®, Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses his session at the American Association of Pharmacy Tecnicians Annual Convention, regarding how the 

 has changed the role of pharmacy technicians and what is expected as we move forward.

Q: In general, how has the COVID-19 pandemic changed the role of pharmacy technicians?

It is really kind of increased the profile and the role of technicians. Some of this is related to the emergency health measures, and so what we've seen is a kind of an increase in the roles and responsibilities of technicians, and I think the 2 things that probably jumped to mind, first, are our immunizations, clearing the path that allows for technicians to do immunizations, under the supervision of a pharmacist, and then also probably related to point-of-care testing. Again, opening up the opportunities and clearing the path for technicians to be more involved in specimen collection and running the point-of-care tests.

Q: What can pharmacy technicians expect moving forward from the COVID-19 pandemic?

My expectation is probably more of the same. I think, probably, formalizing and extending the privileges around immunization and around point-of-care testing, for sure. I think certainly even more responsibility in the dispensing activities, kind of strengthening some of the tech-check-tech type programs, the things reducing technician, or eliminating technician ratios all together. I see the technician moving to having a little bit more autonomy probably at least in the foreseeable future, still, we're under the oversight of a pharmacist, but they're really playing an even bigger role in the delivery of patient care.

Q: How have we seen pharmacy technicians take a more active role in pharmacies?

I think some of the things that we've talked about the immunizations, the testing, stepping up being just being more involved. I think of the evolution over time, from when a technician was really just there to count by fives and put things into the bottle, and now I've seen that that role, expand. I think we would all there's no way pharmacy as it is practiced in America today would exist without pharmacy technicians.

Q: What are some opportunities for pharmacy technicians when it comes to billing and insurance?

I'm not sure if it's a privilege or a punishment. I mean, right? these are some of the necessary things that are struggles for a lot of pharmacies, and certainly the role that that technicians can play, whether that means sitting on hold on a phone call, or I think, one of the better is to just take that part over in the pharmacy, become familiarized with all of the billing mechanisms, the coding, all of those things to help the pharmacy really maximize the revenue for the services that they're providing. Every pharmacy needs a resident expert, and I think that's a fantastic role for pharmacy technician.

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Donald Klepser, PhD, MBA, professor and dean of academic affairs at the College of Pharmacy in the University of Nebraska Medical Center, discusses how the COVID-19 pandemic has changed the role of pharmacy technicians and what is expected as we move forward.

Role of Pharmacy Technicians Continues to Grow in Post-COVID-19 Era

, Yi Lin, MD, PhD, discussed new developments with CAR T therapies for the treatment of multiple myeloma. From idecabagene vicleucel (Abecma), the first approved CAR T therapy for multiple myeloma, to the recently-approved ciltacabtagene autoleucel (Cilta-Cel), Lin said significant steps have been taken.

Q: Abecma was the first CAR T therapy approved for multiple myeloma, and Cilta-Cel is the latest. Can you discuss how Abecma works and how it differs from Cilta-Cel?

So, idecabagene vicleucel, or Ida-Cell, or the name is Abecma, has now been available in standard of care practice for a little over 1 year. This particular CAR construct, CAR T therapy, is also an autologous product made from patients’ own T cells, and it's also prescribed as a one-time treatment. So really, that's I think the most exciting thing about CAR T right now, is it’s a one-time treatment with no maintenance follow up. They are given as essentially a fixed dose, not weight-based, 300 to 460 million CAR T cells per dose. And that's totally dependent on how many of those cells can be manufactured on the patient's own T cells.

In the registration study that led to its approval—again, this is also a very late, relapsed/refractory patient population—the median line of prior therapy was also 6. And again, it was one time dosing. [We saw a] very impressive response—73% of those patients responded, 33% of those patients had deep response. And on that study, we've had longer follow up. So, we are seeing that the median progression-free survival is over 8 months, 8.8 months to be exact, for the entire treated population. But if you look at patients who were able to get that higher dose in the range, or patients were able to achieve deep response, the median progression-free survival is much longer, closer to a year. So, I think in the current landscape of myeloma treatment, this is a very impressive treatment option that's available for our patients.

Q: What is pharmacists’ role in CAR T therapies?

Pharmacists are an integral member of our CAR T teams. They play a critical role. From the very first appointment, where we are evaluating patients and considering their eligibility, planning to go towards that collection of the patient's own cells, pharmacists are very much involved in looking at what was the patient's most recent exposure to the prior salvage treatment, [and] the washout period, because this directly impacts the health of the cell that's collected and the likelihood for successful manufacturing. They are, of course, involved in terms of any bridging management that is needed, trying to optimize the care and preserve organ functions from the drugs that are given to improve the chance that the patients can make it to CAR T dosing. Most of our patients will need a line placement for the cell infusion and there may be need to manage anticoagulation around that time. And then, of course, once we actually get to the CAR T treatment, that is always given with the lympho-depletion chemotherapy drug. And in our myeloma patient population, they don't always have normal kidney functions, for example. So, pharmacists work very closely with our team to look at the appropriate dosing adjustments for the lympho-depletion chemotherapy. Part of the REMS requirements by the FDA, the risk evaluation mitigation system requires that for all patients, prior to getting those with CAR T, that we have reserved for them the first line treatment for cytokine release syndrome, which is tocilizumab IL-6 receptor blockade, so it's ready to go when we need it and there's no delay. And so pharmacists are the essentially the keeper to ensure that we have adequate supplies, and it's ready to go for patients, as well as if there's a need to escalate the management, all the different drugs that are used, including in the acute monitoring periods, really looking very carefully over all the other medication that may be needed for symptom management to also make sure that they are not masking anything we need to monitor, from the standpoint of infection, cytokine release syndrome, and neurologic symptoms. And then moving on, during that time and moving beyond that for even longer-term follow up, antimicrobial prophylaxis and some of the other medication management considerations when you're working with a living drug.

Q: Is there anything you would like to add?

Absolutely. So, I think right now what we're basically telling everybody is that the CAR T is a very individualized treatment that is made from patients’ own cells. There's a lot of logistics in getting the patient through to treatment, and so we definitely encourage everybody who's taking care of these patients to be thinking early about their referral, and if the patient might be a candidate for CAR T, and any considerations in their management to improve the odds to get the patients to treatments. And, as I mentioned at the beginning of the interview, there's a lot of investigations going on for next generation CAR T and innovative CAR T. And so, I think as we learn about these CAR Ts, for example, those that may be more rapidly manufactured or allogeneic platform, we may start to learn what are some of the unique side effects or considerations for management? And I think that's very relevant for the pharmacist practice to understand as these things evolve. How does their management change with the new treatment modalities?

From the first approved CAR T therapy for multiple myeloma, to the recently-approved ciltacabtagene autoleucel, significant steps have been taken.

With New Developments in CAR T Therapies, Progress is Being Made for Patients With Multiple Myeloma

, Ajeet Gajra, MD, MBBS, FACP, discussed research into how an intelligence-based system could help improve the timeliness of referrals to palliative care and hospice services in a community oncology environment.

Q: Can you explain the augmented intelligence-based tool that you discuss in your presentation?

So, this was born out of the work and the tool is owned by Jvion, it’s called Jvion CORE. So, what it is, is a machine learning tool that is commercially available and we published other data ahead of this current study in the 

, where this tool basically integrates clinical information, which is, you know, your tumor, your stage, comorbidities, polypharmacy, age of the patient, gender, all of that. So that's the clinical information. Then it has all of the claims data, you know, because patients may be getting oncology care at the center, but then they also have all this other care that they're receiving, so that gets pulled in from there. The novel piece of this AI tool, the Jvion CORE, is that they integrate data from social determinants of health. So, this is beyond just income, poverty, education. So, many people say, oh, yeah, just use the zip code. No, zip code is too broad. So, this goes much further than the zip code. And this is data that they are able to collect from publicly available databases, like the US Census Bureau, or the USDA, or the NOAA.

And so all of this is brought in, and what essentially, to put it very simply, what they're doing is they're creating these clusters of patients which are similar based on their disease and their social structure, and then trying to assess the trajectory of a patient. So essentially, a patient is being matched to other patients with similar clinical and social characteristics to determine what the outcome or the trajectory might be. So, the key component of this is that the risk of deterioration, risk of mortality, risk of doing poorly, you know, is what is identified. And so, once a patient like that is identified, and of course, in the context of an advanced cancer diagnosis, then these patients are the ones who are appropriate for a palliative care consult.

So, a clinician might say, “Oh, why do I need all of this? Because I know.” But the surprising part has been that there are patients who are obviously, unfortunately, not doing well clinically. And so, everyone knows they need palliative care. But then there are patients who may appear clinically sound or not at risk, but then based on all of these other factors are determined to be at risk. And then also, there's a component of patients who may appear as high risk, but they may have a modifiable risk factor or, you know, a latent infection or some other social issue, like lack of transportation, which can maybe put them in the high-risk bucket. So, it basically amalgamates a lot of information from various sources, and this has been previously validated. And like I said, it's a commercially available tool that we've used for this purpose.

Q: How can this tool be implemented in the real-world setting?

Yeah, so you know, there are some practices utilizing this tool already. And of course, we've worked with one of these practices for the data that we're presenting at ASCO 2022—and this was the Northwest Medical Practice, Dr. Sibel Blau and her team out of Seattle Tacoma area in Washington State. So, the way it works is that the AI system needs to be integrated, or rather, it sits on top of the EMR. So it is EMR [and] EHR agnostic, so it doesn't matter what type of electronic medical record the practice may be using. This AI tool can, let's just say, read off and communicate with the EHR and derive the information that is needed from the HER, and it will generate output and this is a continuous outcome. So, essentially, every week all of the patients that are in the practice or in the EHR are reviewed by the AI tool to identify those at highest risk. Now, there are also other vectors or other components to this AI so, you know, patients can be assessed not only for deterioration and mortality risks, but for pain, for depression, for mental health. Again, a slew of other possibilities and new vectors can be created. You essentially have to train the machine and the learning set and then a validation set, but the bottom line is in the mortality vector or at-risk factor, or risk of deterioration, the tool creates essentially a report for each week in terms of who are the patients who are highest risk. And this report is literally pulled off by the practice to identify the patients, you know, that have been identified with this tool. And then you can take corrective measures, which may include palliative care, or if that is not the case, say someone with adjuvant therapy who doesn't have active cancer, if they are at high risk, well, then they may have something preventable or you know, reversible, that is putting them at high risk, and so it can be addressed in that manner.

Q: What did you find about how the tool impacted timely referrals?

Yeah, so what we've demonstrated in our earlier work with this tool is that utilizing it in the context of palliative care increased the number of palliative care referrals, and also the referrals to hospitals within this practice. This is a large community-based practice, and we also have similar data actually from another practice that has piloted this tool.

But what we found in the current work is about the timeliness. So, we're looking at, okay, well the referrals increased but were they timely referrals? So, what we really found was that, and we chose because this is a real-world study, real world data. So, this is a retrospective look. So, all patients who unfortunately had a mortality event at this practice in the given timeframe, we reviewed their records to see if these patients received a palliative and hospice care referral. So, we did a before and after analysis. So, we did it a before analysis for the time period before the tool was implemented, before the Javion CORE was launched at the practice. And then we did a post period after the Javion CORE launch to see if there was a difference. We know we would like for patients to be referred as early as possible to palliative care, so we chose a 90- to 180-day window. So, again, it could even be longer, but we just have a time point.

So, we noticed that there was almost a 2-fold increase in patients being referred to palliative care in that window. And similarly, we use the shorter window with hospice, to assess if patients were being referred 14 days prior to their mortality to hospice. And we basically quantified it at various time points. And, of course, that's in the poster, I would have to probably look at those numbers quickly. So, the 90- to 180-day window for palliative care was doubled, like I said, [with an] increase by 111%. And then for hospice, actually, the 14- to 90-day pre-mortality referrals increased also by 179%. So, almost a tripling of those referrals in a timely manner. The other important piece was that before the launch of this tool in this practice, 86% of patients were not getting a palliative care referral at all. And so, after the tool was launched, that number decreased to 72%. Of course, you may argue there's still a lot of patients not receiving palliative care. But again, you know, we have the whole pandemic and all of that in this time period. But the bottom line is that it was a movement in the appropriate direction. And similarly, prior to the deployment of this tool, 83% of folks were not receiving a former hospice referral—that doesn't mean that they weren't getting hospice. And this number dropped to almost 52%, so a dramatic decrease in patients who were not being formally referred to hospice, and then we saw in the longer time points, a lot of patients being referred earlier in their course. So, that's the takeaway: Patients started to be referred earlier in the course of palliative care, earlier in the course of hospice, because the bottom line and the takeaway is, you know, the earlier in the course that we can do that, the better I think it is for patient outcomesand for quality of life.

You know, I think this is a valuable tool. It's already shown utility in a community oncology setting and, you know, certainly larger studies would generate more data and greater confidence in its utility across various practice types.

An intelligence-based system could help improve the timeliness of referrals to palliative care and hospice services in a community oncology environment.

Augmented Intelligence Tool Helps Ensure Timely Referrals to Palliative Care for Patients With Advanced Cancer

 and today I'm speaking with Elizabeth Ruzzo, founder and CEO of Adyn, about the impact of the reversal of Roe v Wade and how it will affect pharmacies. So, before the Roe v Wade reversal, what was the pharmacist’s role in 

 My understanding is that pharmacists play a really important role in reproductive health care, including prescribing hormonal contraception and emergency contraception in some states, but pharmacists have had a limited role and involvement in abortion care, primarily due to FDA’s regulations around dispensing abortion pills specifically. My understanding is, that even prior to Roe, pharmacists in most states weren't able to dispense this directly. Usually, it was done in clinics themselves.

 I think for now, because of that, there aren't going to be big implications for pharmacies, specifically, because they weren't yet dispensing. I think, hopefully, they will see an increase in volume for helping provide highly effective methods of contraception.

What are the long-term ramifications of this ruling on women's health care and women's health care access?

 I mean that is a loaded question, right? I think that women are not going to stop getting abortions, they're going to stop getting legal abortions, and abortion is health care. It's also really important if someone has, for example, an ectopic pregnancy, if there's a problem with the fetus, sometimes if a woman has severe preeclampsia. It is a lifelifesaving technique used to save the living mother. Part of the problem here is that also doctors in these states are not going to be trained even in how to do these procedures. So the real truth is that the impact is that women are going to die. Estimates are that there'll be a 21% increase in pregnancy related deaths, and that number rises to 33% in non-Hispanic Blacks, so it just has devastating implications.

I think the other implication is that women are going to need to rely more than ever on highly effective methods of birth control, and potentially Plan B.

How might the reverse will impact the right to privacy? And what does our right to privacy have to do with birth control?

 This ruling basically was based on a right to privacy. That is the same underpinning of several other rulings like Griswold, which gave us the constitutional right to privacy. Specifically, that a married couple was free to choose their own contraception. There was another case after that in 1973 that also extended that right to unmarried women, and so by taking down this right to privacy-related rule with Roe, it opens the door for not just those to specific to contraception, but a number of other rulings related to gay marriage, interracial marriage, and more.

What are the economic benefits of birth control?

 I really think that birth control is freedom, right? It gives individuals the freedom to pursue higher education, and as a result, careers that are higher paying. There's also a big economic burden of unintended pregnancy to the country at large. In 2019, there was an estimate that annual direct medical costs from unintended pregnancy in the US were at least $5.5 billion. It's a really massive strain on the economy, and even when we've seen declines in pregnancy rates, the annual costs of unintended pregnancies have continued to climb.

The other thing I like to point out about potential economic benefits is what an economic benefit an individual would get from finding the best method for them more quickly. What I mean by that is a lot of times people experience unwanted side effects on birth control, and frequently, what this means is that they have to go to a different specialist. Let's say you have acne, maybe then you go to your dermatologist, you have to pay that copay. Maybe you get a prescription for a topical drug to treat that, and so on. So part that's a big part of what we're doing at Adyn, we're trying to help people skip that trial and error and instead use precision medicine to find the right birth control more quickly and get a personalized contraceptive counseling visit for that same reason and save people the burden of both time and money associated with not being on the right birth control.

What are the implications of this decision on future birth control access? 

 I think hopefully right now, the answer is, it's not having an impact. But the reality that we spoke about before with regard to Griswold, and the right to privacy means that potentially access to birth control is very much next on the chopping block. That is just a devastating reality. I think it's really important for us to make sure that we're out there educating about what all of the reasons birth control is really used. It is a hormonal medicine that is used to do all kinds of things and treat reproductive health disorders of all kinds. It's not just about preventing pregnancy.

Are there states where legislators are attempting to interpret IUDs as abortion and what are the implications of this?

 I've heard of at least 1 anti-abortion bill in Louisiana that luckily did not pass that was trying to include the IUD. So the copper IUD can be used as emergency contraception. It's 99% effective and present preventing pregnancy if it's used within 120 hours.

However, there is no evidence whatsoever that the copper IUD is an abort efficient. The World Health Organization talks about the effect of copper being pre-fertilization. So what that means is, it's having an effect on the sperm or the ovum. It is not in any way hurting a fertilized embryo.

What might the role of the pharmacy be if contraceptive access were impacted by future decisions at the state level?

 I think if contraceptive access were to be taken away, the pharmacist’s role would really be to help provide unbiased and factually accurate information and resources to patients, in particular, if there were still ways for them to legally obtain birth control. Unfortunately, maybe start having to rely on less highly effective methods like barrier methods. 

What is the importance of contraceptive access for health for both men and women?

 I think it's really important to remember that reproductive health and contraception affect both men and women. It means freedom for both of them. Men also experienced benefits, including economic benefits, from not having unintended pregnancy happened in their life that lets them continue to pursue education and reach different career goals and earning potential as a result.

The other thing is just that birth control, like we talked about a little bit here already, it is medicine. It's really important for the health of women to be able to have access to that it can do things from alleviate PMS symptoms, to manage really serious medical conditions like endometriosis and PCOS. The men in our lives should be supportive of us living our healthiest and most pain free life possible.

And lastly, how can pharmacists help patients during this time?

 I think they can help provide unbiased and factually accurate information and really just act as a resource as much as they can to patients. I think that I would encourage pharmacists to spend extra time with patients fulfilling a highly effective method of contraception to make sure they don't have questions about its use, its safety, that they understand how to quickly recognize any potential side effects, so that they can switch if needed and make sure that they're not suffering unnecessarily because birth control isn't one size fits all. It's really a matter of finding one that that works for you, and with nearly 200 options, there will be 1 out there that should work for you.

I think pharmacists can also remind patients to keep Plan B on hand for instances if they miss several pills or even just to have to share with a friend.

Elizabeth Ruzzo, PhD, founder and CEO of Adyn, discusses the impact of the reversal of Roe v. Wade and how it will affect pharmacies.

Expert Discusses Pharmacist's Role in Contraception, What Reversal of Roe v. Wade Could Mean

To start, how did the pandemic impact testing and screening for HIV?

First, I just want to say thank you for having me on this very important day. For us, National HIV Testing Day is a very important day. We've been a part of this for since 2011, so very happy to be here, considering it an honor. To your question about how to how did COVID impact HIV testing specifically, one of the things that we've seen is that throughout the pandemic, the numbers of tests that have been available to individuals has decreased significantly. The CDC even reported that upwards of 50% of test have declined. So what we know from that is that the pandemic really had a significant impact.

Because if individuals are not able to get into testing, then they're not able to know their HIV status, and knowing your HIV status is critically important because it's a necessary component to either get into antiretroviral therapy, or to take preventative steps, such as pre-exposure prophylaxis to ensure that an individual is protected from acquiring HIV. It's significantly impacted because the amount of tests that were available, and then individuals obtaining an HIV test, and therefore knowing their HIV status, subsequently declined as well.

Why does HIV impact certain communities more than other, such as the LGBT community?

I think that we have 2 things that we still have not been able to achieve. I think 1 is in terms of awareness as well as access for various communities, and so there still needs to be considerable work done around increasing education around the need for an HIV test for those that may be at risk of acquiring HIV. The educational component or awareness component as well as making sure that individuals within various communities have the access to the testing services, as well as the medication services, that can help prevent them from acquiring HIV in the first place. The 2 staples there, in my opinion, 1: education or awareness, as well as, secondly, access.

I believe that if we put some considerable effort around those 2 areas, in the communities that are most impacted right now, and we can really make a difference. That's what we're very passionate about in terms of Walgreens making sure that we're doing both of those to ensure that individuals within whatever community it may be and have the education as well as the access right where they are.

What is Walgreens planning for June 27 this year?

I’m very excited to announce that we are back in our stores for in store activation or in store testing. We've done this since 2011, with a brief break during the pandemic because we couldn't have community-based organizations and health departments and in our stores. But since 2011, we have invited community-based organizations and health departments into our stores to offer free HIV testing. I'm happy to announce that we're back in about 250 cities today with over 300 health departments and community-based organizations in our stores to ensure that patients have access to a critically important HIV test, and they can get it for free. We’ve been receiving messages for people in our stores getting free HIV test, and we're really, really excited to be back in our stores offering this critically important service.

How can pharmacists screen for HIV effectively?

It starts with being a trusted health care professional. So being available within the communities that we serve is a critically important point. So about 78% of Americans live within 5 miles of a Walgreens pharmacy. Being a trusted health care professional embedded within communities. That's really the starting point for us. From there, we have to ensure that our pharmacists are educated, and they know individuals that may be at risk of acquiring HIV and how to potentially help them. So we take training at Walgreens very seriously. We take cultural competency, ensuring that the pharmacists and pharmacy team members have the tools and the resources they need in order to provide services to our patients. So, starts with access, but then also coupled with training, and then really comes down to being available.

Whenever individuals have questions, whether they want to know where I can get a free HIV test and we can provide answers to them. If they want to know various different community organizations that may have other services available, we can point them in the right direction as well. So it's critically important for us to make sure that we have access, we have the training, as well as really the availability to ensure that individuals that may have questions about should I get an HIV test? Or should I take pre-exposure prophylaxis that we can make sure that they get their questions answered?

What can pharmacists do to help promote HIV testing and treatment, including PrEP?

It kind of goes back to what my previous answer was, but really being available. Then also knowing how to point people in the directions that they need to go. I think that, in addition, we're also in a future to where, because of COVID, we've seen what role a pharmacist can play in helping to really make a difference in a pandemic. I think that those lessons can easily be applied to the HIV epidemic. So, whether it's how do I obtain an HIV test? What can I do to protect myself from acquiring HIV? Really being that trusted health care professional that can answer a patient's questions and serve as an access point.

We have, you know, greater than 9000 stores scattered around the country. So you can see from a from an access perspective, if we make sure that all of our pharmacists or at least within Walgreens enterprise are equipped to answer questions, then we can really make a difference. I think we're also looking at a future to where pharmacists would be able to offer the HIV tests themselves and to potentially prescribe a pre-exposure prophylaxis. We've seen a handful of states recently that have passed legislation that will allow our pharmacists to be able to prescribe at least in limited quantities, PrEP. What we've seen based upon research and the clinical trials with pre-exposure prophylaxis is it can really make a big difference of patients’ lives and to prevent them from acquiring HIV and all of that is critically important.

It is an important day for us today. I would encourage anyone that's interested in learning more about some of our services to visit 

https://www.greaterthan.org/free-testing-nhtd-2022/

. You can find out about where testing services are available in various cities, and then also have resources to help answer individuals’ questions that they may have. Thank you again so much on this very important day. 

June 27 is National HIV Testing Day, so Pharmacy Times® sat down with Brad McElya, PharmD, director of Specialty Health Solutions at Walgreens, to discuss the importance of HIV testing.

June 27 is National HIV Testing Day

® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Anna Pham, PharmD, PGY2 ambulatory care resident at Intermountain Healthcare, discusses the role of ambulatory care pharmacists in primary care clinics.

What is the role of the ambulatory pharmacist in primary care clinics and how do they help to improve patient outcomes?

The way I see the role of amatory care pharmacists within primary care is that we work as a mid-level provider to optimize medication use for patients and just help our provider colleagues to optimize prescribing habits for medications and help with other miscellaneous things, anything related to medication access, and making sure our patient is on an efficacious and safe medications.

What is the importance of using ambulatory pharmacists within a patient's primary care?

We see a lot of patients in the primary care clinic for chronic disease management. If we're getting referral from the provider, these patients are most likely uncontrolled or don't understand the medications. So as pharmacists, we do have more free time to really dig in with these patients and get to know them to really optimize their medication use, compared to our provider colleagues who may only see their patient maybe for 20 or 30 minutes every 3 months. Just having the opportunity to have more frequent follow up is an advantage that the pharmacist has to help manage these disease states.

What are some of the different ways in which ambulatory care pharmacists impact patient care and improve adherence?

Like in my primary care setting, we are able to help co-prescribe medications for like diabetes, hypertension, respiratory, anticoagulant. Those are the bread and butter of ambulatory care services, but there's been a push within ambulatory care services to focus on population health and transition of care. So those are ways that we can help target our high-risk patients who are leaving the hospital who are having a lot of medication changes, who may be having access to medication issues with these new medications, so we can improve outcomes there just reduce frequent rehospitalization and emergency department visits.

What are some methods pharmacists can use to effectively communicate with primary care physicians?

I think just taking the team-based approach to helping our provider colleagues in the primary care clinic, so having the approach that the pharmacist has to be in clinic, and we do provide value through helping manage chronic diseases management, but also as we know, medications are just getting more complex and more expensive. So as the medication expert, we can provide value there to help our colleagues in primary care to prescribe medications that are affordable for the patient, but it makes sense based on all the other patient specific factors that the patient wants us to address also.

With such a broad breadth of knowledge necessary in primary care, can you speak about how/why pharmacists are perfectly positioned for this environment?

I would say in pharmacy school, we learn about all different types of drugs and all different disease states. We have a well, broad wealth of knowledge of primary care disease in particular. I know during pharmacy school, I learned a lot about diabetes and hypertension, and we are the drug experts, and we know these drugs in and out. So just having that educational opportunity plus going through possibly 2 years of residency training ambulatory care pharmacy as a position to be a mid-level provider to optimize this medication use in the ambulatory care setting.

Anna Pham, PharmD, PGY2 ambulatory care resident at Intermountain Healthcare, discusses the role of ambulatory care pharmacists in primary care clinics.

Ambulatory Care Pharmacists Play Key Role in Improving Patient Outcomes

In an interview with Pharmacy Times® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Aimee Banks, PharmD, BCPS, MSCS, clinical pharmacist in the Multiple Sclerosis Clinic at Vanderbilt University Medical Center, discusses the role of the pharmacists in patient care, improving outcomes, and managing transitions of care.

 What is the role of pharmacists in caring for these patients and how can they help to improve outcomes?

So many ways that pharmacist play an impactful role in patient care. I think, initially, my first thoughts revolve around education, communication, and setting expectations, specifically with the patient, but even with the care team. Pharmacists to have oftentimes a little bit more room and time to spend with patients, whether it's in clinic and an in person visit, or on the phone as a follow up to an appointment. So one of the roles that I play in my day to day practice is really education upfront, and then regular check ins and follow ups with patients to try to help identify barriers later.

Just a couple of the barriers to hopefully mitigate upfront, and then to resolve if they do occur are financial barriers. These medications are very expensive, and the high cost of the medications can be a really big barrier for access. So, understanding having an awareness of the different types of insurance companies and the different types of financial assistance that's available based on not only the medication, specifically, but even just based on the type of insurance plan that a patient has and what they might be eligible for, that's really important. We can play a really big role in just reducing the financial barrier for patients. That's not as fun, I guess, in the world of clinical pharmacy, but it's really important because if a patient can't access their treatment due to high cost, then that treatment that may be the most ideal for them. If they don't have access to it, then we may have to make therapy adjustments.

So there's the financial piece of it, which is oftentimes a barrier to treatment, and then also maintaining adherence to treatment, but also from a clinical perspective setting expectations is really big for patients, helping them understand not only their therapy, but even sometimes their diagnosis and kind of putting everything together and making it make sense in their own terminology that they understand, which I think pharmacists have a really important role in that area

So, setting expectations, and then coordinating care for all of the different people involved. There's the prescriber, and there's the nursing staff, and there's insurance companies, and there's specialty pharmacies, oftentimes which are mail order, that are only available if that phone call,manufacturer support programs, and third-party financial grant programs. So, just kind of playing like traffic controller in a way and coordinating that care is really important to improve outcomes, and even more clinical from there anytime that a pharmacist can be involved in collaborating with the providers of an interdisciplinary team to make a therapy selection, that's really valuable for the patient, but it also helps promote us as clinical pharmacist and really prove our value and are in our place on the team. Helping providers identify the therapies that are most appropriate for a patient based on not only their diagnosis, but maybe there are other comorbidities, there concomitant medications, and things like that.

So collaborative practice is a hot topic and a key word helping make specific patient treatment plans based on all of the different variables that go into that decision. I think is a place that pharmacists really can play a big role and help the clinic staff and the providers and make a big impact in patient care and outcomes as well.

 How can pharmacists help manage patients through transitions of care (such as inpatient to outpatient)?

It’s hard, transitions of care and management through that is really difficult actually, because there's so many different parties involved. I think it's good to look at it is just an extension of routine care. So, for one, being just present and involved is really important, and really understanding what the different levels of care are, and remembering there's so many different types of transitions of care. I think my default is to think about a patient who is in the hospital being discharged to go home or maybe a patient who's being admitted. I'm trying to coordinate those home medications, and so I'll start kind of with those with those specific transitions.

One thing to consider for an inpatient who's being discharged to an outpatient setting, maybe they need to be initiated on a new therapy during the inpatient stay. One process to be aware of and have an understanding and really know who the primary stakeholders are and how to coordinate conversation and communication among those parties is thinking about discharge planning ahead of time, so rather than waiting until the patient is ready to go home and trying to figure out how they're going to connectmedication that they just started in the hospital.

Discharge planning in advance and starting that benefits verification and investigation for the preparation for the discharge and trying to be proactive and helping the patient access that therapy, even before they're actually discharged to go home is really important.

When we talk about outpatientpatients on the outpatient setting that are admitted to the hospital, we have to try to find a way for them to continue their home medications, and oftentimes, these specialty medications are not on the hospital formulary. So having an understanding of and being aware of the hospital systems nonformulary review process is important.

That's an area that I'm just recently becoming involved in and realizing how complicated it can be, but also so very important to help those patients in that continuation of care process, and then also, most likely, the hospital systems usually have a pathway for helping patients continue home medications within the hospital, so even if the hospital is not able to provide the medication during that stay, there may be a process to have an approval for the patient or a family member to bring in those home medications so that they can continue those throughout the hospital stay, of course, when they're appropriate.

Another important transition of care though, and this is really what I'm involved in more on a day-to-day basis is transitions from one medication to the other for maybe the same diagnosis. So that can be all in an outpatient setting. In my day-to-day, it's in our multiple sclerosis (MS) center, patients may switch from an oral medication that they've been taking at home every day, and they may need to switch to an IV infusion therapy that would be given in an infusion center. Helping coordinate all of those things and making sure that the patient is able to continue their current therapy up into the point that it's no longer appropriate. Always considering wash out period, so there does there need to be a lapse in between maybe an oral to an IV therapy or an IV to a subcutaneously administered at home medication? Sometimes we intentionally have washouts in between those therapies, but also especially within MS and some other disease states, we have to consider that if there is a lapse in therapy that's too long, it can actually increase disease activity. Patients with MS for example, can have sort of like a rebound phenomenon. We have to be really careful so that we don't allow them to have too long of a gap in between those therapies.

I think pharmacists really especially are more aware, I think, of that piece of it, even sometimes in the providers are and we can really be involved in the day-to-day details of coordinating the care with, again, the prescriber, the nursing team, the infusion center, the insurance company, financial assistance programs, and all those things to make sure that patients transition appropriately from one medication to the other.

I mentioned communication and setting expectations earlier, I am so passionate about that I can't emphasize that enough, it is so important to keep the patient at the center of the conversation, either the patient or their family member or their caregiver or their representative. It's really great if everybody on the care team knows what's going on, but if no one remembers to update the patient on where we're at and what needs to happen next, and any steps that they might need to take along that journey, then we've missed a really important piece. I practice it day-to-day or I try to practice it day-to-day and I teach strongly that patient centric decision making and communication is so important. I think that's important on the pharmacist role and how we can improve outcomes for patients, but also in any transition of care whether it's health care settings, or even just medication switches.

Aimee Banks, PharmD, BCPS, MSCS, clinical pharmacist in the Multiple Sclerosis Clinic at Vanderbilt University Medical Center, discusses the role of the pharmacists in patient care, improving outcomes, and managing transitions of care.


Pharmacists Are Essential in Managing Transitions of Care for Patients

® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Jeff Betcher, BSPharm, MBA, director of pharmacy at Mayo Clinic in Arizona, discusses how automated chemotherapy dose rounding can help decrease drug waste and cost.

What is the pharmacist’s role in an oncology care team?

 I think there are a lot of roles for the pharmacist, the oncology care team, starting with cancer screening, and prevention, also patient education with many of these newer oral oncology medications as well as the IV therapies that are available. They're also involved with guidelines, consensus-based guidelines and evidence-based guidelines, and then selecting dosing and therapy management for patients.

How can pharmacists help guide treatment and improve tolerability for patients?

I think that's a great question, especially with all the new oral cancer therapies that are available. I think much of this starts with participation in, again, evidence-based or consensus-based guideline organizations to develop guidelines, and then helping with adherence of those guidelines within your clinical practice. I think also the pharmacist can play an important role as with all medications in selecting the appropriate medication for the cancer as well as the supportive care agents that would be important to that patient. I think we strive to improve and optimize the drug therapy management plans, but also try to eliminate toxicity, minimize toxicity and financial toxicity as well.

A recent study you conducted found that implementing automated chemotherapy dose rounding can help decrease drug waste and cost. What is automated chemotherapy dose rounding?

Automated chemotherapy dose rounding is where you utilize your electronic health record (EHR) to implement guidelines that have actually been supported by different organizations like the Hematology Oncology Pharmacy Association in 2018. Dose rounding guidelines are input into the HER, and those can be standardizing dose rounding to vial size, which is many times utilized. Most centers use within a 5% to 10% of the original prescriber, original dose ordered dose, and then we go ahead and put that into the system. The rules can include dose banding, which takes a range of dosages and puts them within different bands of dosing. Then there's also we also added an additional nuance to the system where even if you were now able to save a vial and round to a vial size, we would round to the next measurable volume that was easily measured. It would minimize technician calculation errors as well as improving efficiency.

I think it can help improve patient care many ways. One, it can reduce cost to both the patient and the payer. Ultimately, that reduces the healthcare burden financially. Two, it can help improve safety within the pharmacy and the oncology unit as well. If you have multiple practitioners, nurses, pharmacists all doing these dose calculations down to very small minuet quantities, it's many times much easier if you have a rounded dose, and it makes it simpler and much safer.

What is the role of the pharmacist in automated chemotherapy dose rounding?

I think there are multiple cheers to that. I think early on the role is to get the protocol to see the vision put together and implement a team and then get buy in from the provider group as well as the nursing group that you're working with at your institution. Second is to have the right subject matter experts at the table, so you're compounding pharmacist, you're compounding technicians. They're very important to help you decide what those dose bands could and should look like as well as what the next safest volume would be as far as the rounding protocol. Then the pharmacy informaticists is key to being able to develop this within the medical record so that it presents the dose rounded for the physician so that then it's easy for them to apply that to the plan. I can't overemphasize the importance of having the subject matter experts and the informaticist involved with this process.

Jeff Betcher, BSPharm, MBA, director of pharmacy at Mayo Clinic in Arizona, discusses how automated chemotherapy dose rounding can help decrease drug waste and cost.


Expert Discusses Automated Chemotherapy Dose Rounding

® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Tina Saleh, PharmD, PGY1 specialty pharmacy resident at the University of Illinois Hospital and Health Science System, discusses how oral anticancer agents differ from infusions and how pharmacists can improve tolerability for patients.

How are oral anticancer agents different from infusions in terms of tolerability for patients?

 Oral and infusion anticancer agents both have a lot of toxicities associated with them. In general, with the infusion anticancer agents, a lot of those have more acute toxicities because they're getting a bolus dose, they might have infusion related reactions.

With the oral anticancer agent side effects, they might be a little bit slower to come on. but there's also a lot of toxicities with the oral meds, and there's financial toxicity. So, a lot of the copays of those medications can be in the 1000s, and so we have to do a lot of work to get them grant assistance and find them funding to help with that as well.

How can a pharmacist help to improve the tolerability of these agents for patients?

 I think the 2 biggest roles here that pharmacist play are, first, education, so before the patient even starts to medication, we give them so much information about the side effects and how they can manage those side effects. We're also making sure that they have supportive therapy with them. With any time we dispense an oral anticancer agent, we're always making sure that they might need an anti-diarrheal or anti-emetic, and we make sure we dispense those as well and educate the patient on how to use those. We give them all the tools to manage any side effects that may come up.

How can a pharmacist within a health system’s specialty pharmacy effectively communicate with physicians to achieve optimal patient outcomes?

 Being a health-system-based specialty pharmacy, we have a lot of systems in place that help us to directly communicate with the whole medical team in the cancer center. We're able to contact them via our EMR or via telephone or face-to-face, and then we use that communication to let them know of any issues that come up because every time before we dispense a medication each month, we're looking at their labs, we're making sure that they are not having any acute visits in between their clinic visits. Anytime an issue comes up, we're able to let the doctors know and then maybe adjust the medication or dose or things like that.

How can pharmacists help manage or improve adherence with these oral agents?

 Being a specialty pharmacy, we're calling the patient each month and even if they miss 1 dose, we find out, and then the pharmacist can call a patient and counsel them and find out if it was due to forgetfulness, so maybe they'll need a pillbox, which we can send them or a phone alarm. If it was due to a side effect, we can make sure that they have the correct supportive therapy that goes along with that.

Can you speak to the growing importance of oral anticancer drugs, particularly during the pandemic?

 I think over the past couple of decades, there's been a huge shift towards oral anti-cancer agents. The future of oncology is definitely oral medications, and then, in terms of the pandemic, it was really great because patients didn't have to come into their clinic visits to get the infusion every few weeks, they were able to start their oncology medications from the comfort of their own home. So that was a big help.

Why is pharmacist intervention important, especially in hematology and oncology?

 I think pharmacists play a vital role in the hematology and oncology space. Physicians will diagnose and they treat, but we have a huge role in making sure that they're on the correct medication, making sure that they know how to take the medications correctly, that they're not having any side effects, that they're adherent, so I think being a specialty pharmacist in oncology, we have a pretty significant impact in those patients and their entire chemotherapy regimen.

Tina Saleh, PharmD, PGY1 specialty pharmacy resident at the University of Illinois Hospital and Health Science System, discusses how oral anticancer agents differ from infusions and how pharmacists can improve tolerability for patients.

Pharmacists Play Essential Role in Tolerability for Patients on Oral Anticancer Agents

® at the American Society of Health-System Pharmacists Summer Meetings and Exhibition, Angela Livingood, PharmD, MHA, BCGP, CPHQ, diversion specialist at Novant Health, discusses what drug diversion is and why it is important for pharmacists to be aware of it.

 What is drug diversion and why is it important for pharmacists to be aware of it?

 drug diversion is the hijacking of medications from its intended use through the medication use process from the manufacturer to the ultimate use or the patient. It can occur anywhere within that process from transport and delivery to the facility to receiving it within the facility to waste. Manipulating the waste process after preparing a dose for patients, so anytime that the drug does not follow the path predicted is drug diversion.

It's important for pharmacists to be aware of because we are the ultimate professional group responsible for how medications are used and stored and secured within institutions, and we carry that responsibility, and it is a high one. We hold many permits related to the management of medications particularly controlled substances, or we are the powers of attorney for the ultimate executive leader that holds that responsibility, and that's a high trust environment that we work in. So, the responsibility is great in making sure that we know where the medications are and what's being done with them.

Also accrediting organizations expect that pharmacist and technicians play a key role in medication management and we are responsible for maintaining those standards, as well as any regulatory agency will be looking to us to have a key role in preventing diversion as well as detecting it.

 How does drug diversion differ in a hospital setting compared to a retail setting?

 Great question because diversion can occur anywhere in any practice setting. So, in an institution like a hospital acute care facility, regardless of size, typically diversion is because the diverter or the teammate taking those medications is planning to use it for personal use, for personal treatment of some condition that they feel they have, or they may actually have a diagnosis of. In smaller cases, it may be that they are going to divert those medications from the patient to use to treat a family member, close relatives, or friends.

In the retail setting, however, most likely, the reason for diversion will be for resale in an alternative market. Not that there cannot be diversion in a retail setting for your personal use nor that resale does not happen in an acute care setting, but that's the key difference institutions where diversion occurs, it's typically for personal use, and in retail, it's typically for resale.

 What are effective ways at monitoring inventory, especially with controlled substances?

 Knowing your inventory, limiting access to who can manipulate those inventories, creating redundancy so you do not have the same people ordering and receiving your inventory, and appropriate witnessing of all functions that require interventions with medications particularly controlled substances. On delivery, making sure that there is a witness to watch the pharmacy teammate receive into the floor stock or into the automated dispensing cabinets, and then checking the reports that you have in your vault, whether it's a manual perpetual inventory or whether it is through some technology. With automated dispensing cabinets that you have, it's monitoring those reports to look for any discrepancies that may appear and that cannot be resolved.

 What are some methods pharmacists can take to prevent drug diversion?

 Number 1, let your teammates know that you do have a drug diversion program and that it's not meant to be a “gotcha.” It's meant to protect patient safety as well as teammates safety. Leverage whatever reporting aspects you have at your facility through your automated dispensing cabinets and pharmacy storage devices, or if it's a manual process, make sure that you're reconciling what you receive with what you give out and what is allotted for patient use, chart review, and use auditing.

Also consider if you are able to have a drug diversion specialist on staff that has training and has developed skills to look for abnormal patterns of use. Finally, it's a team approach. So, listen to your teammates on the frontline for any complaints or gut instincts that they have, and have a good working relationship with your nursing leadership and nursing partners as well as your security or company police. If you have the luxury of having that at your institution, those partners are invaluable in our attempts to prevent drug diversion.

 How can the prevention of drug diversion bring awareness to the opioid pandemic?

 drug diversion prevention programs ensure that the medications obtained by facility follow the medication use process that is expected and that keeps opioids and other substances that could be misused off the streets and out of the public.

Also, drug diversion prevention programs work hand in hand with opioid stewardship programs to make sure that the appropriate amounts of opioids are being prescribed and utilized by our patients and available to their caregivers, so that we minimize the amount of medication available to the public, not as a means of not controlling pain or treating a disorder but just not having extra available that could be tempting to people that have illicit uses in mind.

Angela Livingood, PharmD, MHA, BCGP, CPHQ, diversion specialist at Novant Health, discusses what drug diversion is and why it is important for pharmacists to be aware of it.


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