The Progression of Immunization - Episode 8
ACIP Guidelines and Best Practice Recommendations
Experts in the field of immunization discuss screening and administration recommendations, with consideration of the ACIP Guidelines and APhA training program.
Troy Trygstad, PharmD, MBA, PhD: So pop quiz, ACIP stands for what?
Dorothy Loy, PharmD, MBA: Advisory Committee on Immunization Practices.
Troy Trygstad, PharmD, MBA, PhD: Well done.
Tana Kaefer, PharmD: I was going to say American.
Troy Trygstad, PharmD, MBA, PhD: What is the role of ACIPs, because you’ve won the pop quiz? What is the role of ACIP in public health? Let’s start there.
Dorothy Loy, PharmD, MBA: They’re the rule-setting committee and guidance around and really determine what the standard is for our pharmacists to provide immunizations—to what specific patients, what age ranges. They’re really the standard of our protocols.
Troy Trygstad, PharmD, MBA, PhD: You said they provide guidance, but you start with rules. Because they’re such a solid guidance-producing entity, it really becomes the rules, right?
Dorothy Loy, PharmD, MBA: Yeah.
Troy Trygstad, PharmD, MBA, PhD: For coverage, for lots of other circumstances. Then how do those recommendations flow from them to practice and policies?
Dorothy Loy, PharmD, MBA: Those are the foundation for practice, and that’s how our pharmacists are trained to practice based off the ACIP guidelines. But that does influence the payer world as well, as far as what they’re willing to reimburse pharmacies for and what they’re going to cover based on plan. That kind of feeds the rules from a pharmacist’s standpoint but also the coverage from a payer’s standpoint.
Troy Trygstad, PharmD, MBA, PhD: So A-C-I-P— they will come out with new recommendations at what frequency, typically?
Dorothy Loy, PharmD, MBA: It depends. In most cases they meet once a quarter, so they can come out as frequently as once a quarter. Sometimes there are smaller tweaks to existing immunization rules or schedules. But I would say maybe twice a year we see bigger changes for maybe wholly new vaccines or just drastic changes for certain age ranges.
Troy Trygstad, PharmD, MBA, PhD: New vaccines, new evidence, new pandemics—that’s generally the remit for ACIP.
Michael Popovich: Yes.
Troy Trygstad, PharmD, MBA, PhD: How would they affect you with decision support and data? Because you’ve kind of got to download whatever comes down the pike from this guideline producing. With it becoming the rules group, and how does it influence what you do?
Michael Popovich: They represent the standard of best practice for providing immunizations. And if a series recommendation changes—there are a lot of changes. It’s kind of a big deal. But to apply it into practice, you have to understand it, because it’s changing all the time. But what public health will do, and what we will do, is turn those rules into an online decision-support system. For the public health immunization registries, we have to update those every time there’s a change, which as Dorothy says, is probably twice a year. You’re updating the decision-support engine, so that when in fact a recommendation is being made on what the individual needs, it’s based upon the latest recommendations from the ACIP schedule. If you don’t keep that current, then you lose that opportunity to provide best-practice information back to the practitioner, or the pharmacist in this case. So it’s kind of a big deal to stay on top of it. It’s complex.
Troy Trygstad, PharmD, MBA, PhD: Yeah. So it’s a big deal. Dorothy, Walgreens has 9000 stores. How in the world, every quarter, every so often, how are you pushing that down to 9000 locations with 5 to 10 FTEs [full-time equivalents] in each 1 of those locations?
Dorothy Loy, PharmD, MBA: It really does take a lot of work to keep people up-to-date on all the different guidelines that come out. Typically, we’re training our pharmacists always, so this is a part of that training. But when there’s a major change, we really like to have an incentive for our pharmacists to really pay attention. Many times we’ll make sure that they’re taking CE [continuing education]—accredited training, so they have that incentive to review the training and understand the actual changes that are happening. Again, I think it goes back to making it relevant to them so they can make it relevant to the patient. What was the actual change? Is it significant to the patient? And how much do we need to explain to the patient about what changed and maybe why it changed?
Troy Trygstad, PharmD, MBA, PhD: And so there are workflow changes. Are those coming along with the new recommendations? “Hey, we have to change some workflow, ask a new question.” Is it an entire package that goes every single time there’s a change?
Dorothy Loy, PharmD, MBA: Every year we train all our staff on workflow and process when it comes to immunizations, because we think it’s that important. And so we do that at least once a year, and I’ll try to wrap up all the changes in immunization rules through that yearly training. But when there are drastic changes, there are changes to some of the workflow, as far as the questions the pharmacist may be asking a patient. We try to minimize all that and all the disruption to make it simple. Maybe it’s as easy as talking points for our technicians on the new standards for meningo [meningococcal] vaccine. Or making it as simple as offering that information to the patient through digital tools, so that patient can then consume the information and understand it.
Troy Trygstad, PharmD, MBA, PhD: Tell me more about some of these other things—travel recommendations, comorbidities. How are you starting to find that niche in your pharmacies? You’ve got decision support maybe that says, “Oh, I can see that they may have these conditions because of the other medications they’re on. I can see their age.” How are we going beyond, again, just the generalized ACIP guidelines, to specific targeted communications to specific populations? So for comorbidities, what does that conversation look like?
Dorothy Loy, PharmD, MBA: I think it goes back to the broader conversation with that patient around the medications that they’re coming in for and the reasons they may be at higher risk for some of these vaccine-preventable diseases. And then saying, “Hey, this is what you’re going to need to be getting, from a vaccine perspective.” And this is kind of setting the expectation that this is what the schedule may look like. So back to the point of, “Hey, maybe at the age of 65 you’ll have to come back in for your next pneumonia vaccine.” Something like that makes it easy for the patient to understand how their health condition fits into their risk for a vaccine-preventable disease.
Troy Trygstad, PharmD, MBA, PhD: So we’re moving away from, “You’re supposed to do it, so do it,” to “Here’s why, here’s the importance of it—not only for you but for your family, your coworkers—and the rationale. And oh by the way, here’s what follow-up looks like as well.” Excellent. What’s the single most important workflow you’ve implemented in your pharmacy to optimize vaccine screening and administration, Tana?
Tana Kaefer, PharmD: The screening that makes it easier for, as I’ve mentioned before, our technicians and our pharmacists to feel more confident.
Troy Trygstad, PharmD, MBA, PhD: At drop-off.
Tana Kaefer, PharmD: Yes.
Troy Trygstad, PharmD, MBA, PhD: So if you’re onboarding the patient, they’re getting their meds—here’s the fastest, easiest, most efficient way of screening, so you can have a targeted patient-specific conversation.
Tana Kaefer, PharmD: Right, beyond flu.
Troy Trygstad, PharmD, MBA, PhD: Beyond flu, excellent. Dorothy?
Dorothy Loy, PharmD, MBA: It really goes back to some of the digital tools we have. To let that patient see that information, understand maybe what some of the recommendations are before they even walk into the pharmacy, so they can bring that conversation up. Or when the pharmacist does bring it up, they know that it’s not the pharmacist just making things up but that it actually is based on some facts. I think having some of those tools available for our patients has been instrumental in making sure some of that knowledge is there beforehand.
Troy Trygstad, PharmD, MBA, PhD: We’re pretty familiar now with the APhA [American Pharmacists Association] training program. All of us who have immunized have gone through it. So it’s nice to have a universal program. It’s pretty well-established training now. If you could add 1 thing to that training as experienced immunization specialists, what would you add?
Tana Kaefer, PharmD: For me personally, I would add how to administer to pediatrics. I really would like to have that added. Because we do that for flu.
Troy Trygstad, PharmD, MBA, PhD: Sure, good point. What else?
Dorothy Loy, PharmD, MBA: I would like to add scenario role playing for our pharmacists to feel comfortable. And now there are actually technicians in certain states who can administer vaccines, so also letting them do that role play to understand how to approach a patient in the first place. Again, I think the administration a lot of people are very comfortable with. But how to approach the patient and let them know what is recommended.
Troy Trygstad, PharmD, MBA, PhD: Emily? Mike?
Michael Popovich: Things are good.
Troy Trygstad, PharmD, MBA, PhD: You take care of it.
Michael Popovich: There probably should be a focus on data and analytics, and using that.
Troy Trygstad, PharmD, MBA, PhD: Ah, sure.
Michael Popovich: You know, part of the objective of using data is to empower the pharmacists so that they have a good conversation to engage the consumers.
Troy Trygstad, PharmD, MBA, PhD: We miss that all the time, though. Right? We focus on the care, which is great; that’s natural. But it’s really care, workflow, and billing.
Michael Popovich: Right.
Troy Trygstad, PharmD, MBA, PhD: We miss the workflow and the billing part every time we educate on something, and that’s what hangs us up from providing the care. This idea of, “Where do I find information, how do use decision support and workflow as a part of those exercises?” What else? What other training gaps are out there?
Michael Popovich: Oh, there are going to be training gaps. All we have to do is ask the patient. You know, when you come in.
Troy Trygstad, PharmD, MBA, PhD: So there’s an aspect of motivational interviewing?
Michael Popovich: The social engagement kind of aspects.