. One thing Susie mentioned in her comments was that more people would come to the pharmacy as opposed to mass clinics. I think we’re seeing this a lot with second doses. These mass clinics are going by the wayside, so people who got their first dose at a mass clinic are now coming to the pharmacy for the second dose.

 Definitely. I think there’s a preference to go to the pharmacy over these mass clinics. You feel safer, especially with children. I see that a lot of parents are wanting to take their kids to the actual pharmacist, who they know and trust, vs someone they might not be familiar with.

Liz, let me ask you something quickly. Along those lines, we look to pharmacy as the place we trust for our immunization services. When pharmacists take, as Susie alluded to, the show on the road, and you’re going off-site to an employer work site or a school, do you still engage patients, and they have that same trust not being in the store itself but being in a workplace or a school or in a community center, let’s say?

Absolutely. For an employer group of a well-known university, or a school district, when they put their trust in a pharmacy to take care of their students, our patients, it shows trust, and it brings to the forefront, to parents out in the world, that pharmacists can do that because we bring that service to them. Then they think of us moving forward as, “Oh gosh, we can go to our local pharmacy and get immunizations done.” It’s been a great opportunity to grow that knowledge base, which still seems to be lacking in the general population, that pharmacies and pharmacists can be the central place for immunization. Going out into the world and doing immunizations outside of our 4 walls is very beneficial.

Ed Cohen, PharmD, FAPhA, leads a discussion in which panelists share thoughts on pharmacies being at the center of immunization services for the entire family.

Thoughts On Pharmacies as The Center of Immunization Services

Life-saving vaccines have had a profound impact in this country and worldwide. According to the CDC, from 2006 to 2017, almost 3.5 billion doses of vaccines were distributed in the United States.

 From an economic perspective, every $1 spent on vaccines amounts to $3 in direct benefits, and these benefits can go up to $10 if societal costs are included.

 Globally, 2 to 3 million fewer deaths in the world occur each year because people are vaccinated and protected.

Today, almost anyone can receive immunizations against 17 once common and potentially deadly infectious diseases in the United States.

 However, many patients still fall through the cracks because providers fail to ask about topics such as travel plans, school health needs, or if they have received immunizations for high-risk environments. Although we have made great strides, nearly eradicating numerous vaccine-preventable illnesses, we still have some work to do to get our current immunization trends and populations up to date. For example, on one end of the spectrum, the percentage of patients across every age group has improved for influenza coverage in the United States.

 Conversely, the need for immunization improvement continues in the area of pneumococcal disease, which is lingering below Healthy People 2020 targets

Pharmacists have been involved with vaccines since the 1800s, but have actively been involved in the routine immunization of patients only for the past 20 years or so. The role of pharmacists in the provision of vaccines has changed and expanded considerably since the first immunization training program in 1994. Since then, pharmacists have progressed from being vaccine advocates to becoming full partners in providing immunizations. Today, many patients may not imagine going anywhere but a pharmacy to get their flu shot.

As the emphasis on preventive care continues to grow, many states are expanding the role of pharmacists as experts in immunizations. According to the most recent update from the American Pharmacists Association in January 2018, pharmacists in all 50 states, as well as the District of Columbia and Puerto Rico, are permitted to administer immunizations.

 Depending on the state, pharmacists can administer vaccines pursuant to a prescription or according to a protocol, while in others, no physician oversight is required. In all but 4 states, pharmacists can provide any vaccine to patients, and in about half of states, pharmacists can provide vaccinations to patients of any age. In every state, pharmacists can administer the most commonly sought adult vaccines for influenza, pneumococcal disease, shingles, and tetanus/diphtheria/pertussis. In 2017, Idaho became the first state to allow pharmacy technicians to administer immunizations, although a pharmacist is still required to perform all of the clinical elements of the immunization, such as prescription verification and patient counseling.

Currently, immunization is the #1 patient care service offered by community pharmacists, highlighting the important role pharmacists play in public health. A total of 73% of community pharmacies offer immunization services, according to 2018 NCPA Digest.

 If one subscribes to the glass-halfempty mentality, only 73% of independent community pharmacies offer immunizations. Clearly, with less restrictive state laws and regulations, that number needs to be, and should be, higher. If your pharmacy is not offering vaccinations as a patient service, consider that you are missing out on an opportunity to help your patients and expand your business.

Look at the recent multistate measles outbreak as an example.

 This resurgence of a disease that had nearly been eradicated may offer the perfect opportunity for pharmacists to start a conversation with patients and employers about the services that are offered which go beyond dispensing. As the most accessible health care providers, community pharmacists have the opportunity, and the obligation, to help patients understand vaccine safety and help dispel the myths created by the small but vocal antivaccine movement.

More than 100 million Americans get a flu shot every year,

 which produces $4 billion to $5 billion in revenue,

 yet the immunization market remains largely untapped. A huge opportunity is waiting to be uncovered beyond the flu shot. Pharmacists should use the flu shot “encounter” to access the patient immunization record, identify gaps in care, and proactively recommend other age-appropriate vaccines. As Beverly Schaefer, RPh, pharmacist and owner of Katterman’s Sand Point Pharmacy in Seattle, Washington, stated, “If you want to add profit to your bottom line, increase the number of immunizations that you’re doing. Every single immunization that you do adds to your bottom line. There are no exceptions.”

Offering immunizations provides opportunities for pharmacies far beyond the revenue that is generated from this service. Pharmacy-based immunization services help build a relationship based on trust between the patient and the pharmacist, leading the patient to rely more on the pharmacist for a wide array of services such as medication synchronization, diabetes education, over-the-counter recommendations, prescription delivery, health screenings, medication therapy management services, and traditional prescription dispensing. Immunizations go a long way toward branding the pharmacy as a destination for health and wellness, an important differentiator in today’s competitive marketplace, which includes a growing number of online and mail-order pharmacies.

Finally, immunizations are a core service set for pharmacies participating in enhanced services networks such as the Community Pharmacy Enhanced Services Network. These pharmacies are required to screen patients for Advisory Committee on Immunization Practices—recommended immunizations, educate patients about needed immunizations, and, if necessary, refer to other health care providers. In today’s health care environment, with the focus on collaborative, team-based care, it is critical that health care providers try to eliminate any remaining and, in some cases, perceived barriers (ie, physician opposition) to providing this important public health service.

Immunizations are among the best ways for pharmacists to demonstrate their value. Pharmacy-based immunization services not only save costs and produce revenue, but also improve patient health and contribute to better outcomes, illustrating the value that pharmacists bring to the entire health care team. Let’s seize the opportunities before us and leverage our position as America’s most accessible health care providers to positively impact public health.

 is the senior director, strategic initiatives, at the National Community Pharmacists Association in Richmond, Virginia.

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Measles (rubeola): measles cases and outbreaks: measles cases in 2019. CDC website. cdc.gov/measles/cases-outbreaks.html. Reviewed July 15, 2019. Accessed July 16, 2019.

Influenza (flu): historical reference of seasonal influenza vaccine doses distributed. CDC website. cdc.gov/flu/prevent/vaccinesupply.htm. Reviewed August 23, 2018. Accessed July 16, 2019.

How to make immunizations a pharmacy profit center. PBA Health website. pbahealth.com/how-to-make-immunizations-a-pharmacy-profit-center/. Published March 15, 2019. Accessed July 16, 2019.

John O. Beckner, RPh

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