Greater Health Care Lessons for Pharmacy and Beyond in the COVID-19 Crisis
The COVID-19 pandemic shows that pharmacists can serve as nationally recognized providers and can contribute greatly to policy as it pertains to disease management, outbreaks, and workplace safety.
As we all can attest to in one way, shape, or form, the coronavirus disease 2019 (COVID-19) pandemic has challenged us as individuals and professionals. COVID-19 has upended our daily routines, how our society operates, and has certainly tested the readiness of our health care system—from the smallest of outpatient clinics to the largest of hospitals.
Although we are still in the midst of the crisis, of which there is no precedent, it is fair to reflect upon and acknowledge the various health care lessons of the coronavirus shutdown and what we can learn from this situation to prevent or mitigate dangerous outbreaks in the future, hopefully saving lives in the process.
We cannot bring back those who have tragically died as a result of COVID-19. But we can at least try to reduce the risk of future fatalities by addressing patient access to preventative measures and care; how and where they can access these services; and how pharmacists can play a large role in implementing newer, non-traditional patient care methods that were once seen as unconventional, but are now more appropriate than ever before in light of COVID-19.
It may not seem like it now, but among the chaos caused by COVID-19, there are many silver linings and important lessons to be learned, especially as it pertains to patient care and potential creative solutions in pharmacy. Pharmacists can play an integral role in implementing such solutions and can help spearhead programs, business models, and policies that have broader patient outreach, which can hopefully lead to better outcomes. Implementation and continuation of these programs, models, and policies can help bring our profession closer to what it was originally intended to be: nationally recognized providers.
Below is a list of potential options that may be adopted to further the scope of pharmacy practice, provide different avenues of care, and improve workplace and patient safety. It may not turn into a be-all, end-all to the crisis; however, at a minimum, it will hopefully spark a conversation among pharmacists as it pertains to decision-making and the tailoring of policy.
Here are just a few ideas on how we can apply the expertise and skillsets of pharmacists to the current COVID-19 situation and the following reassessment phase:
Potential expansion of telehealth within the bounds of HIPAA, of course, to respect patient privacy rights. Telehealth can help address both minor and intermediate health concerns, and help providers make appropriate referrals and recommendations, if necessary.
Patients can access a provider through appropriately vetted, encrypted digital health applications, and can receive medication counseling or other forms of care. For example, a patient can describe their symptoms or adverse effects (AEs) while the pharmacist assesses signs of illness or potential signs of AEs through the application.
The pharmacist can then make a recommendation or referral. The use of an official user app, however, is not the only example of telehealth. In fact, basic telephone conversations between the patient and practitioner can be used. Practitioners can type their written notes within their own electronic health software that operates by their own facilities’ server and firewall protection if there are concerns about privacy, which is becoming an increasingly more relevant discussion as it pertains to personal device use regarding telehealth during COVID-19.
In that type of scenario, the provider can also keep the hard copy notes as well as a hard copy log. That way there is no transfer of information into a telehealth application and, therefore, can remain compliant with HIPAA so long as it is disposed of properly once done.
Telehealth may also provide a unique platform for remote medication therapy management and can provide a more personal service or personalized medical attention to regions where direct in-person care may be more difficult to access. From a generalized perspective, telehealth can serve as a conduit for regions of the country that do not have immediate access to a health care professional, while also maintaining the integrity of one-on-one discussions between the patient and provider.
So, whether it is a specially-designated digital application or just a video or telephone conference followed by notes, telehealth can help meet the needs of patients that would’ve otherwise been blocked from care. Many states in which in the process of recognizing telehealth as an appropriate route of health care and COVID-19 has only accelerated that process. Hopefully this trend will continue or maintain momentum, considering that these services were well overdue even prior to COVID-19.
AMBULATORY CARE EXPANSION
A more rapid implementation of the clinic/community pharmacy hybrid model (similar to the model presented during the CVS Health/Aetna merger) can better use pharmacist education and training while providing important services to communities. A type of expanded clinic/pharmacy that allows pharmacists to provide ambulatory care services in a typical retail setting can assist in treating chronic disease while other facilities focus their attention on acute illnesses, as in the case of COVID-19. This model can avoid placing an additional strain on acute or emergent care facilities.
The adoption of an improved and more expansive clinic/community model mentioned above can facilitate the expansion of point-of-care (POC) testing services available within these new clinically oriented community pharmacies. In turn, this can provide opportunities for pharmacists to help the patient obtain critical information that can facilitate access to appropriate treatment and better health outcomes. Expanded POC services and the subsequent results can also help foster health education services for patients who show risk factors for certain disease states, such as high blood pressure, high cholesterol, diabetes.
ANNUAL WELLNESS VISITS
A wider embrace and greater use of Medicare’s Annual Wellness Visits (AWV) may even be incorporated into the hybrid clinic/community pharmacy format. The Medicare AWV is possibly one of the most underutilized billable services that pharmacists can provide, yet it is among the most comprehensive services that can be offered by pharmacists to screen patients for major disease states upon enrolling in Medicare. Pharmacists who conduct the Medicare AWV can help determine underlying disease states, such as those mentioned above, all of which have demonstrated to be risk factors for poorer outcomes when these patients are exposed to infectious diseases, such as COVID-19.
There is also a case being made for expansion of the pharmacist’s role in preventative medicine, including furnishing of medication in emergency situations pertaining to both non-infectious and infectious diseases. There are already some examples of such responsibilities.
In California, for example, pharmacists are allowed to furnish post-exposure prophylaxis to patients who have had exposure or suspected exposure to HIV. The Department of Veterans Affairs (VA) system has also set the precedent in many ways as it pertains to pharmacist responsibilities. The VA system allows pharmacists to order labs—could such responsibilities be granted in the clinic/community pharmacy hybrid model?
A case is now made for collaboration with the American Medical Association to determine and delegate billable responsibilities (CPT codes) that have not yet been associated with pharmacy in order to relieve physician overburden. There is a potential that this will allow pharmacists to better assist in rural and overloaded nonrural areas alike in the hope of meeting community needs without necessarily having an individual collaborative practice agreement with a physician.
All the aforementioned services can be billable under an issued CPT code, which are copyrighted by the AMA and can thus be billed outside a collaborative practice agreement. It’s important that we help our physician partners with tasks that can easily be delegated to pharmacists so physicians can focus on aspects of their profession that require more of their attention.
However, this delegation of certain responsibilities can be achieved more rapidly if there is widespread expansion of pharmacist responsibilities, notably by the AMA through respective CPT codes. This leaves a collaborative practice agreement for these widely recognized responsibilities unnecessary for services that can be extensively used by pharmacists.
IMPROVED INDUSTRIAL HYGIENE
With an increased focus on cleanliness, there has been improved industrial hygiene across all health systems and more up-to-date national standards pertaining to actual health facility design, engineering codes, and personal protective equipment (PPE). Many health care facilities need to improve their infrastructure to make their facilities more conducive to the health and safety of patients, staff, and health care professionals, which includes pharmacists.
One can think of multiple examples commonly seen in facilities, starting with wooden handrails. The wooden handrails commonly seen in hospitals should probably be replaced with metal rails, since metal has shown a degree of antimicrobial and antiviral activity.
The other example is carpet in hospital floors. Carpets are contaminated easily with dirt, dust, stains from body fluid, food, and more, which can harbor disease. I have seen this type of flooring on actual patient floors in some of the most well-funded hospitals, not just struggling rural hospitals.
A better, easier to clean, and cheaper option would be to install higher end, textured vinyl that looks like wood, is slip resistant yet durable, easy to disinfect, and is even cheaper than carpet per square foot. Another important example is the lack or complete absence of negative pressure rooms in skilled nursing facilities.
It is estimated that a large percentage of COVID-19 fatalities are from skilled nursing facilities. Negative pressure rooms can minimize the risk of spreading diseases such as COVID-19 by allowing quick mobilization of positive patients. This would provide a degree of protection to other patients and the staff, including pharmacists.
It is pleasing to see recent literature on potential ways to sterilize PPE for possible re-use in cases of a shortage. A recently published and National Institutes of Health-validated article by R. Fischer et al (2020) regarding N95 mask sterilization has shown that processes such as exposure to UV light, and vaporized hydrogen peroxide may provide sterilization of N95 masks while allowing for some extended use of this subtype of PPE.
The article had compared different methods of sterilization and was able to rank the methods in relation to how long it would take to sterilize the PPE and how many times after the sterilization process was the PPE still viable for proper use. From a hospital and industrial hygiene standpoint, something as simple as the implementation of frequent surface sterilization (not just within an intravenous admixture hood) should be part of hospital environmental maintenance policies, building code, and accreditation where applicable, especially if further studies support it.
UV light has established itself as a sterilizer by creating damage to genetic material, thus can potentially contribute to inhibition of viral replication or replication of other infectious agents, like bacteria. Hydrogen peroxide and isopropyl alcohol destroy infectious agents through oxidation and denaturation respectively, leading to structural destruction of viruses and bacteria.
Industrial hygiene does not only apply to inpatient facilities. There are plenty of options that community pharmacies can adopt in order to uphold and continue vital services to patients.
COVID-19 has increased awareness on how important it is for individuals to maintain overall health, especially with respect to available vaccines. However, social distancing and stay-at-home orders have decreased immunization traffic at retail pharmacies, putting patients at risk for other communicable diseases other than COVID-19.
Sneeze guard plexiglass has found a place in the community setting to help protect frontline workers who are most susceptible to direct-to-patient contact and can be expanded for instances in which immunizations could be offered to patients to improve the public health. These shields can be an alternative for pharmacies that do not have enough access or inventory of essential PPE.
There may be better ideas out there but we certainly cannot put patients at risk. If grocery store checkout counters and fast-food chains have invested in these vertical sneeze guards, then pharmacies should be able to do the same.
The industrial hygiene suggestions above are just a few examples that need to be part of the standardization process through OSHA and hospital building codes with regards to uniformity and implementation of higher standards within our country’s health care facilities.
When all is said and done with the COVID-19 shutdown, we will look back and see which novel strategies worked and which aspects of business, commerce, and communication are better off returning back to pre-COVID-19 days. Society’s COVID-19 response has affected every facet of life and has forced us to reanalyze what we were previously comfortable with.
The hope is to mostly return back to normalcy (if that can even be defined anymore), but in an improved version of ourselves. Innovative ideas that help reduce the risk of another COVID-19 shutdown will include an expanded role for pharmacists as part of the broader health care team.
Although COVID-19 continues to cost society greatly from an economic perspective, it has forced us to act and has the potential to boost health care by improving efficiency, streamlining access to care by perhaps also setting the groundwork for improved quality of the care. Maybe some of these ideas seem unnecessary, but to honor those affected by COVID-19 and to help our fellow health care providers, we really should start this conversation.
Pharmacy leaders should also be at the forefront of promoting a shift in how we help patients while also displaying how important it is for pharmacists to use their education more appropriately in a dynamic society. Pharmacists can fulfill roles as nationally recognized providers and can contribute greatly to policy as it pertains to disease management, outbreaks, and workplace safety. There will be dramatic changes to health care and we need to be part of the dialogue. Now is the time.
About the Authors
Yasmin Moatazedi will graduate from the Marshall B. Ketchum College of Pharmacy in May 2020.
Jonathan Ogurchak, PharmD, CSP, is the founder and CEO of STACK, a pharmacy business operations software, and serves as preceptor for a virtual Advanced Pharmacy Practice Experiential Rotation for specialty pharmacy, during which this article was composed.