Jeffery Goad, PharmD, MPH, associate dean of Academic Affairs in School of Pharmacy at Chapman University discusses the future of pharmacy when it comes to immunizations.

Q: How has the COVID-19 pandemic impacted immunizations and immunization strategies in the pharmacy?

I think pre-pandemic, a lot of pharmacies were focusing in on influenza primarily, and then trying to branch out, depending on the state where they practice, into other immunizations. I think what really changed in the focus is developing a larger scale strategy to handle the masses of people who need a vaccination, need a COVID vaccination. So that required a lot of infrastructure, changing staffing, through the prep back, getting technicians involved in getting vaccines. It had to be a total system revise just by the sheer volume, not really the training. The administration of vaccines, the structures in place to train pharmacists, and to document, were pretty much already in place. It was really handling the sheer volume of patients that were coming through that pharmacy had to get a strategy in place quickly, very quickly, to be able to handle not only the initial surge, but the multiple changes in population, so learning to give vaccines to an adolescent, and then, you know, not too long after that, learning how to give it to a 5-year-old.

There were also some changes that had to take place in privacy areas and things like that, and parental consent that they may not have been used to. There were strategies that pharmacy had to engage very quickly, to be able to manage just the sheer volume of patients coming through.

Q: How have digital systems helped to advance immunization scheduling and coordination in the pharmacy?

I think digital systems were already on their way, but like many things, the pandemic just accelerated their adoptions. One of the things that has helped pharmacy is the scheduling aspect. I think maybe larger chains had already started to implement scheduling software to get their patients scheduled for various immunizations or other services. Independent pharmacy had to figure that out pretty quickly, how to deal, again, with the masses of people to avoid lines out the door.

So instead of doing the walk in, which was really the hallmark of what pharmacy offered for immunization services, allowing patients to while they're in the store, in a grocery store, whatever setting the pharmacy is located, being able to go into the pharmacy and get a vaccine, there was something that was really important in our early days to make a case for access, and pharmacy.

Now, flash forward to the pandemic, and the sheer volume of patients meant that pharmacy needed to revert back to an appointment-based system, and that's where the digital systems come in, so everything from scheduling software, to online consent forms, and online vaccine information statements that can be delivered to patients. A lot of different systems had to be put in place to accelerate the process of getting a patient in and then decreasing the amount of time they spent in the pharmacy.

Because again, if you remember early on the pandemic, it was more about not keeping people in a place too long in a small environment, which most pharmacies, by definition, are small environments that they work in, and keep them six feet apart. Sometimes we forget about the early pandemic mitigation strategies we had in place that made it difficult to have lots of people coming through for service. Our digital systems were incredibly important just to manage, again, the volume of patients coming through. I think this is 1 of those things that will last, going beyond the pandemic, as people got used to being able to easily go online, make an appointment, fill out their form, so that when they come to the pharmacy, it's a much more streamlined process for them.

Q: What further technological assistance would be beneficial as we move forward with current immunization practices?

I think 2 areas that would really enable pharmacy to take advantage a lot of the digital transformation. One is an interoperability and really sometimes just connection to the electronic health record. So as states, either through the federal Prep Act or through changes around state laws, have allowed pharmacists to give many vaccines. In fact, according to the Prep Act, being able to give pediatric vaccines means that connection and collaboration and communication with pediatric colleagues, for example, are is incredibly important. It's very difficult to do that by fax. People don't have faxes like they use to anymore. So having the ability to connect to a physician's electronic health record, to be able to transfer that information back and forth is going to be vital, but that still continues to be a problem.

Everything from state laws and access to information or corporate policies, down to just the computer interoperability, our systems talking to their system, so that remains a challenge. But it's something that is going to be incredibly important going forward, not only for immunizations, but for other clinical services.

Then the other digital piece, I think, is the immunization information systems. The IIS or registries as they're sometimes called. Pharmacies have had to learn in states where maybe they weren't mandated to enter into the registry before how to connect, and actually to learn what the value of that is. Now that patients know that their immunization records are in the registry from the pharmacists, it really helps the patient to know where to go to get their immunization record if they went to different pharmacies, different clinics. So having pharmacy be a part of that digital revolution, and particularly around the immunization information systems, is incredibly important to making sure patients realize that pharmacy is part of their team, their health care team, and it allows pharmacy to have that backend documentation system.

But just like the EHR, there are also interoperability challenges in different states because there is no federal immunization information system currently, even after COVID. There still is no federal system, it's still state by state, and every state does a little different, and everyone's system is a little different. So something that pharmacy is still working toward, but the pandemics certainly accelerated their processes.

Q: What advancements have been made possible in the immunization space due to the tireless work of pharmacy professionals during the pandemic?

I think patients had a very visceral response in seeing that their pharmacists were still on the front lines. So as medicalclinics were shutting down and elective procedures were going away, the 2 places that consistently remained open, the hospitals and the pharmacies. So I think that's something that people will remember, you know, their pharmacists and face shields and mass, but still there and coming out to give them immunizations, coming out to talk to them about their medications. I think that's something that patients hopefully will see going forward that pharmacy could manage this in a pandemic in such a stressful environment. What else can they manage? So I think there are lots of different services and opportunities that patients now we'll start expecting from pharmacy, the federal government, even, as recently as our president, saying that we want pharmacists to be involved in test-to-treat for COVID vaccine. I think all of these, this role changes, these visible changes that people have seen, are definitely going to help pharmacy in the future, to get people to realize that during this pandemic, our pharmacists were there, they were caring for you. And they can do a lot more than you think they can.

Q: What are your hopes for the future of immunizations in the pharmacy?

I think if you look at the evolution of immunizations and pharmacy, and just other services from medications, and being dispensed at physician's offices, the turn of last century to now being a staple that you only get your medications from pharmacies, right? I think immunizations is probably heading in that direction. Just the sheer access issues, that ability to access on a weekend or late nights, the computer systems, the digital systems we have in place to manage immunizations and other services for patients and having that pharmacist right there, that health care professional who can now supervise technicians and giving vaccines.

I think all of these coupled together mean that we're going to see pharmacists as a quintessential figure in immunization delivery, and maybe in decades to come. It may be the place that you go to get an immunization. Again, it's a preventative health care service. It's not a sick care service, and pharmacists do preventative health care services, I think, better than any other system. So, the future I think we should be thinking, immunization and pharmacy as being synonymous.

Videos

How the COVID-19 Pandemic Continues to Shape Immunization in Pharmacy

Daniel Krinsky, MS, owner and president of EduCare4U and PGx101, and Stefanie Ferreri, PharmD, Smith and Olsen Distinguished professor at the Eshelman School of Pharmacy in the University of North Carolina, discuss the additions, removals, and changed to OTC products in the past 2 years.

Q: What are some were some of the most notable OTC products that were removed or that entered the marketplace since 2020?

 That’s a great question because there are a lot of products that have been removed over the last couple of years. Most of these products were removed for a couple different reasons. One was that they had contamination. The other was that they included unapproved new medications, so that was a lot of supplements that were marketed in this country that should not have been.

I don't know that there's any significant, real big brand name products other than there were some sunscreen products that had benzene in them, lotrimin and tinactin. The over-the-counter fungal antifungal sprays also had benzene. There were some odor eater products that had benzene. Some other sunscreens like Neutrogena and Aveeno that also had benzene. So, there were a number of products that had contaminants in them potentially dangerous.

A couple other products that were removed that were more common. In the OTC area, there was an opera seltzer product that was mislabeled where the ingredients information was not accurate. That was an ibuprofen, children's Advil product that was removed because proper dosing device was included, and the markings were incorrect.

There were a few other OTCs, a lot of the products that are removed each year are products in the categories of weight loss, weight management, sexual enhancement products, the products that have ingredients that are prescription that are included in overseas products that are brought to this country and sold and when the FDA does their evaluations of some of these. They find that these ingredients are in there, and they're immediately removed.

But as far as products that were removed over the last year or so those are the main ones that were taken off the market.

As far as new products are concerned, there were some new products that were introduced that I think have some great value in the self-care area. The first is the diclofenac gel, and that's the topical pain reliever. It can be used up to 4 times a day for a number of different areas of the body for pain. It's a great counselling opportunity for pharmacists to make sure that the entire spectrum of pain management is being addressed.

There were a few products that were introduced the old patenting eyedrops as the ophthalmic antihistamines were recently introduced. There's interesting product that was brought to markets. A little over 2 years ago, what was new to us to introduce, in this year's meeting, product called Advil dual action as both acetaminophen and ibuprofen. There was also an AleveX, which is a topical analgesic that does not have the typical ingredients that approximate it's in a lead, so it's one of those brand extensions that they're using. It has menthol and camphor in it. It's a topical product, but we have to be careful with the brand extension and the naming of those things.

There was another type of aspirin product called Vazalore that was introduced. It's a liquid filled capsule that's claimed to have a better disillusion distribution than some of the more traditional aspirin products. It has a lasting, intranasal antihistamine was brought to markets. So those are the main ones that he saw that were introduced more recently that have some therapeutic value in the OTC section.

As always, there's a lot of immune support products and other products that fit in that category of natural products and supplements that were introduced that were are being promoted for immune support, a lot of new CBD products that you know people need to be aware of. So we're seeing a lot of new things being introduced, and we just need to make sure that we're on top of this stuff and we're taking the opportunity to counsel our patients.

Q: Are there any new therapeutic updates to OTC products?

 Probably the biggest area for the new therapeutic updates is in the area of antihistamines. A lot of antihistamines have been introduced to the market that are relatively new, olopatadine is one and for eyedrops that we're starting to see. We have the long-acting, we also have short acting also azelastine, the nasal spray, so we're getting more and more allergy relief from intranasal and intraocular things to help that have really been introduced in the market in the last 2 to 3 years, and a lot of MI2s and so things that the pharmacists really need to be more aware of.

Then probably the other notable thing not as many options but the topical NSAIDs are now being introduced. They've been available in other countries for long periods of time, but now they're slowly to be introduced in the United States. So that's another option for pharmacists in the US to be aware of with the diclofenac sodium topical gel.

Q: What other updates should pharmacists be aware of?

 Things that are weak, that didn't quite make the new products yet but are emerging within the self-care category or within the OTC realm that pharmacists need to be aware of is that we're starting to see hormonal contraceptives getting a lot more statewide recognition. So many more states are recognizing OTC hormonal contraceptives and whether that's the oral, whether it's a vaginal, whether it's a patch, you're starting to see pharmacists providing and also prescribing hormonal contraception. So that's something that, depending on the state that people are practicing, and you might need to be staying up to date on,

We're also starting to see more legislative action around a cigarettes, where more and more states are starting to pull the flavored versions of the e-cigarettes and getting more legislation around vaping as well as e-cigarettes just like we had with the typical tobacco cigarettes.

So that's another area that pharmacists are starting to get engaged in upcoming, Dan can probably speak to this a little bit more, but we're starting to see more community pharmacists getting engaged in OTC hearing aids. I know that that's something that has entered the market, and so you're starting to see little kiosks related to hearing aids and also related to kiosk or also starting to see vending machines. So vending machines with things such as Naloxone kits and needle exchanges, condoms, Plan B. So lots of things that are starting to emerge in community pharmacies that we need to be aware of.

There's a few other things that I'll mention, more states are starting to restrict sales of dextromethorphan, just because of the safety issues, so they're restricting is similar to what we're seeing with pseudoephedrine. If we see more states that are restricting access to that it's primarily because of safety issues with that product and some of the potential that we've seen with abuse.

Then we're starting to see some additional recommendations on limiting the use of low dose aspirin to specific patient populations and making sure that folks that are taking the product are actually candidates for the product and not folks that just kind of decide on their own that they think they need low dose aspirin when in more detailed assessment would determine that they're probably not a candidate for low dose aspirin at this particular time.

Then you always worried about the potential interactions, even with low dose aspirin with other medications that can cause bleeding. There are patients that are on anticoagulants in a platelet agents and those types of things. We just need to pay a little bit more attention for interacting with our patients.

Q: What are some of the most common OTC products for patients?

 We see that allergies are really an area that are very commonly purchased over-the-counter which coincides with many of our new products in the last 1 to 2 years. So a lot of allergy medications, not just oral, but also intranasal interocular, lots of places emerging there.

In addition to allergies, we also have analgesics, we also have antifungal. During COVID, we've been seeing a lot of cough, cold, flu, now COVID as well, so a lot of upper respiratory sort of things over the counter. In addition, we have lower GI, where you think more constipation, we also have upper GI, where you think more heartburn or indigestion.

A lot of patients come in seeking information on sleep. They want a magic pill that's going to help them with sort of sleep. Smoking cessation is another one we just discussed, and then we also have people come in looking for medicated skin, so like first aid or anti age products. Those are probably the 9 most common categories of why patients interact with their pharmacist on OTC medications.

Exactly what Stefanie said, I'll just add a couple of other areas. Some testing as an area, we're seeing tremendous growth. We're seeing a lot of people with wearable devices that are able to take more proactive approach to things like hypertension, even diabetes, AFib and conditions like that. Then the whole area of CAM and natural products and supplements is huge. We see so many people that are taking products that have been recommended to them through health care providers, but more often been recommended by friends and neighbors and internet advertising sites that might not be so reputable. So it's a great opportunity for us to make sure that we're collecting all that information and evaluating for potential interactions and safety issues because there are a lot of those types of issues with that category of products.

Q: More broadly, what should pharmacists know about OTC products in general? What is essential for pharmacists to help patients?

Well, I'm a firm believer in a structured patient assessment process, and I know it takes time and I know community pharmacists are extremely busy, and you've got that challenge with what you want to do versus what you feel you can do. But again, I think that we need to practice pharmacy, first and foremost, and we need to be able to assess our patients carefully before determining which, if any OTC products are appropriate for that individual. So I'm, like I said, I'm a firm believer in a patient assessment process, I use what's called a quest scholar, which allows us to systematically go through and collect information and then determine if they're a candidate, and if so, which products might be appropriate for them? How do we counsel them on those products? What type of response should they expect them what kind of follow up we want to do?

Then just, I think, even if you don't know a lot about the products, just taking the time to read product labeling is important because products change so much. We see a lot of brand extensions. We were not going to know everything but knowing where to look and where to get information, just helping patients to read labels and understand what they should be doing when they take that product home is extremely important. I think, half of health care is self-care. And I think we have a responsibility to address those needs.

 I think of OTC medications very similar to prescription medicines. Many of these medicines were prescription medicines that made the switch to nonprescription. So I think there is a falsehood among patients as well as some health care providers that OTC medicines because they don't require a prescription are deemed safe. That is, when they are taking correctly, yes, they are safe. And it's really the pharmacist’s role and responsibility by doing that pharmacist patient centered process that Dan was mentioning to make sure it's the right drug for the right patient and they're taking it at the right time and making sure that there's no drug interactions or adverse events depending on different special populations because as we age, certain OTC medications are affect our bodies differently, pediatric patients, or if you have another disease state, it can affect their body differently.

So again, I think the pharmacists are the ones who have, most of the time, have all of the medications for that 1 patient in 1 location. So being that central repository for making sure the patients know to go to them regarding their OTCs, as well as their prescriptions, as well as their herbals and their dietary supplements, and making sure that they check for any drug-drug interactions for safety and efficacy.

Q: What is the value of the pharmacist to patient in terms of OTC products?

 The one thing I always tell when I work on interprofessional teams, many other health care providers don't get classes and nonprescription drugs. We are probably the only health care provider that does get education in nonprescription drugs, and so to me, that is really the value that we bring to the team. We're the medication therapy experts, and so we think about the medications and how the medications affect that patient, and that patient alone, again, that patient has a lot of things going on. So utilizing a pharmacist patient care process, we need to be thinking about all medications, not just OTC medications, but which medications are safe and effective, and that's what we the pharmacy, pharmacists bring to the health care team for our patients.

I would just add with the last line of defense, once people get to us, they're going home, and if we don't catch something, if we don't take advantage of an opportunity, that could be very serious. Once the patient gets home, it's going to be really unusual for somebody else to be able to step in before that product is consumed and the patient begins that therapy. We should take that responsibility very seriously, and we do have all the products in the pharmacy and they're relatively close to the pharmacy. I'm a firm believer and shelf talkers and helping engage patients and getting them to ask us questions, and we should initiate that conversation as well. Being the last line of defense, I think we should take that responsibility very seriously, and I know a lot of our colleagues do take it very seriously which is a great thing.

 My last-minute thoughts regarding pharmacists being involved in nonprescription products and self-care in general for our patients is that there is growing opportunities around self-care. There's a lot of emerging opportunities, and really self-care. Most patients want to take care of themselves first before they interact with the hospital before they interact with going to a primary care provider, and many times they come into a community pharmacy as the first point of care within the health care system. They might try to take care of it by themselves and they may get it right. They may not get it right, but many times pharmacist are the first-time health care providers that they interact with.

I think that's really important for us to recognize that we have to help patients navigate their health on whether or not they are a self-care candidate or whether or not they should be referred to a primary care provider to get a work that workup a diagnosis if something more serious is going on. We have a lot of great opportunities to engage with our patients, and I think that we need to remember that and make sure that our patients also advocate on our behalf for all the things that we do for them.

I think we can empower our pharmacy technicians a little bit more to free up a little bit of time to help us in the self-care area. I think too often pharmacists feel tied to that computer, tied to the pharmacy, when there's people at the OTC section that could really use our assistance. I think if we empower our technicians and provide them with some additional training and have confidence in their abilities that it will free us up to spend more time in self-care area. I only see this area continuing to grow.

As Stefanie mentioned, more people are wanting to take more control over their health. I think of all the self-testing devices and all the products that are available collectively, they have those opportunities, but they need a little guidance and assistance and I think we can be that person to do that. I love the area of self-care. I love the area of empowering patients with the correct information to better manage their lives. It's all about improving their quality of life, and I think we can do that a lot through self-care.

Experts Discuss How Over-The-Counter Medication Has Changed Since 2020

Lisa Cordes, PharmD, BCACP, BCOP, oncology clinical pharmacy specialist at the National Institutes of Health, discusses treatment options and telehealth for prostate cancer care.

Q: What are the current screening recommendations for prostate cancer?

The primary screening recommendations for prostate cancer come from the United States Preventive Services Task Force and also the American Cancer Society. The US Preventive Services Task Force recommends that men aged 55 to 69 make an informed and individualized decision regarding PSA-based screening for men aged 70 years and older the task force recommends against PSA-based screening.

The recommendations from the American Cancer Society are a little bit different than those from the taskforce in that the American Cancer Society recommendations, which also take into account factors such as family history and race. The American Cancer Society essentially recommends that men in 3 different categories have the opportunity for an individual decision regarding screening. The first of those groups is men with more than 1 first degree relative who was diagnosed with prostate cancer at an early age, and that's defined as a diagnosis before the age of 65. And for that population, the American Cancer Society recommends patients have the opportunity to make an informed decision regarding screening starting at the age of 40.

The second group is men with just 1 relative first degree relative diagnosed with prostate cancer at an early age and again, that's defined as earlier than 65 years ago, years of age, or an African American man. And for these patients, the American Cancer Society recommends that an informed decision start at the beginning of the age of 45 years old.

All other men with an average risk and with a life expectancy of at least 10 years should have the opportunity of an informed decision for screening starting at the age of 50. The American Cancer Society recommends that men who want to be screened have a PSA test, and also a digital rectal exam may also be part of that screening.

As you can imagine, prostate cancer screening recommendations can be a little bit confusing for our patients. So, it's important that we reform we inform them of the risks and the benefits of the screening so that they can determine whether the PSA based screening is right for them.

Q: What are the current approved approaches for treatment of prostate cancer?

For patients with localized prostate cancer, surgery and radiation continue to be the mainstays of treatment. For patients with more advanced prostate cancer, though, we've seen multiple new therapies approved in the past 10 years that has significantly impacted outcomes in this population. Androgen deprivation therapy and cytotoxic chemotherapy such as docetaxel, so played a key role in this population, but treatments such as targeted therapies, immunotherapies, and radiopharmaceuticals are now part of the treatment landscape.

Some of the novel therapies are only approved in various specific subsets of patients for prostate cancer. For example, radium 2 to 3 is only approved in patients with metastatic disease and bone metastases. The blue cell T is approved for patients with minimal symptoms or asymptomatic metastatic disease. And then we're capturing the proper BCR, a mutated prostate cancer, and there are also multiple newer generation antiandrogens available now, and these include enzalutamide, abiraterone, apalutamide, and darolutamide. These are all orally administered therapies and I have demonstrated improvement in survival when given to patients with advances.

Q: Are there any new drugs in the pipeline of note that show promise in treating prostate cancer?

In prostate cancer research right now, there continues to be a lot of emphasis on optimizing the sequence of administration of FDA approved therapies and also moving these proof therapies earlier in the disease course.

However, there are a number of new therapies in the pipeline as well. The targeted therapies continue to show promise in prostate cancer. There has been a lot of attention on a KT inhibitors as well as agents that target DNA damage repair radiopharmaceuticals targeting Prostate Specific membrane antigen or PSA may have also been developed. For example, a large phase 3 trial recently demonstrated that there was a survival advantage when giving a product called Laetitia 177. PSMA 6.7.

In patients with PSMA positive metastatic prostate cancer, immune checkpoint inhibitors are approved for various types of solid tumors, but for this particular population, they're typically studied in combination with other agents in hopes that that'll improve the efficacy in patients with prostate cancer. And we've seen in recent years a trend towards anti-cancer agents being approved for a very specific subset of patients. And we're likely to see that trend to continue in the future.

Q: What are some opportunities to optimize treatments for prostate cancer?

The community pharmacists can make a substantial impact on medication optimization in patients with prostate cancer. First of all, these anti-cancer therapies are incredibly expensive and pharmacists can play a large role by finding copay programs or patient assistance programs that can help with the financial aspect of it.

Also, some of these oral therapies are only available from specialty pharmacies, and so pharmacists can help navigate that unfamiliar territory with these patients. Also, drug-drug interactions and drug-herbal interactions are a significant challenge. And that's particularly true for our newer antiandrogens.

Many pharmacists can play a key role in alerting prescribers of potential interactions, and either making a recommendation for monitoring or else suggesting an alternate therapy. Examples of some potential interactions include Cytochrome P 450, mediated interactions, and also monitoring and watching out for overlapping toxicities.

This is the case, for example, with medications that lower seizure threshold and concurrent use with apalutamide or enzalutamide. Additionally, close monitoring for adverse events is required for all of these anti-cancer therapies. The community pharmacist is perfectly positioned to help watch for these toxicities and support and make supportive care recommendations, which helps our patients stay on these therapies longer.

Q: What are some strategies for managing prostate cancer care and treatment in the home, and has telehealth advanced to support this opportunity?

Many of the therapies used in prostate cancer are orally administered, but they do still require close follow up, and the management strategy really depends on the individual medication itself.

But at the start of each new therapy, it's really important that we provide these patients with extensive counseling and instructions regarding when to call their oncology team if they're experiencing side effects or if they have questions. We also encourage them very simple yet very effective strategies such as having patients create medication reminders and their phones and keeping a log of their side effects so that we can review them when they come in for their next appointment.

The COVID-19 pandemic has allowed us to really embrace telemedicine and allow for more frequent interactions with our patients between our office visits specifically. For example, reaching out to a patient after starting a new therapy to tack on their compliance and also detect for any new toxicities is extremely important.

Telemedicine allows us to have that convenience for our patients. It helps reduce the spread of COVID-19 while it still allows us to check in on them and ensure they're doing well.

Expert Discusses the Current Screening Recommendations for Prostate Cancer

Andrew Bzowyckyi, PharmD, BCPS, CDCES, associate professor at Pacific University Oregon and clinic pharmacist at Legacy Medical Group discusses the differences in GLP-1 receptor agonists and insulin for the management of diabetes.

Q: What are the characteristics of different GLP-1 receptor agonists for diabetes?

Yeah, so there's a lot of things to think about when you've got the GLP-1 receptor agonists. A couple of the ones that I think of are dosing frequency. So we've got some that are daily, some that are weekly titration schedules, some, you can step up kind of, again, weekly, some monthly, we've got fixed dose pens, and we've got titratable pens, we've got single use pens, and so you kind of use it and throw it away, you've got multi use pens, so you use the same pen multiple times, you know, some patients prefer 1 over the other.

You've got, obviously, most of them are injectable. We've got an oral GLP-1 receptor agonist now, and so we're getting different dosage forms and needle considerations. So, some are co-packaged with needles, some aren't, some have like a thicker needle size, and so lots of different things to think about.

And then obviously, cost formulary status is going to be huge, and then weight loss impact, some are more effective at weight loss, some are less effective. And so taking that into consideration is always going to be important as well.

Q: What insulin treatments are currently available? Are there any new treatments in the pipeline?

Yeah, so insulin has been something that's been around for what seems like forever. For the longest time, there weren't a whole lot of developments. And then you know, all of a sudden everything hit. Some of the most recent developments are probably on the extremes of our durations of action.

So, we're having a lot of growth in the ultra-rapids. The almost immediate acting insulins, and then on the other end, we're having more, obviously, ultra-long-acting. So those are probably the 2 biggest developments recently. We're seeing a lot more biosimilars, specifically Glargine. So long-acting insulin, another biosimilar agent was just recently approved. And then we've still have the rest of our armamentarium.

So, the rapid insulin, short insulin, intermediate, and then some long-acting insulins as well. And then don't forget those premixes they're kind of making a comeback with insulin affordability issues and flexibility of dosing, trying to kind of reduce those overall doses. We have our premixes, including I always forget about the basal GLP-1 combos. So, we still have to have those as well, in terms of new insulin treatments.

Q: What are the differences between insulin and GLP-1 receptor agonists?

A couple things. So, there's a few once weekly basal insulins that are in development one's in phase three, and then there's at least 1 in phase two trials. So, this would be really interesting to see how this plays out. And kind of what the patient reception is to a once weekly basal insulin.

It's a huge game changer in this space, and then there's also an oral insulin. That's currently in phase three trials. So, lots to come in this area trying to get insulin, that I don't know that just have different characteristics, because again, the more options we have the better for patients.

So, the difference between the 2 is really the way I describe it to patients, because I have this conversation all the time, you know, when you're thinking between the 2, presenting them both to the patient, insulin really helps supplement the body's needs.

So it just goes straight to the source. It's more direct, and basically replaces what your body may be missing or may not have enough of. And then GLP-1RA is, on the other hand, they're targeting the increasing system. They help promote endogenous insulin production, but they're not insulin themselves, and that's an important concept to emphasize to patients who may be nervous about starting insulin. Not that that's a bad thing, but some people thinking that you know you're promoting your endogenous insulin is a little bit more palatable sometimes for a patient to process.

And then on top of that, they offer other beneficial effects from that increasing system. So delayed gastric emptying, promoting satiety, suppressing gluconeogenesis. You kind of get the multi-factors there, versus insulin just goes, you know, straight to the source. It's very direct, and both have pros, and both have cons.

Q: When should a pharmacists consider initiating a GLP-1 receptor agonist instead of insulin?

If you look at the American Diabetes Association (ADA) standards of care, that are recently published, but even the last couple offerings, really the GLP-1 should be strongly considered in patients as that first injectable. Prior to adding basil, it should really be considered. And then again, prior to adding bolus, so if you haven't added it yet, you know, thinking about it.

Then the GLP-1 RAs, they really kind of provide that overall package deal benefits, so benefits on weight, benefits on cardiovascular risk, certain agents, but kind of as a class as well. There's a low hypoglycemia risk, so lots of different benefits there.

However, obviously, contraindications exist. There can be barriers to access and then there will always be intolerances. And so GLP-1s aren't for everyone, but it's certainly considered kind of first line prior to, not first line necessarily, but prior to starting either basil or bolus insulin, because it kind of provides a whole package deal.

Q: Why might patients want to prioritize GLP-1RA or insulin over the alternatives?

Yeah, and so this speaks a little bit to what I was kind of describing previously where there's, there's pros and cons to both. For insulin, really the priority there is for patients who are experiencing glucose toxicity, or if you suspect a severe insulin deficient state. So, significantly elevated glucose standards recommend over 300, you know, agency over 10, signs and symptoms of catabolism. The frequent thirst, the frequent urination, where even if you think the patient might have type 1 diabetes, or lot of latent autoimmune diabetes, in adults, any type of situation like that, kind of your first jump should be towards insulin.

And then if it is a true glucose toxicity, and initial glucose is clear, the patient may not need to be on insulin indefinitely, it could be something that you can rearrange the treatment later. On the other hand, so for the GLP-1s, thinking overweight, patients who are obese, looking to lose some weight, if you suspect overeating, snacking, or portion sizes might be a concern. This is another area to kind of help so rather than kind of giving insulin to treat the overeating and the snacking, we can give a GLP-1 to help kind of prevent the overeating and then established atherosclerotic cardiovascular disease.

So again, some of the GLP-1 receptor agonist have specific indications in either establish a cardiovascular disease, or you know, if there's indicators of high risk, another time to consider these over insulin. So really kind of looking between the 2. There's, again, pros and cons to both and so really looking at that specific patient to see what their needs are and then getting them an agent that can help meet those needs.

Yeah, the 1 other thing I just really want to emphasize is the GLP-1 in the basal insulins, even though the mealtime insulins are really a few of the different agents that we have. And that was just the very specific focus of my talk, but do not in any way mean to disregard any of the other agents that we have, in terms of SDLT-2 inhibitors, Metformin, TZD, every medication class that we have considered valuable purpose, and so I think that's important to mention.

My talk was very focused, but it is important to kind of think about all of the different options we have when we're treating patients.

Expert Discusses GLP-1 Receptor Agonists for Treatment of Diabetes

Melissa Somma McGivney, PharmD, FCCP, FAPhA, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy, gives a brief overview of the best practices when it comes to billing in a pharmacy.

Q: What are some of the current pathways of pharmacist payment for patient services?

It's highly varied across the country. So, when we think about pharmacists’ payment for services, so much of it is local. The first thing is when we think about pharmacists in the community in particular, it's really about access. And so you're looking particularly focused on what is it that those people need in that particular community, and that often comes down to a state level.

So there's really five ways that pharmacists can get paid for services, as many of us are advocating for, we'd love to be providers under Medicare Part B, but until then, we have to advocate for the services that we provide.

So pharmacists can be paid for medication therapy management services under Medicare Part D, in some states that Medicaid plans, so those local plans have said, we want to make sure that our patients, our members, have access to pharmacist and the community. So, they've derived their own ways to contract with groups of pharmacies to pay for services or pay for patient access in a state Medicaid plan.Numerous examples of that throughout the entire country.

We're seeing a growth in employer plans as well. So, employers saying we want to keep folks healthy as part of having employees that's keeping them on jobs, keeping them healthy, wanting them to stay employed with us, and they're finding that connecting them with local pharmacies, because 80% of chronic disease management is actually drug therapy. When you realize that you realize, oh, having a drug expert, as a part of this really does make a difference, and so we're seeing a growth in employers, again, that local flair to what is happening.

We're also starting to see health systems, in some cases, connecting with local or regional pharmacies, because again, they want to keep people, once they're discharged from a hospital environment, they want to keep people at home, they don't want to see them circling back, and they're recognizing that some of the most significant issues upon discharge often revolve around drug therapy.

There's been an opportunity to do call-based and telephonic care, but there's still a subset of individuals that need higher intensity Person to Person Care, and in some cases, we're actually seeing health systems partnering with local pharmacies.

We can never forget that patients and caregivers can pay for services as well, and certainly that's been around for a long time.

Q: Can you give a brief overview of best practices when billing in a pharmacy?

When we talk about billing, I need to actually start with what happens before billing, because billing happens after the care, and it happens after everything has actually been designed in the pharmacy. So it’s the outcome? And in order to get to the outcome that we want is to be able to drop that bill. There are a few things that have to happen before that occurs, and some of it starts right in the pharmacy itself with systems in place to transition from a traditional dispensing only model, so product only model, to where you're actually taking care of the patient within that workflow. That includes some re designation of who does what within the pharmacy.

So, looking at the work that the technicians doing that cashier and the pharmacist, and are they all doing the work and at the most efficient at that top part of their skill set? So that's the first thing is looking at the redesign.

There's technology that's needed. We have to be able to have patients make appointments. We need to be able to have an electronic system that captures health information and can transmit those bills and can transmit that information. We have to be able to accept payments in new ways, from health insurers, and potentially from employers that don't necessarily come through the dispensing system.

We also have to have all of the tools in place in the pharmacy to be able to provide care. So, some of those things are relatively simple, you know, we want to have our blood pressure cuff, we want to have scales to measure people's height and weight, but we also have to apply for laboratory licenses. So there's a CLIA waiver that has to be applied for the state and the federal level. So you have to have all those things in place in order to provide the care in order to eventually be able to bill.

The other really best practice, which is a big part of what you asked, is having someone in the pharmacy or within the pharmacy team who has a designated responsibility for adjudicating billing and adjudicating claims and then looking at any rejected claims. So we're used to claims coming in a dispensing model all coming at us in a relatively standardized way. It doesn't work that way with patient care billing, so some things might come in electronically, some things might come in on paper and a whole variety and they come in in different timeframes.

Having someone within the pharmacy, or within the organization, that was responsible for making sure that the bills are coming in, and that you're getting paid for everything, or they can call or they can be able to work with the payer, if something did get rejected. Having a billing leader within the pharmacy or the organization is really, really very important as well.

Q: How can pharmacists prepare their practice for patient care payments?

The preparation is the key, as I was mentioning, there's 4 areas of preparation, and the first is really workflow design, and it first starts with a culture change of focusing on the whole patient versus the 1 problem that they might be having today when they're picking up their prescription. It's a change of anticipating patient needs thinking ahead, planning ahead, when they come versus reacting to whatever's coming. They'll always be some reaction, right, there's always going to be some patients who are going to need an acute medication for an acute need.

When we take a look, in general, about 80% of what happens in a pharmacy is about chronic medications, and about 20% of on the given day, it is acute, so the goal is to get that at present in a more predictable fashion. The way you can do that is through medication synchronization, planning out with the patient when they're going to get their meds and attaching what we call an appointment-based model to that. That transition from managing things just as they come at us to planning the care is the game changer. What it does is it helps plan out the work of the pharmacy team, and at the same time, it actually brings in oftentimes a more consistent flow of revenue, if you're thinking about it from a business perspective, for the dispensing of the drugs alone.

The appointment that medication synchronization helps the patient, the appointment helps the patient, and at the same time, it helps the business from a workflow perspective, and also, really from a financial perspective. When you transition to that appointment-based model, once you have the contracts in place, it's easier than to tag in those contracted services during those once-a-month appointments, helpful to that patient because they know what to expect. It's not coming at them randomly and helpful to the pharmacy team because they can plan out those things. So having this level of planned or anticipated care really helps to stabilize what's going on within the pharmacy.

The second thing is patient engagement, and 1 of the very first things that we encourage the pharmacy teams that we work with is to reintroduce themselves to their patients. Their patients have been used to a certain way of working and that's, you know, varied for any given pharmacy. But if they want to develop this in a new way, and to start taking care of the patient, they have to tell the patient and let the patient know this is happening and encourage that patient to work with them. This is the way welcome to my new practice.

We've actually seen a number of pharmacies do this, and some of them have gone as far as actually having the patient sign a contract with them. This is what you can expect from us. If you don't want this, here's the other thing that you can sign. So being really intentional about engaging that patient and letting them know, you know, what to expect that's different.

The other thing with patient engagement is to be really thoughtful about the staff that is working alongside the pharmacist, thinking about the work that the technician does, and some pharmacies are starting to change what a career ladder could look like for pharmacy technician. Perhaps they work as a pharmacy technician doing the work with regard to dispensing, and then, perhaps, that could be a patient care technician, where they're learning to engage the patient, perhaps they're the ones doing the blood pressure checks and the height and weight. There's a really interesting career ladder that can be built for the individuals that really create the entirety of the practice.

The other thing that we're seeing with patient engagement is that once you go to a patient care technician, the next level can be a community health worker. This is actually a training and a designation that is growing and communities all over the US, but we're seeing an opportunity for folks that really think about engaging the patient and connecting them to services in the community, and being a bit of a navigator for patients who need it so that they can get their totality of their care.

The third aspect of what has to happen in the pharmacy to prepare you for billing is really about looking at the way the whole practice is managed. I mentioned some technology things that need to occur; there's the need to have a scheduling system, there's a need for a patient care record, that we can adjudicate the claims, there's also a need to be able to communicate electronically with patients. In some cases, we're seeing that pharmacies are able to get into the electronic health records through a contract with local area health systems, so that they can actually engage in 2-way dialogue electronically with the prescribers. So there's a number of technology things that have to happen.

The other thing that we see in the practice management area is the ability, from a financial standpoint, to be able to take in the flow of funds from this new variety of different ways. Qhen we get into medical billing, so when we're taking care of patients, we often will need, through that contract, to actually be able to drop a medical bill. Money comes in in a different way, and so making sure that the pharmacy or the whole team is able to bring that money in in a different way is important.

It's really important personnel management changes, so people's jobs descriptions have to evolve, including the pharmacist, including the technician, including every person that's in that space, including delivery driver, you know, the delivery drivers have an incredible eye. They get to witness things that the pharmacist doesn't always see because they're driving to an individual's home and dropping it off, or sometimes they're invited into the home in ways that they understand the totality of the patient's experience, and then information has to come back to the pharmacist so we can think through how we can best help the individual. There's a lot of roles and responsibilities that end up evolving. When we transition to this patient care focused pharmacy, as you know, in instead of doing a traditional of dispensing only.

Finally, in practice management, you need to have some dashboards, you need to know how you're doing because what's so different when you're billing for patient care services is you don't know once you provide a claim to anywhere, you don't know if you're going to get paid the same amount, you don't know exactly the timeframe that you're going to get paid.

It's not like we do with drug dispensing where, you know, either right away, whether your claim has been accepted or not, and so you really need a set of dashboards to be able to know “Have I been able to take care of all the patients that I can in this contract? Where am I at?”

Some of the contracts allow you to see a patient every single month, some might be once a year, some might be 3 times a year, so you need a way to account for this variability between the contract. So really having dashboards created specifically for the work and the contracts that you have to serve people in your particular pharmacy becomes really important.

Finally, you know, business development. Patient care is a part of a whole community, making sure to know where the referral sources are in your community, reaching out whether it's the local doctors, offices, dentists, hospitals, but there's also the community organizations that are in the area that serve all kinds of needs that can also be referral sources in both directions. It’s really helpful to know what community resources are available.

Everything from what's going on at the local library to the local food bank to knowing where the Area Agency on Aging is, where's Meals on Wheels, all of those different types of services, and can be where we refer out from a pharmacy perspective, but at the same time, they could also be services that refer back to the pharmacy as well. So, it's a real holistic relook at the pharmacy when you start thinking about billing for patient care services.

Q: What are some patient care services that pharmacists can be reimbursed for?

It's a great question, and there's a lot of answers to it. I'll start with when we look at what pharmacists are paid for. It's always our expertise in looking at the patient's medications. And so when we start there, I'll tell you about a whole bunch of different services that we're seeing, but all of them are connected by that, you know, we're paid for that expertise that we have in being able to identify, prevent, and solve drug therapy problems that that's what we do, inherently.

The individual services since the early 2000s, it was medication therapy management, so you know, looking at a patient's holistically at their medications, certainly comprehensive medication reviews. We're seeing that really coming into the Medicaid space. So, while early 2000s, we're looking at Medicare, we still are, but now we're seeing in the Medicaid space, just how helpful pharmacists are able to be with individuals that are on multiple medications.

We're obviously seeing vaccines throughout the entire country. We're seeing point of care testing throughout the entire country, but we're also starting to see pharmacists, again, based on local and regional needs focused on caring for people with diabetes, focused on people who have asthma. We're seeing contracts for individuals who are pediatric patients, so pediatric asthma and helping them to manage keeping them in school. We're also seeing hypertension management. We're seeing pharmacists doing dis depression screenings. So when you think about the work that a pharmacist does, our access is really important, particularly in the community.

We have this expertise of drug therapy, and then we also walk in access, that becomes really important, particularly to individuals who may not already be connected to care. I think that's the other theme is that we have this opportunity to reconnect people to care. We can't take care of every single thing an individual needs, but as I mentioned earlier, 80% of chronic disease management is drugs, we can help with a drug therapy and reconnect back to the care that the individual needs.

Q: What is important for pharmacists to remember when it comes to billing, reimbursement, and payment?

That it starts before you drop the bill, and I think that's the hardest thing, you know, I've been at this for long enough where we just wanted to hurry up and bill and then, you know, you realize you got to change the practice, you've got to be set up, you have to be ready before you can actually be able to get that payment. I think that that's a really, really hard transition because you have to invest, first, in making the practice changes, so the practice changes the workflow redesign. That's why that medication, saying feminization, and they put in base model becomes so important because they help on the traditional dispensing side and they set you up for patient care, so that has to happen.

First, we have to rethink about the individuals who are within the pharmacy team and how we can use their skill sets at the highest level, so practice change happens before payment, contracting for patient care services happens before payment. There has to be a contract between the payer, whether that's a Medicare, Medicaid, employer group, and the group of pharmacies before you can submit a bill, and that's true for drugs and that’s true for any healthcare issue.

Again, we can't just submit a bill because we took care of the patient, we have to have a contract for that service, contracting for patient care services does become more attainable when you're part of a represented group, so what I mean by that, as you can imagine, a health care pair would rather contract with 1 place that can represent 150, for example, versus contracting with 150 individual pharmacists or pharmacies, and the health payers are really interested in how can I contract 1 way, but I can get a whole lot. We're seeing that happening more and more, where you have contracted entities, you need to have a baseline set of services that you're willing to offer. You have to have the technology in place to be able to make those services happen, and you have to have a payment infrastructure again, before billing can even occur because you can get to the bill.

But if you can't adjudicate that claim, you're not going to be able to get paid for the services. We're seeing that contracting often is meeting a local or regional need. There are some things that can happen throughout the country, but we're seeing some really interesting things that are happening regionally or locally, based on what the individuals need.

Then that's the access point. So, community pharmacies become an access point in addition to other places that folks can get receive care, and the moment is now we have demonstrated the collectively, the profession of pharmacy has demonstrated the value that we bring during this pandemic and how critical it has been to have access points in communities all throughout the United States. We've been able to demonstrate that we can get vaccine to the highest need individuals and that we can go outside of the walls of the pharmacy to be able to provide care in neighborhoods where care might not easily be accessed.

We've demonstrated that we can safely and effectively do point of care testing and we're able to get people access to their needed medications, even when other things have closed down. There hasn't been a more clear example of the value and what pharmacists can bring, and the public has said, we want you because they're coming in our doors.

The time to advocate, the time to step up and say we could do this and to create these changes is now and we're seeing that during the pandemic, and we've had a lot less chronic care management happening and so the need is even greater for so many individuals. I do think the time to step in and step up is right now, and we are seeing, from where I'm sitting in Pennsylvania, the number of patient care opportunities in pharmacies has grown significantly over the past 12 months, and it's really because of the work that pharmacists and teams have done in communities and demonstrated our value.

Melissa Somma McGivney, PharmD, FCCP, FAPhA, professor and associate dean for community partnerships at the University of Pittsburgh School of Pharmacy, gives a brief overview of the best practices when it comes to billing in a pharmacy. 

Expert Discusses Pathways of Pharmacist Payment for Patient Services

In this month's episode, Mark Garofoli, director of Experiential Learning Program at WVU School of Pharmacy, discusses the role and impact of pharmacy technicians on opioids in the pharmacy. He mentions the process of dispensing opioids, new changes to the dispensing of controlled drugs, and best practices for pain management.

If you would like to share your Pharmacy Technician Tips, email agallagher@pharmacytimes.com

Podcasts

Mark Garofoli, director of Experiential Learning Program at WVU School of Pharmacy, discusses the role and impact of pharmacy technicians on opioids in the pharmacy.

Pharmacy Focus Podcast: Pharmacy Tech Talk - Episode 6

® interview, David Zgarrick, PhD, FAPhA, professor in the department of pharmacy and health systems sciences at Northeastern University, discussed how the COVID-19 pandemic has changed pharmacists and pharmacies and what that means going forward.

He addressed the 3 most impactful and lasting changes, how pharmacy technician's roles have chnages, and what can be expected for the pharmacy profession in the next few years.

Hi, I'm Ashley Gallagher from pharmacy times, and today I'm speaking with David Zgarrick professor in the Department of Pharmacy and Health Systems Sciences at Northeastern University, about how the COVID-19 pandemic has changed pharmacists and pharmacies and what this could mean going forward.

The COVID-19 pandemic has impacted the way pharmacy staff and pharmacies in general operate. What are 3 of the most impactful and lasting changes you have seen in the pharmacy profession?

: Thank you so much, Ashley. It's so nice to meet you, and so nice to have a chance to speak with your viewers today. 3 things that I look to in terms of changes in the pharmacy profession that are coming forward as a result of COVID.

First and foremost is that immunizations and vaccinations no longer are peripheral to dispensing prescriptions and other aspects of the community pharmacy business model. They now have become a central part of that business model and must be planned for accordingly, including things like pharmacy design, personnel, financial marketing, everything that we do now includes immunizations and vaccinations as part of that business model.

The second is the rise of telehealth and telepharmacy. We now recognize that remote work, whether by pharmacy personnel or by our patients themselves, will be an important part of community pharmacy practice moving forward.

The third aspect is that patients health care providers and communities look to pharmacies not only as sources of medications, but also as important health resource centers for information. pharmacies will continue to be the most accessible point of health care in the United States.

: As pharmacists take on more clinical roles, what changes within pharmacies will need to be made?

: First and foremost, I think one of the biggest changes that will have to occur in pharmacies is our information management systems. Just simply how is it that we capture the clinical interventions that we are making on behalf of our patients and what interventions or what outcomes those interventions will actually have?

That means that information is needed and the data is going to need be evaluated from those from what we gather, in order to be able to help continue our value proposition. Pharmacists, as they go into more clinical roles will certainly need to be able to show what value those clinical roles bring to patients and bring to those paying for care, and it's important that we have information systems in place that will help us be able to document and solidify that value proposition.

: Pharmacy technicians have also seen a growth in their roles, such as administering vaccines. Moving forward, how will the roles continue to expand?

: I think it's fair to say that as pharmacy technicians grow in their capabilities, and as pharmacies look to support from other personnel in order to enable them to practice both at the top of their license, as well as to manage the financial aspects of a pharmacy practice, we're going to continue to look more and more to pharmacy technicians.

On one hand, it's fair to say that pharmacy technicians roles simply certainly will be continued to expand in the future. I do think a important caveat to that, though, is that technicians are now going to need to be paid consummate with the level of expectations and responsibilities that they have that they're taking on.

We simply cannot ask technicians to do the types of roles that pharmacists have traditionally done and continue to pay them at a level that pharmacy technicians need to get paid. If we want to expect more from pharmacy technicians, pharmacies are going to have to figure out how are they going to pay pharmacy technicians at a level that is consonant with their responsibilities.

: How have patient expectations changed since the pandemic began? And how can pharmacists best meet those expectations?

: Patients still continued to seek answers for their health. And probably 1 of the things that has happened as a result of that pandemic, is there is so much more health information that is out there and available and it comes from a variety of sources.

As we all know not all of this health information that patients receive is good information and and 1 of the things that we as pharmacists can do to help patients meet those expectations is to help our patients learn how to be critical of evaluators and consumers of healthcare information just like we as pharmacists, you know, critically evaluate the drug literature and the information that we have to help us make decisions about patient care.

We can take steps that help our patients better use and better sift through all the information that they have as well. And I think that's a very, very important role that we can do is is really, you know, the public looks to pharmacists, because we are so accessible as a source of information to be able to help them make sense of everything that they're seeing and hearing.

: With the addition of more roles for pharmacists and pharmacy technicians, how is burnout being addressed?

: Burnout is a very important issue in pharmacy right now. I know recently, there was a American Pharmacists Association just sponsored a summit that addressed the burnout of pharmacists and pharmacy personnel.

I'm very active. I'm on the board of directors of the American Association of Colleges of pharmacy and 1 of our tenants of our new strategic plan is the health and wellness of all people in essence, the the pharmacy arena, everyone from student pharmacists, to pharmacy professors, to the clinicians and practitioners that we work with being paying more attention to health and wellness, which goes beyond just simply saying, 'Yes, I understand it's an issue or here's a free slice of pizza.'

It really means, you know, paying heed to the issues and being able to address them in a very meaningful way. And that can be what are we doing to support our personnel on a personal level, including enabling them, the time and the space to get the help and the resources that they need so that they can continue to provide the high quality care that we depend on them.

The ability to be able to provide support personnel so that when people do take a step back, that, that their role, in essence isn't being missed that somebody else can step in and do the job that those people otherwise would. Sometimes we as pharmacists can be our own worst enemy, because we may need the time to be able to address our own personal health.

Yet, we also recognize that if we aren't there in those patient care roles, it's very difficult to imagine who else will be there. So again, it's important that pharmacies and pharmacists work together to make sure that we have ample amounts of trained personnel and then also that even things like regulations and other things that can limit the capabilities of pharmacists and give limit where and how pharmacy personnel can work. Some of those things need to be addressed so that we can provide more resources to the pharmacy personnel that need them.

: How has telehealth proven to be an effective tool for the pharmacy profession? And how has it helped to alleviate some stress from pharmacists?

: Telehealth has certainly proven to be essential as we have navigated through the pandemic. First and foremost, it provided a safe way for our patients, as well our personnel to be able to interact with each other, particularly when we didn't have the protections of the vaccine and what we know about how to most effectively deal with the virus.

As time went on, there was likely less need for the safety and protection that telehealth provided and more people just simply recognize the convenience that telehealth provides and continues to provide, you know, particularly patients who have busy lives are able to interact with pharmacy personnel in ways that do not mean that they have to come physically to the pharmacy in order to be able to get the help and the information that they need.

Telehealth in some ways has alleviated some stress on pharmacists and has enable us to be able to interact with patients in ways that we hadn't been able to interact with before. And other ways it might be fair to say that it has created some stress for pharmacists for 1 telehealth is something, is a form of technology that many pharmacy personnel have had to learn. You know, we have to learn how to make the most effective use of telehealth and that has taken some time and effort.

Another thing as far as telehealth goes, is that we have to make sure that it's available to all pharmacists where they need it when they need it. It does sometimes mean that pharmacists feel like they're taking their work home with them and that, in turn, can create some more stress.

One of the great potentials for telehealth is it can help address what we might call some of the, you know, geographic misappropriation, so to speak of pharmacy personnel. We don't necessarily have a shortage of pharmacists today, or pharmacy personnel, but they're not always in the places where we need them to be, or especially where patients need to have the assistance from pharmacy personnel. And so telehealth certainly provides a platform upon which we can provide services to our patients without the geographic barriers that we've traditionally had.

One potential barrier that we do have to address as we move forward with this is some of the legal and regulatory barriers. The barriers that state that we as a pharmacist, of course, have to be licensed to be able to provide care to patients typically based on what state they are living in and where we are providing those services.

What we're going to be seeing is the need for our health regulators, particularly our Boards of Pharmacy, to work together to see how we can address the need, of course to have safe and effective and regulated health care professionals providing services across geographic barriers and across geographic boundaries that are traditionally defined, where one has a pharmacy license.

: What can we expect for the future of pharmacy as a profession in the next few years?

: I continue to be optimistic for the future of our profession if for no other reason that patients continue to need medications and pharmacists continue to be the experts with regards to medication use, and so long as we can continue to use our knowledge, our information, our experience, to help patients achieve desired outcomes with their medications. They're certainly going to be a good place for pharmacists.

What I see evolving and changing over time is just simply the fact that it's not going to be in anyone's best interest to have a pharmacist focus their time and efforts and energy on tasks like dispensing. That's not to say dispensing isn't an important and essential issue. It's just that there are other people and other technologies that can more effectively do those those dispensing duties.

Pharmacists, on the other hand will be focusing their efforts on helping others get the best value for their medications. One of the things that's, interestingly enough, as we see medications getting more and more expensive, and we certainly see that within certain categories and classes of drugs. This actually presents more opportunities for pharmacists to be able to step in and make sure that those drugs are being used safely and effectively.

We can see almost an instant return on the pharmacists investment of their time, just simply by alleviating the misuse of very expensive drugs and to helping ensure patients get the desired outcomes with respect to using the most effective, most expensive drugs.

David Zgarrick, PhD, FAPhA, professor in the department of pharmacy and health systems sciences at Northeastern University, also addresses what the future of the pharmacy profession could look like.

Interviews