Fred Gebhart

Immunization is one of the most familiar pharmacy clinical services; approximately 77% of community pharmacies offer flu vaccines and 73% provide other immunizations, according to the National Community Pharmacists Association (NCPA).

 All 50 states have had authorized pharmacists to immunize patients in some form since 2010, but promoting such services also is necessary to achieve results.

“People don’t often come in out of nowhere asking for flu vaccine or a shingles shot,” said Beverly Schaefer, RPh. “You need to start the conversation.”

Schaefer has been starting immunization conversations at Katterman’s Sand Point Pharmacy in Seattle, Washington, for more than a decade. She is co-owner and evangelist-in-chief for a program that delivered over 4000 influenza immunizations from September 1 to October 10, 2020, even amid store closures for Sundays and Labor Day weekend.

Promoting immunization services is more about generating questions and providing information than about selling, she said. Something as simple as a countertop card asking “Have you had your shingles vaccine yet?” can be highly effective. Patients see the sign while they’re doing something else, such as having a prescription filled, asking a question, or looking for an OTC product, Schaefer explained.

“If they know about shingles vaccine, they think, ‘Oops, I need to get that done,’ ” she said. “If they don’t know about it, they ask what it is. Either way, you started that first conversation that leads to immunization. And because they asked the question, you’re providing information they can use, not trying to sell them some product they may or may not want.”

The scenario is different for severe acute respiratory syndrome coronavirus 2 vaccines. The coronavirus disease 2019 (COVID-19) pandemic itself is starting vaccine conversations around the world.

“Vaccine demand greatly exceeds supply right now,” said John Vinson, PharmD, CEO of the Arkansas Pharmacy Association. Community pharmacies have been the primary distribution point for COVID-19 immunizations in Arkansas since the first doses were delivered in late December 2020.

“Anytime demand greatly exceeds supply, you don’t have to do a lot of marketing,” Vinson said. “But you do have to do a lot of planning to get that vaccine into as many people as possible, as fast as you can.”

Planning is part of any successful immunization program. Under normal circumstances, state laws and regulations govern pharmacy immunization programs.

“Some states have [been] pretty liberal with vaccine authority,” noted John Beckner, RPh, NCPA senior director of strategic initiatives. “Others are still pretty restrictive, whether it’s limited pharmacists to certain vaccines or certain age groups.”

Pharmacists must tailor their immunization programs to meet state requirements. That could mean not providing pediatric immunizations or only providing select vaccines such as influenza, shingles, or measles-mumps-rubella.

In Wisconsin, however, changes to the state pharmacy act that took effect in early 2020 allow pharmacists to prescribe and administer any vaccine approved by the FDA as recommended by the CDC. Pediatric vaccines must be reported within 7 days.

Wisconsin’s broad immunization authority was no accident. The Pharmacy Society of Wisconsin (PSW) actively promoted pharmacy-based immunization—first with other providers, then with state legislators and regulators—to expand vaccine access.

“We worked with other health care providers to expand immunization authority for pharmacists and to get more patients into pharmacies to get vaccines,” said Sarah Sorum, PharmD, PSW executive vice president and chief executive officer. “It started with a formal survey that documented what we knew, that other providers recognize pharmacists as fully competent to provide vaccines, and that pharmacists are more accessible than any other providers. We went to the state as a group saying that better vaccine uptake is better health care regardless of who administers it. Easy access makes pharmacy an easy immunization choice for patients everywhere.”

COVID-19 gives pharmacies nationwide similar authority. The US Department of Health & Human Services (HHS) promulgated rules under the Public Health Emergency (PHE) Declaration allowing pharmacists to administer any FDA-approved vaccine. While the PHE continues, HHS rules override state regulation to give pharmacists broad immunization authority.

“Pharmacy is taking on a much more active role making sure that children as well as adults aren’t falling behind in their immunizations,” said Michael Hogue, PharmD, FAPhA, FNAP, president of the American Pharmacists Association and dean and professor at Loma Linda University School of Pharmacy in California. “And with kids, pharmacists are strengthening their connections to pediatricians to refer for developmental checks and well-child visits that are usually tied to childhood immunizations. That’s the kind of thing too many people don’t realize pharmacists are doing.”

 Many pharmacists have been too busy providing immunization services to talk about it.

 “Pharmacists get into this business to help people, to serve our patients,” said Hannah Fish, PharmD, NCPA associate director of strategic initiatives

. “We don’t always remember that we have to promote ourselves and our services to better care for patients.”

 That’s where sparking that initial conversation about immunization matters. Countertop signs can start the conversation for patients who are already in the pharmacy. Sidewalk signs are just as effective at bringing in drive-by traffic.

“They don’t suddenly swerve into the parking lot asking for a shingles shot or FluMist,” Schaeffer said. “But when you see that sign every day when you drive by, it has a cumulative effect. One day people stop in and the conversation starts.”

Word of mouth and social media can be more effective over a broader area. Schaeffer used Twitter to spread the word about appointment-only flu vaccinations. The problem wasn’t publicity, but staff time.

It takes at least 10 minutes to enter new patient information for an influenza vaccine. That’s no problem for the occasional walk-in patient, but for 4000 new flu vaccine immunizations, 10-minute periods add up. Schaeffer expects to administer 7000 to 10,000 COVID-19 immunizations during the next few months.

“That kind of time takes some modification to workflow,” she said. “When you start promoting immunizations and ramping up your program, you have to take staff time into consideration.”

 Pharmacies nationwide should be preparing to modify their workflow for COVID-19 immunizations, talking with patients about vaccines in general and COVID-19 in particular.

 “Community pharmacies are the key distribution point for COVID-19 vaccines for the CDC,” Hogue said. “They are expecting that community-based pharmacies will pick up the yeoman’s work in administering vaccines in local communities. Having adequate staffing is going to be key to success in this.”

Trust and information are also key. Vaccine misinformation has been growing for years, noted Anna Dopp, PharmD, senior director of clinical guidelines and quality improvement  for the American Society of Health-System Pharmacists.

“Pharmacists are already the most trusted voice with patients,” Dopp said. “Vaccine choices often come down to a one-on-one interaction between the patient and the pharmacist. That relationship, that trust, will likely be the driver for someone to access care and get a vaccine from there. And pharmacists are available. We have the flexibility to meet people wherever they are.”

Arkansas pharmacies are adapting familiar onsite clinic models to promote and deliver COVID-19 vaccines. In the initial rollout to long-term care facilities, community pharmacies vaccinated 100% of residents and staff within 72 hours, Vinson reported. Similar on-site delivery by chain providers in the state took about 30 days.

Immunizing about 300 million individuals against COVID-19 could be the beginning of greater pharmacy involvement. State and national pharmacy groups built on the success of pharmacy-based novel influenza A (H1N1) vaccines to expand immunization authority for pharmacy. COVID-19 could provide a similar boost.

“COVID-19 is absolutely transformational for the profession,” Vinson said. “Pharmacists are not only the prescribers of the vaccine, they’re also the educators, counselors, and providers. Protection from this deadly virus will elevate the status of our profession.”

NCPA releases 2020 digest report. News release. NCPA. October 19, 2020. Accessed January 8, 2021. 

https://ncpa.org/newsroom/news-releases/2020/10/19/ncpa-releases-2020-digest-report

Articles

Pharmacists can employ several strategies to enhance these programs. 

Promote Immunization Services More Effectively

Telepharmacy began as a pilot project to bring pharmacy services to rural North Dakota communities too small to support a fulltime pharmacist. Two decades later, telepharmacy is an everyday reality across the country. The concept remains the same: a pharmacist in one location provides services electronically to patients in another location. But pharmacists, providers, patients, prescribers, payers, and regulators are all recognizing the benefi ts that virtual services can bring to pharmacy

There is a wide spectrum of needs that telepharmacy can meet, according to Adam Chesler, PharmD, MBA, the director of regulatory and legislative a­ airs for Cardinal Health and former vice president of operations at TelePharm, an early telepharmacy technology provider. Cardinal acquired TelePharm in 2016 and is now among the largest telepharmacy technology providers in the United States.

Do you have a deaf patient who needs an American Sign Language consultation? How about freeing up pharmacists for clinical activities or to spend more time on immunizations? Telepharmacy does all that and more, and can be further used to:

• Balance work load across multiple pharmacy locations 

• Open an urban location that seems unlikely to support a pharmacist 

• Take over an independent pharmacy whose owner is ready to retire 

• Provide pharmacy services inside a physician practice or clinic 

• Consult with patients who can’t leave home 

• Bring pharmacy services to disaster relief and homeless shelters

“We have seen a surge in remote consultation, especially during COVID-19 [coronavirus disease 2019],” Chesler said. “Patients needed telepharmacy more than ever when physician offices were closed and pharmacy was the only place to get any kind of access to care. The reality is that we can have a pharmacist just about anywhere to get questions answered on prescription or OTC medications, get an interactions check, adjust therapies for patients, [or] verify a product before dispensing. Telepharmacy puts pharmacists in the cloud. That means they can be anywhere that you ever wanted a pharmacist to be.”

Devin Trone, PharmD, took a familiar route into telepharmacy. He used telepharmacy out of one of his Medicap Pharmacies in Meridian, Idaho, to provide remote services for a new store in Garden Valley, a rural mountain town about 50 miles away. Pharmacy technicians in the new store took care of customers, while a touchscreen video link brought in a pharmacist as needed to check prescriptions before dispensing, provide consults, and answer patient questions. 

“It didn’t take us long to realize we could use the same telepharmacy system as part of our quality control workfl ow for all our prescriptions,” Trone said. “We have 4 locations, so you know that some aren’t as busy as the others. Instead of having scripts back up on the busier location, why not use telepharmacy to distribute the workfl ow? Putting all of our pharmacists in the cloud helps keep any one pharmacist from getting overloaded. Telepharmacy gives pharmacists more time with patients and cuts wait times at all of our locations.”

With 4 stores, Trone has at least 3 pharmacists in the cloud during all open hours. But even the smallest location doesn’t depend entirely on telepharmacy. All 4 locations have a pharmacist physically on site at scheduled times. It helps remind patients that there really is a pharmacist available, he explained. And there are some services, such as immunizations, that can only be provided in person.

What can be done virtually and what must be done in person depends on the state, Trone said. In Idaho, technicians who have completed a certification program may provide immunizations under the supervision of a pharmacist, which can be done virtually. But in Oregon, for example, where Trone also has a pharmacy, immunizations can only be administered by pharmacists.

Telepharmacy is also an easy route to growth. Taking the pharmacists out of the local workflow and putting them in the cloud removed them from the physical dispensing flow. What no one had recognized is that they had been doing part of the technicians’ jobs as well as their own.

“When we put our pharmacists in the cloud, we discovered that 40% to 50% of their time had been spent on mundane things like stuffing bags, stickering, applying labels,” Trone said. “Working in the cloud helps them focus on pharmacist-only activities. We could easily add another 500 prescriptions a day without making our pharmacists work harder. We will be able to continue growth without over taxing or adding pharmacist labor.”

NuCara focuses on rural, small-town health care with pharmacies in Illinois, Iowa, Minnesota, North Dakota, and Texas. The company looks at telepharmacy as a tool to improve patient care and extend the reach of pharmacists. But instead of relying entirely on virtual services, NuCara is developing a hybrid model that combines telepharmacy with in-person pharmacist services to provide the best of both.

“We had the second pilot telepharmacy in Iowa, a little town called Zearing, population 500,” said Brett Barker, PharmD, vice president of pharmacy at NuCara Management Group. “When we got into telepharmacy, we were looking at the majority of rural independent pharmacies in the Midwest being owned by pharmacists in the later stages of their career. They wanted an exit strategy, but they didn’t want to abandon their communities. Telepharmacy can meet both those goals.”

The obvious approach is to take over an existing pharmacy from the retiring owner and convert directly to telepharmacy operations, Barker continued. But telepharmacy also offers more options and more flexibility. Some rural pharmacists had cut their operations to half-days, whereas others split their time between retail operations and the local hospital.

A town of 500 may not be able to support a full-time pharmacist, Barker said, but there is no lack of demand for pharmacy services. A small medical clinic in Zearing had a call list of 3 dozen pharmacies that patients used that were within a 60-minute driving radius.

Few patients were using any one pharmacy consistently, Barker said. Which pharmacy they used for which prescription depended on where they had to go that day or week. And if they didn’t have to go to a larger town, they may not have filled a prescription at all.

“What we were seeing was patients using a combination of mail order, whatever happened to be in prescribers’ sample closets, multiple pharmacies, and maybe not getting to a pharmacy at all,” he explained. “And that’s definitely not better. Telepharmacy can bring all those prescriptions to 1 place, with 1 pharmacist or 1 group of pharmacists looking at them all. And even if you don’t have a pharmacist in town every day, you have technicians who know the patients who can oftentimes identify problems they can refer to the pharmacist.”

However, the flexibility that telepharmacy can provide is not a panacea, he continued. A live pharmacist in the pharmacy is still the gold standard for pharmacy practice, but that isn’t always economically viable. Telepharmacy gives patients and providers options they might not have had before.

“Obviously, there’s a learning curve for patients and prescribers,” Barker said. “But people grasp the concept immediately, especially with the broad push for telehealth services during COVID-19. We also train our technicians to walk patients through the process because there are people out there who have never used a touchscreen device before. Patients get so used to remote counseling that they walk right up to the station expecting to use it. It’s a surprise on days when we have a pharmacist on site and they can talk to the pharmacist in person.”

“The hybrid telepharmacy model maintains a pharmacist in those locations at least part of the time and pharmacy services all the time,” he continued. “Too many people think ‘all or nothing’ when it comes to telepharmacy. Just like there’s a spectrum of pharmacy services, there’s a spectrum of telepharmacy. If there’s an unfilled need for pharmacy services, there’s a good chance telepharmacy can help fill that gap.”

Telepharmacy brings patient services anywhere. 

Putting Pharmacists in the Cloud

A daily fixed-dose combination polypill with 4 common cardiovascular medications can reduce the risk of primary cardiovascular disease by 21%, according to new research. Adding daily low-dose aspirin reduces primary cardiovascular risk by 31%. 

The polypill used in the study cost about $0.50 per dose per day, said Salim Yusuf, MD, DPhil, professor of medicine, clinical epidemiology, and biostatistics and director of the McMaster University Population Health Research Institute in Hamilton, Ontario, Canada. He said large-scale production could cut cost to as little as $0.10 per dose per day.

“If even half the people who were eligible took this polypill-aspirin combination, we could prevent 3 to 5 million people from getting a heart attack or stroke, or dying from heart disease or stroke every year,” Yusuf said. “Polypill could be used very effectively to reduce the impact of cardiovascular disease in every part of the world, rich or poor.”

The International Polycap Study-3 (TIPS-3) is the largest trial ever of a quadruple fixed-dose combination to prevent cardiovascular disease. The polypill includes thiazide 25 mg, atenolol 100 mg, ramipril 10 mg, and simvastatin 40 mg taken once daily.

The trial compared polypill, 75 mg aspirin, and polypill plus aspirin with placebo in 5713 participants across 9 countries for 4.6 years. The trial was planned to run for 10 years with 7000 participants, but supply problems and the coronavirus disease 2019 (COVID-19) pandemic cut the program short.

“You see these people in your clinic or pharmacy every day,” said Prem Pais, MD, professor of medicine at St. John's Research Institute in Bangalore, India.

“They were all middle-aged, men 50 or older, women 55 and older. They all had at least 1 risk factor for cardiovascular disease—overweight, high blood pressure, elevated cholesterol, elevated glucose or diabetes, smokers. But no one had any known cardiovascular disease. This was about primary prevention, reducing the risk of that first cardiovascular event. ”

At least a half-dozen companies sell polypills outside the US, Pais noted. But they are not widely used because there have been no large, international studies showing that they actually reduce heart attack, stroke, and death. Prior studies looked at surrogate markers such as blood pressure, not clinical events.

“I think this will change our practice,” Yusuf said.

Results of TIPS-3 were presented at the American Heart Association Scientific Sessions and published simultaneously in the 

The trial was complicated by logistical delays in manufacturing and distribution as well as access interruptions from COVID-19 closures. Pais noted that nonadherence was high, 43% by the end of the study, but only 5% of nonadherence was due to adverse effects.

There was no difference in gastrointestinal bleeding between the aspirin group and placebo and there were more serious adverse events in the placebo group than in the polypill group.

The primary results of the trial that made headlines were based on an intent-to-treat analysis, which includes everyone enrolled in the trial, even if they could not get the drug or placebo. A subanalysis of participants who had less than a 30-day interruption in supply showed 45% lower risk for primary cardiovascular events with the polypill plus aspirin versus placebo.

“This first-generation polypill is not magic, but it would be clinically worthwhile,” Yusuf said. “In the future, there will be polypills with greater cholesterol reduction, greater reductions of blood pressure. And my guess is that they will have a greater effect on reducing first cardiovascular events.”

The study was funded by the Wellcome Trust, Cadila Pharmaceuticals, an Indian polypill maker, and other research organizations around the world.

1. Yusuf S, Joseph P, Dans A, et al. Polypill with or without aspirin in persons without cardiovascular disease. 

“This first-generation polypill is not magic, but it would be clinically worthwhile.”

Fixed-Dose Combination Polypill Reduces Primary Cardiovascular Disease Risk

Cannabidiol (CBD) may be the biggest business booster pharmacy has seen in years. Statista forecasts $1.9 billion in CBD sales in the US by 2022, up from $535 million in 2018.

said Tim Gregorius, RPh, vice president of operations for PRS Pharmacy 

Services in Latrobe, Pennsylvania.“There are drug interactions, there are [adverse] effects, there are dosing considerations. The clerk at the gas station 

and the nice lady at the convenience store should not be selling CBD. CBD belongs in a pharmacy.”

Don’t try to compete on price, warned Mike Bellesine, RPh, owner of El Dorado TrueCare Pharmacy in El Dorado, Kansas.

“You can buy CBD from any smoke shop, from Amazon,” he said.“ We have brought our prices down somewhat, but we focus on the professional aspect. We are the CBD specialists.”

Pharmacists can build financial suc- cess with CBD around 3 elements:

Pharmacy regulations for CBD products vary by state.

California, for example, does not explicitly permit sale of ingestibles in pharmacies, said Ken Thai, PharmD, chief executive officer of K & B Pharmacy Associates in Los Angeles.

“We used to carry a full line of CBD products in our stores, but have cut back 

to topicals because state board inspectors are inconsistent. Some are fine with gummies and tinctures, some are not.”

Some CBD products also contain THC, which may not be noted on the product label. Kansas allows up to 5% THC in CBD products, according to 

Bellesine. Still, employers can terminate employees who test positive for THC. Bellesine uses only manufacturers that certify their products contain no 

THC, then sends samples to a local lab for confirmation.

“The only acceptable level of THC for us is 0,”Bellesine said.“Our suppliers know it, our customers know it, their employers know it. That has brought a lot of customers to our doorsteps.”

PRS also screens manufacturers. Products can be sold only to pharmacies or similar health care outlets, and packaging cannot carry mari-

juana leaves or similar deceptive elements. All products must be free of THC, certified by the manufacturer and a third party certificate of analysis, then veri

Judy Leventhal, president of Leventhal Productions in St. Louis, Missouri, spent 3 years hammering out advertising guidelines with TV networks and streaming services. Leventhal is the only advertising agency devoted exclu- sively to independent pharmacies.

”Essentially, we can’t show products, we can’t talk benefits,”she explained. “What we can do is position the pharmacist as the CBD expert and education resource. This can be tremendously effetive, especially with older audiences.” The most successful CBD marketing focuses not on patients and customers, but on prescribers. Pharmacists can be the go-to source for CBD information, just as they are for drug information.

“We advise focusing on prescribers in town,” Gregorius said.“Tell them about your CBD knowledge and your certified THC-free products.”

Bellesine’s only CBD pitch is to local physicians. Window signs and sandwich boards advertise his THC-free product lines. Inside, products are arranged on clear shelves behind a plastic barrier that separates a technician line from the rest of the store.

“Customers can see product clearly, but they have to ask for it,” he explained. “That gives us an easy opening to talk about how CBD might help. That kind of low-key, in-store positioning is cheap, easy, and it works.”

Patients are bombarded by a bevy of purported benefits, but pharmacists may not make therapeutic claims.

“I can’t tell you that CBD is a sleep aid,” Bellesine said. “But I can tell you that other customers have told me that it helps them sleep better. And I can tell them that CBD doesn’t work for everyone, but this is what it did for me.”

CBD price may be an issue for some customers. Bellesine offers 2 options.

One is a high-dose formulation, cheaper per use but more costly at the register. The other is a low-dose formulation, which is cheaper at the register but more expensive per use.

“If CBD doesn’t help, they’re not out a lot of cash with the low-dose choice,” he said.“And if it does work, they come back for the higher dose bottle to save money. Either way, I’ve helped my customer.”

Tips for building financial success with CBD for your pharmacy.