Telepharmacy is on a roll. In 2001, when North Dakota became the first state to enact regulations allowing the practice.

 By early 2023, 28 states will allow some form of telepharmacy, and Kansas is poised to finalize regulations later this year, according to telepharmacy services provider TelePharm. Approval is advancing in other jurisdictions as well.

“Through the pandemic, there has been a drastic uptake in technology, especially remote technology,” said Brett H. Barker, PharmD, vice president of operations for NuCara Pharmacy, which operates physical stores and telepharmacies in Illinois, Iowa, Minnesota, North Dakota, and Texas. “I think we jumped forward a decade in about 2 weeks back in March 2021 with [individuals’] comfort levels, uptake, and acceptance of remote care. Telepharmacy is good for patients, good for communities, and good for pharmacists.”

Telepharmacy is also a challenge. Roughly 40% of states do not allow telepharmacy, cautioned Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists. Among states allowing telepharmacy, no two have adopted the same practice regulations.

Payers take similarly diverse approaches. Washington and some other states require commercial insurers to reimburse pharmacists on the same basis as physicians, nurse practitioners, and other health care providers. However, most states are silent on payment parity and most commercial payers still balk at paying for nondispensing services, although that could change as the profession continues to push for provider status at state and federal levels.

Medicare does not recognize pharmacists as providers, Kliethermes noted, although the program does reimburse pharmacists up to $150 per month for complex chronic care management. Medicaid reimbursement for pharmacists varies by state.

The biggest financial difference between a traditional pharmacy and a telepharmacy is the cost structure. The return on investment for a traditional pharmacy depends largely on prescription volume, front-end sales, and pharmacist costs. Telepharmacy lowers the financial bar by sharing pharmacist time across multiple dispensing locations.

According to Barker, reimbursement for remote dispensing is similar to conventional in-person dispensing. The current telepharmacy break-even point is around 70 to 80 prescriptions daily, he said, but the number varies by patient population, prescription mix, payer mix, and other familiar factors.

On the cost side, telepharmacy requires more video hardware than conventional pharmacy to facilitate real-time pharmacist monitoring and conversations, but the cost of off-the-shelf hardware is low—and falling. But best practices, and in many cases state regulations, call for off-site storage of all video and still images from both the remote telepharmacy site and the supervising pharmacist, which increases cloud storage costs.

Telepharmacy software providers typically charge an activation fee and monthly use fees, Barker added. The total cost is roughly equivalent to having a pharmacist on site 1 day per week. Telepharmacy providers should expect to pay for the best technicians available.

“You absolutely need rock star pharmacy technicians because they have a higher level of responsibility and visibility in telepharmacy,” Barker said. “You need good problem solvers who can think on their feet and you need a high level of trust. When you have a telepharmacy, the technician is the public face of the pharmacy.”

Getting paid for virtual clinical services can be as challenging as payment for face-to-face clinical services, Kliethermes said. Medicare reimburses pharmacists for telehealth complex chronic care management. One pharmacy provider, Tabula Rasa HealthCare, is being reimbursed under PACE, the federal Program of All-Inclusive Care for the Elderly, which covers frail older adults who are often eligible for Medicare and Medicaid. However, Medicare payments to pharmacists are more the exception than the rule.

“Because Medicare does not recognize pharmacists as providers, it limits reimbursement regardless of the applicable practice act,” she said. “That makes reimbursement challenging because not all of the Medicare telehealth codes are applicable to pharmacists.”

Technicians are also part of the clinical service and revenue mix. A growing number of states allow pharmacy technicians to administer point-of-care tests, immunizations, specimen collection, and other clinical services under pharmacist supervision, Barker noted.

“All of those clinical services can happen safely and effectively through the telepharmacy model,” he said. “At this point, the model is proven and works well. Telepharmacy is letting us extend the reach of our pharmacists and their clinical services. Pharmacists are delivering the same care they provide in a traditional community pharmacy; they’re just delivering it in a different model.”

Tzanetakos G, Ullrich F, Meuller K. Telepharmacy rules and statutes: a 50-state survey. 

Telehealth in your pharmacy practice. American Pharmacists Association. June 1, 2020. Accessed February 23, 2022. 

https://aphanet.pharmacist.com/sites/default/files/audience/APhACOVID-19Telehealth0620_web.pdf

Telehealth. American Pharmacists Association. Accessed February 23, 2022. 

https://pharmacist.com/Practice/Practice-Resources/Telehealth

Articles

Before the pandemic, telepharmacy and telehealth were nice ideas. Today, they’re crucial to delivering personalized care with limited in-person contact.

Telepharmacy Rising: Challenges Accompany the Growth of Telepharmacy Use

So much has changed over the past few decades in how we consume media. The advent and proliferation of social media, subscription-based news outlets, and the ubiquitous presence of the internet have created an ultrafragmented audience for anyone marketing a product or service. Amid all this “noise,” it has become increasingly difficult to know when, where, and how to get the attention of potential customers.

Do I need a website and social media, or is only one sufficient? 

The functions of a website and of social media platforms are different. Independent pharmacies should have both to ensure adequate information about the business is available online.

Which comes first? Creating a social media account is less involved but building a website allows for a compre- hensive digital storefront—a home base if you will—and provides a destination for all other messaging to point. Many free builder tools (GoDaddy, Wix, and Mailchimp, for example) provide easy- to-use templates for simple websites. Good sites will include a welcome message to visitors, bullet points on what sets your business apart from other pharmacies, contact information, a clear photo of the building, and an introduction to your lead pharmacist. Remember, people want to do business with people, not “brands.”

Once your website is in place, social media begins to serve an important function. No matter which platform you choose, social media is a terrific way to add personality to your brand and connect with your audience in a more con- versational way. Facebook and Twitter provide simple avenues to disseminate health care news and updates in a timely manner. With social media, your audience will want to talk to you. Be careful not to provide any diagnostic health care advice or individualized feedback to a patient on social platforms. Keep those conversations between you and patients inside your pharmacy.

How do I choose the right social media platform?

First, identify your customer. If you’re located in a bustling college town, you may be successful with a presence on Instagram or TikTok—but in a market with an older audience, TikTok may be an unwise choice. Most businesses should at least have a Facebook page; consumers tend to use Facebook to find simple information like store hours, location, and information on promotions. A Facebook page also provides a consistent opportunity for businesses to interact and maintain a presence with potential customers.

Identify your objective before you start. Determine what you want to accomplish in 1 year, then break that down into smaller pieces. Are you looking for new patients or customers, or would you like a higher spend in your store from existing patients? Are you hoping to expand point-of-care services or frontline retail options to generate more revenue?

Each of these goals requires a different marketing approach. Review and assess your progress toward the goal on a monthly or quarterly basis. Don’t wait until the end of the year to “pass” or “fail.”

 What is your brand promise? What sets your business apart from other pharmacies? Marketing materials must be consist- ent and include your main message. Each touchpoint with your customers contributes to your pharmacy’s unique voice in the marketplace, and this rein- forcement helps build a clear, consistent reputation across your audience.

 Build the effort into standard daily or weekly pharmacy operations. Whether you choose to do the work yourself or with staff inside your pharmacy, or you contract with a third-party marketing agency, consistency is key. Inconsistent marketing efforts are rarely successful and typically end up being a waste of valuable resources. Choose someone who has an existing interest and ability to engage in these activities regularly to handle the duties.

 Choose simple, measurable initiatives to get started. Once you get comfortable with your public messaging and learn what can be measured, expand from there. Ideally, work up to having 2 or 3 channels activated in 1 marketing campaign.

My budget is limited. How do I know this is working?

In our current age of technology, there are so many tools available to measure the effectiveness of a campaign, especially on social media. Marketers can measure clicks, views, shares, and comments to see what type of content resonates with the audience. Most marketing platforms include tools built into their systems, making these metrics highly visible and easy to understand. Once you have insight into the content that is driving the most response, it becomes easier to identify where to allocate resources most effectively.

The most cherished characteristics of an independent pharmacy are the personal service and relationships built between staff and patients. To build on this foundation, pharmacies can and should be asking satisfied patients for positive online reviews. Many consumers consult the internet before choosing to do business with a company. If your pharmacy has an abundance of happy customers recommending your store online, that is a great way to cultivate testimonial “marketing” without spending anything.

A small business should never be the community’s best-kept secret. Every marketing initiative is a conversation with 1 individual at a time, even when communicating to a much larger audience. The enthusiasm that brought you to—and that keeps you going in—the independent pharmacy space is what makes you special in your community. Communicate your passion in an authentic, consistent way and you will be primed for success.

Ginny Langbehn is director of marketing and corporate communications at American Associated Pharmacies (AAP), one of the nation’s largest cooperatives for independent pharmacies.

Cut through the online noise with these digital marketing tips for your independent pharmacy. 

Thriving in a Digital World: Marketing Strategies for Independent Pharmacies

I frequently remind my fellow pharmacists that their license hangs by a nail on the wall. It is not bolted there; if you are not happy, find yourself a new nail.

Given the current climate of community and hospital practice, I know several pharmacists who will not be looking for a new nail but who instead have given up entirely on this profession. The common thread among these colleagues is that they practice community pharmacy, but I am quite confident the same feelings hold true for my brothers and sisters in hospital pharmacy practice. (I would love to hear their stories as well.)

Each of these pharmacists’ names have been changed.

 Bob wanted to run heavy equipment, like his father. His father insisted that he go to pharmacy school, which he did. Bob graduated at the
top of his class and never worked more than a couple of hours of relief. He loved the bulldozer and the backhoe more than the computer and the counting tray. Because pharmacy was never his passion, we cannot count him among the disgruntled.

 Nate was one of my student pharmacists who had a passion for hospital pharmacy. He practiced in the hospital setting for 7 years. Of all the pharmacists who left the profession, he was truly called to a higher duty: Nate enrolled in the seminary and will be ordained as a priest in the next few years. Sometimes salary, staffing, and satisfaction do not really matter when one hears a higher calling. When we attended morning Mass together, I knew there was something special about him.

 Diana practiced pharmacy for at least 30 years at a grocery store chain. She has been less than pleased for some time with her staffing, management, and environment. She left the profession to take up her passion of baking. She opened a bakery and is extremely satisfied now.

 Donna had an excellent position as a clinical pharmacist. She shared her amazing skills with physicians and nurses, but mostly with patients. Donna and her husband moved away to be closer to family. Although there are numerous opportunities available to her, she would do “anything” to not work in commu- nity pharmacy practice; she is happy being a grandma, and I doubt she will reenter community practice.

 I met Jerry when he worked as a representative for a drug company. He knew his products well and was an asset to his company. Jerry left that company and took a job practicing community pharmacy for 20 years. Although he is a few years younger than me, the demands from his grocery store chain have made him leave the profession to pursue his true passions. He is an avid fisherman and hunter and will change his income stream from pharmacist to taxidermist and maple sugar manufacturer.

 Of all my pharmacist friends and acquaintances, this loss troubles me the most. Abe comes from a family of pharmacists: his mother, father, and cousins are all pharmacists. He has been out of school only 8 years. During the 8 years he practiced, Abe took a newly opened grocery store pharmacy to the top in prescription volume and sales. The metrics, demands of management, and lack of staffing have made him give up on the profession and work for his mother-in-law’s health care business. He has never been happier and gets to spend time with his growing family.

Enrollments in pharmacy schools are down and for many schools, wait- ing lists no longer exist. Thanks to the glut of pharmacists produced by academia and the miserable working conditions that the 4 major chains— “Corner,”“Three Letter,”“Spark,” and “Lefty”—have created, many excellent, seasoned pharmacists have left the profession to be priests, bakers, taxider- mists, or maple sugar makers... anything but chain pharmacists.

Feel free to send your management my way. I want to keep those nails covered with satisfied licensed pharmacists.

Peter A. Kreckel, RPh, practices community pharmacy in Lemont Furnace, Pennsylvania.

Our columnist shares true stories of pharmacists who have left the practice for their own greener pastures. 

Empty Nails Are the Cure for What Ailed Them

The past 2 years have been quite the roller-coaster ride for health care. Although workforce challenges existed previously, the COVID-19 pandemic has shined a spotlight on health systems labor and workforce needs and the critical role of pharmacy in the care team.

Let’s start with the elephant in the room: How has the pandemic impacted health system pharmacy workforces? There is no doubt the pandemic has stressed the nation’s workforces, but health care workers have felt the brunt of that stress. The volume of patients being cared for has changed drastically. Cancelled procedures and avoidance of care have led to layoffs and furloughs, whereas surge periods have led to an influx of higher acuity patients, requiring treatment in new locations, filling of ambulatory care gaps, and pulling out all stops for additional staff.

New or expanded services have also led to pharmacy-focused efforts to support new treatments, vaccinations, prophylaxis, and changing sites of care to telehealth and home infusion. Overall, this was positive, reflecting the importance of pharmacy. However, drug shortages and recalls, compounded during the pandemic, only added insult to injury. This was positive overall and reflects the importance of pharmacy. That drug shortages and recalls were compounded during the pandemic added insult to injury.

The result of these challenges is a negative impact on the mental health and well-being of the workforce, leading to higher levels of burnout. This, plus the additional dynamics of the pandemic, has resulted in increased resignations. Although specific figures are not available for pharmacy, the American Hospital Association reported that job postings for allied clinical staff have increased by 41% between January 2020 and January 2022.

Recruitment and retention are top concerns for health system pharmacy leaders, with technician staff short- ages representing the biggest concern. This is a multifaceted problem that goes well beyond burnout that will require a multipronged approach.

Additional challenges not related to the pandemic include the pharmacy enterprise scope, workforce skill mix, and pharmacy labor metrics. The pharmacy enterprise describes the broad scope of health system pharmacy services, ranging from acute critical care to ambulatory clinics to outpatient and specialty pharmacies, home infusion, and beyond. This diverse scope requires a diverse work- force that can adapt to advances in care and technology.

Despite this diverse workload, pharmacy departments are often held to single labor metrics related to doses dispensed, which is a metric that is not reflective of the diverse and complex work of the enterprise. As pharmacy leaders, it is critical that we know our business and labor needs so we can advocate for the appropriate roles and resources and ensure we are providing safe and efficient patient care, achieving quality and financial goals, and supporting the safety and well-being of our pharmacy teams.

Is your department the right size? Assessing key areas, such as workload and acuity metrics, labor metrics, and benchmarks, are necessary to deter- mine whether we have the right number and skill mix in our workforce. Research published in the

 American Journal of Health-System Pharmacy

3 provided specific examples of these metrics from a recent capacity analysis at an academic medical center (

Some of these metrics are overlooked as the workforce is assessed, which can cause strain and reduce engagement. Other organizations, such as the American Nurses Credentialing Center Magnet Recognition Program, have exemplary models for supporting training and professional development. By looking to these organizations, health systems leadership can ensure there is budget for training days, annual competencies, new technologies, and professional development to prevent gaps.

The health system pharmacy workforce has been a priority topic in several recent publications for the American Society of Health-System Pharmacists (ASHP) Foundation Pharmacy Forecasts

 and the high-value pharmacy enterprise framework.

 In addition, the newly formed Health System Strategy Council of the American Pharmacists Association will also address workforce challenges. 

include excerpts of the recommendations related to workforce. These key concepts can be used as a checklist to evaluate whether health systems leadership have imple- mented these recommendations.

The pandemic has highlighted cracks in our health system pharmacy workforce that can be addressed with systematic capacity analysis, justifica- tion of resources, and implementation of strong workforce engagement and development plans.

Data brief: workforce issues remain at the forefront of pandemic-related challenges for hospitals. American Hospital Association. January 24 2022. Accessed February 15, 2022. 

https://www.aha.org/issue-brief/2022-01-25-data-brief-workforce-issues-remain-forefront-pandemic-related-challenges

2022 AHA health care talent scan. American Hospital Association. Accessed February 15, 2022. 

Vaeth S, Zaniewski A, Polat N, et al. Justification of nearly 50 staff members through robust metrics and capacity analysis at an academic medical center. 

. 2021;78(17):1603-1626. doi:10.1093/ajhp/zxab299

Vermeulen LC, Swarthout MD, Alexander GC, et al. ASHP Foundation Pharmacy Forecast 2020: strategic planning advice for pharmacy departments in hospitals and health systems. 

. 2020;77(2):84-112. doi:10.1093/ajhp/zxz283

DiPiro JT, Fox ER, Kesselheim AS, et al. ASHP Foundation Pharmacy Forecast 2021: strategic planning advice for pharmacy departments in hospitals and health systems. 

.2021;78(6):472-497. doi:10.1093/ajhp/zxaa429

DiPiro JT, Carmichael JM, Johnson VB, et al. ASHP Foundation Pharmacy Forecast 2022: strategic planning guidance for pharmacy departments in hospitals and health systems. 

. 2022;79(2):23-51. doi:10.1093/ajph/zxab355

Rough S, Shane R, Armitstead JA, et al. The high-value pharmacy enterprise framework: advancing pharmacy practice in health systems through a consensus-based, strategic approach. 

.2021;78(6):498-510. doi:10.1093/ajhp/zxaa431

The COVID-19 pandemic has exposed the cracks in health system pharmacy. Here’s how the workforce can adapt.

Workforce Challenges for Health System Pharmacy

Throughout much of United States history—and certainly until the 1950s—the community drugstore served as a “primary gathering place–a hangout for school kids and a social center for adults—all drawn there by the sweet confections of the soda fountain,” reported the 

The neighborhood pharmacy’s role as a gathering spot also firmly placed the pharmacist as the most accessible health care provider, explained Mitch Rothholz, RPh, chief of governance and state affiliates and executive director at the American Pharmacists Association (APhA). In fact, a 2022 study revealed patients go to their community pharmacies “almost twice as often as they visit their physicians or other [qualified health providers].”

Pharmacists have helped community members with public health challenges throughout the history of the United States, Rothholz said. Some of the most pressing public health challenges today include chronic diseases, prescription drug overdoses, vaccine access, and cigarette smoking and vaping, per the American Public Health Association.

Pharmacists around the country tackle these issues every day, said Rothholz, adding that pharmacists also help community members with prevention of sexually transmitted diseases, opioid substance use disorder, stroke prevention, and screenings for mental health.

In addition, over 400,000 pharmacists and over 100,000 pharmacy technicians are trained to administer vaccinations “across the life span,” Rothholz said. “Our limitations with [vaccinations are associated with] state laws and regulations and what payers are willing to pay.”

Pharmacists are already engaged in public health efforts when they’re testing patients for influenza, strep throat, or sexually transmitted diseases, or facilitating smoking cessation programs, he explained. However, the challenge is demonstrating the value of these services to health plans and getting employers to support these programs financially, Rothholz explained, adding that pharmacists are increasingly “getting outside the 4 walls of the pharmacy.”

Ensuring Community Pharmacists Could Administer the COVID-19 Vaccine

The ability for pharmacists to administer the COVID-19 vaccine was certainly helpful at the peak of the pandemic, which is soon projected to result in the deaths of 1 million US residents. As of February 9, the CDC reported that over 229.2 million doses of the COVID-19 vaccine were administered and by retail pharmacies across the country. There are 21 retail pharmacy partners in the program, according to the agency.

As early as January 2021, community pharmacies in West Virginia helped boost COVID-19 vaccination rates. 

 reported that community pharmacies’ success in the state was because of long-standing relationships built with long-term care sites.

Approximately 2400 miles away, in Delano, California, Komoto Pharmacy has administered over 11,000 COVID-19 vaccines since early 2021. But it was during the fall of 2020 that Brian Komoto, PharmD, president and CEO of Komoto Pharmacy, realized community pharmacists wouldn’t be able to administer the vaccine that would soon become available to adults across the state.

It took 3 months for Komoto to navigate and execute a pathway to work with the federal and state government to ensure community pharmacists could administer the COVID-19 vaccine. An important milestone in that journey was reached when California Governor Gavin Newsom issued an executive order that allowed pharmacists, pharmacy technicians, dentists, and nurses to administer the vaccine beginning January 27, 2021.6

Since then, Komoto Pharmacy has provided vaccinations at dozens of farms, 6 schools, and multiple vaccination sites located in nearby municipal gathering places across their agricultural community.

Earlier this year, APhA awarded Komoto the Daniel B. Smith Practice Excellence Award, in part because of his establishment of the Komoto Family Foundation, which is dedicated to promoting wellness and health equity in partnership with under-resourced communities.

 The foundation—which helps improves access to pharma- cist-provided health care services—has, according to APhA, saved patients over $3.7 million since it was founded in 2013.

Exposing Pharmacy Students to Public Health

Hoai-An Truong, PharmD, MPH, started volunteering in the public health field 20 years ago. Since then, he’s been involved in blood pressure screening and diabetes risk assessment, as well as being deployed by the Federal Emergency Management Agency (FEMA) at COVID-19 vaccine sites in both Norfolk, Virginia, and Las Cruces, New Mexico.

In May 2021, Truong was a volunteer vaccinator with 2 of his students at the University of Maryland Eastern Shore in Princess Anne, where he serves as a professor of pharmacy administration and public health. Vaccination sites in Norfolk and neighboring city, Hampton, Virginia, included churches, high schools, and jails.

“As members of the pharmacy profession, we contributed to the vaccine preparation, quality control,and administration of the 2-step [Pfiz- er-BioNTech] vaccine, as well as the single-dose counterpart produced by Johnson and Johnson,” wrote Truong, along with students Randi Wright and Michelle Yang, in an article published by the university.

During their FEMA deployment, the trio spent their days tackling vaccine hesitancy and trypanophobia (fear of the needle) by “providing education and demonstrating compassion,” Truong, Wright, and Yang wrote.

Truong remembers a time when he was able to convince a COVID-19 vaccine-hesitant husband to accept the vaccine. “The husband and wife came together to get the vaccine [for the wife]. The husband came to be supportive, but he was ‘on the fence,’” he said.

Instead of lecturing the couple, Truong thanked them for getting vac- cinated and told them,“You’re doing this for your family, your community, and for me, as a health care professional. You’re protecting me and the rest of [your community].”

His advice for putting a patient at ease about the vaccine is straight-for- ward: Never prepare the vaccine vial in front of the patient, minimize theiranxiety, and distract them. One idea is to ask, “What are you doing for dinner tonight?” Truong said.

In addition to his teaching and public health activities, Truong wrote a book called 

The Pharmacist in Public Health: Education, Applications, and Opportunities

, with coauthors James Bresette and Jill Sellers. Published
in 2010, the book covers topics such as the development and mission of pharmacy in the United States Public Health Service, medication therapy management as a way to improve public health, telehealth challenges and opportunities associated with public health pharmacy, and strate- gies and opportunities for students’ involvement in public health.

What keeps Truong engaged in public health—particularly in the areas of disaster services and emer- gencies—is that “so much goes into planning,” he said. “If [the planning] is done well, it’s virtually never seen. What is seen are the people doing the work at the vaccination site or outside the home of a person who [has] just lost everything in a fire or a natural disaster.”

Galloway P. Old-time drugstore just a soda fountain memory. 

.Published January 10, 1985. Accessed March 7, 2022. 

https://www.chicagotribune.com/news/ct-xpm-1985-01-10-8501020847-story.html

Valliant SN, Burbage SC, Pathak S, Urick BY. Pharmacists as accessible health care providers: quantifying the opportunity. 

.2022;28(1):85-90. doi:10.18553/jcmp.2022.28.1.85

Topics and issues. American Public Health Association. Accessed March 7, 2022. 

The Federal Retail Pharmacy Program for COVID-19 vaccination. CDC. Updated March 7, 2022. Accessed March 7, 2022. 

https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html

Noguchi Y. Why West Virginia’s winning the race to get COVID-19 vaccine into arms. NPR. Published January 7, 2021. Accessed March 7, 2022. 

https://www.npr.org/sections/health-shots/2021/01/07/954409347/why-west-virginias-winning-the-race-to-get-covid-19-vaccine-into-arms

Executive Order N-02-21. Executive Department State of California. January 27, 2021. Accessed March 7, 2022. 

https://www.gov.ca.gov/wp-content/uploads/2021/01/1.27.21-EO-N-02-21.pdf

Negatu J. American Pharmacists Association announces recipients of 2022 APhA Academy awards. December 7, 2021. Accessed March 7, 2022. 

https://www.pharmacist.com/About/Newsroom/american-pharmacists-association-announces-recipients-of-2022-apha-academy-awards

Wright R, Yang M, Truong H. A FEMA-nominal experience. University of Maryland Eastern Shore. May 27, 2021. Accessed March 7, 2022. 

https://wwwcp.umes.edu/pr/a-fema-nominal-experience/

. American Pharmacists Association; 2010.

Pharmacists are making waves in public health practice.

Public Health and Pharmacy Intersect, Providing Opportunities

Vaccine errors have always occurred, but an increased demand for vaccines and workforce shortages have increased the possibility for errors at the pharmacy. Historically, the most common vaccination errors are the wrong vaccine, the wrong age for vaccination, and the wrong vaccine dose. Most errors occur due to lack of time, being rushed, impatience, lack of staffing, or everyone showing up at the same time or when the pharmacy is about to close.

“It is so easy to skip steps and think you have done this 1000 times, so what could go wrong? The best advice is to approach each vaccination with care,” said Simona Dorf, PharmD, BCMAS, clinical pharmacist manager for First Databank. “Check the vaccine administration record form carefully before mixing or drawing up the vaccine and scan the barcodes to ensure the same vaccine that is billed is being prepared for administration.”

Jay Phipps, PharmD, president and CEO of Phipps Pharmacy in Jackson, Tennessee, noted administration technique–related vaccination errors have increased recently. These include shoulder injuries related to vaccine administration, use of the wrong needle size, and the administration of a dose lower than authorized.

Numerous safeguards can be put in place to keep vaccination errors from happening, such as creating physical barriers for vaccine storage. Phipps noted the importance of developing a plan for vaccine storage in refrigerators and freezers that is well organized and properly labeled.

“The plan should include separating vaccines,” he said. “Pediatric, adult, and adult over 65 vaccines should be stored in separate, labeled plastic bins of different colors. All individual syringes containing vaccines should be clearly labeled for each patient. If doses are being drawn up in advance without patient specifics, then each syringe should be labeled with [the] name of vaccine, date, and time.” Additionally, Phipps noted that, if the pharmacy management system allows, barcode scanning should be confirmed for the correct vaccine.

One overlooked vaccine error can result from inappropriate vaccine storage. The CDC recommends storing vaccines in separate, self-contained units that only refrigerate or only freeze. If a combination refrigerator/freezer must be used, only refrigerated vaccines should be stored in the unit, and a separate standalone freezer should be used for frozen vaccines.

Another thing that can help eliminate errors is utilizing a separate area for vaccine preparation. “ [Preparation and] administration should be in a separate area away from distractions and interruptions,” Phipps said. “Reference material should be posted that includes vaccines dilution requirements, if applicable; storage; route of administration; and length of needle for each vaccine at the pharmacy. A Do Not Disturb sign is also recommended when vaccines are being prepared or administered.”

“Immediately prior to administration, the patient’s name, date of birth, vaccine type, and number [of] shot in [the] series should be confirmed,” Phipps said. “[Although] the workload of all pharmacy staff is significant, the short amount of time to confirm the information is insignificant in comparison [with] the potential for error.”

If a pharmacist is making travel vaccine recommendations, they must carefully review the patient’s travel itinerary and pay particular attention to not only the country to which the person is traveling but also the exact region of the country. “Vaccine recommendations might vary from city to rural area,” Dorf said.

In a perfect world, vaccines would be scheduled in a dedicated block of time each day, with adequate staff to provide the vaccinations, said Phipps. Staff would be responsible for only vaccine delivery and would not be dispensing at the same time. However, he doesn’t know anyone who practices in that bubble.

“Distractions from patients, coworkers, telephone calls, [and] the constant barrage of alerts we receive from social media are commonplace,” he said. “[Although] most professional pharmacy staff are not actively using their personal phone while involved in vaccine preparation or in direct patient care, it is not uncommon for them to glance at messages or alerts on smart watches. Each time our focus is taken from the patient, the risk of error increases.”

Vaccine administration: preventing vaccine administration errors. CDC. January 5, 2021. Accessed March 7, 2022. http://www.cdc.gov/vaccines/hcp/admin/downloads/vaccine-administration-preventing-errors.pdf

Vaccination errors are common but preventable mistakes.

Best Practices to Prevent Vaccination Errors

The tentacles of racial and cultural health care disparities extend their reach deep into the fabric of American culture. The complexities are painfully entrenched throughout American identity: from where a person lives and their cultural identity to one’s complexion and economic standing. Sadly, a patient’s experience accessing and navigating the United States health care system also falls on this list, an unfortunate consequence of inherent bias borne from all too common effects of systemic racism and implicit biases. Although many factors contribute to the substandard experiences marginalized communities face in the health care setting, perhaps no reason bears greater weight than the basis on which the United States health care system was founded.

From health care access to medication use disparities, minority populations often bear the brunt of a system not weighted in their favor. While the problem isn’t new—the CDC published a Health Disparities and Inequalities Report in a 2013 issue of 

Morbidity and Mortality Weekly Report (MMWR)

—the COVID-19 pandemic threw many of the issues surrounding care equity into sharp relief.

Research throughout the pandemic has shown that some racial and ethnic minority groups are more likely, disproportionately so, to be negatively impacted by COVID-19.

 The reason is multifaceted: in some communities, racial and ethnic minorities were more likely to be working essential service jobs, increasing the risk of exposure to SARS-CoV-2. And because of systemic disparities in care access, many of these individuals were already living with conditions predisposed to experience worse COVID-19 outcomes.

Even after treatments like monoclonal antibodies became available, a 

 report found that of a total of nearly 6 million patients in PCORnet health care systems evaluated, “mean monthly [monoclonal antibody use] among all patients with positive SARS-CoV-2 test results” were lower among patients who were Black, Asian, Hispanic, or non-Hispanic compared with patients who were White.

Socioeconomic Factors Contribute to Care, Medication Disparities

Both race and socioeconomic standing play strong roles in dictating a person’s success. A person’s financial background, for example, can be an indicator of their overall health. In fact, personal wealth is so predictive of individual health outcomes and overall health that the scales remain drastically imbalanced and in favor of those with financial security.

“The US health care system was designed by and set up to care for White people, so of course, it does the best job caring for White people,” said Andrew Schmelz, PharmD, assistant professor of pharmacy practice at Butler University in Indianapolis.

“Because our health care system is structured around businesses and management of payment and profit, how much money someone has directly impacts how healthy they are,” Schmelz told 

. “This creates an environment where money, which…is controlled by social factors, plays an outsized role in determining health outcomes.

Historically, the United States health care system has focused on the biologic drivers of health, Schmelz explained. However, emerging data indicate that social determinants—which include access to clean water and healthy foods, the ability to afford medications, and adequate housing, among others—also affect overall health and well-being.

Chronic diseases tend to be more prevalent in Latino and Black communities as opposed to the White population.6 As a result, these communities are predisposed to use more medication. But despite these higher incidences of medication use, less access to medical care and greater financial constraints in these communities mean that many still struggle to achieve optimal rates of medication adherence. In fact, both groups are at least 50% more likely to have poorer adherence rates than the White population.

A growing body of evidence indicates that Black patients face additional barriers in the form of discrimination and the effects of implicit bias by health care providers. In health care education settings, curriculum on race- and ethnicity-based health inequities can be limited,

 and compounded by biases that certain medications—for example, those used to treat pain—may work “better” or worse in patients based on race.

Language differences can further amplify medication use disparities. Such is the case for members of Latino and Asian communities who have language barriers when receiving care.

“[One] contributing factor to the low incidence of medication use [among] Latino and Asian communities is a lack of health literacy due to language barriers,” Donney John, PharmD, executive director of NOVA ScriptsCentral in Falls Church, Virginia, told 

Across the spectrum, members of non–English-speaking communities may not feel comfortable asking questions of their health care provider, concerned about appearing as if they are “questioning” or not respecting their provider’s knowledge and training, John explained. But sometimes, medication information is not translated into a language that patients can easily understand, leading to vital information being lost in translation.

John encourages pharmacists and other health care professionals to seek resources other than Google Translate. Although this tool can be beneficial in day-to-day life, instances of inaccurate translation of medication-related information have been noted.

Misunderstandings and patient engagement hesitancy owing to language barriers are not the only factors leading to disparity and inequality across the health care system. In some communities, individuals may prefer to turn to alternative healing practices, which could result in lower medication use. Once again, cultural idiosyncrasies make the situation more difficult to quantify.

“I would argue that non-Hispanic White [individuals] may also follow these practices and have some more common to their own culture—for example, doing “cleanses” to remove “toxins” from the GI tract,” Schmelz said. “Also, medication use for specific diseases (eg, drugs for opioid use disorder) has been historically stigmatized, and populations with higher incidence of these problems [are] disproportionately affected.”

The brutal murder of George Floyd by police in 2020 ignited widespread discussions around diversity, equity, and inclusion (DE&I), said Schmelz. Although encouraging, DE&I as a field isn’t new, and there is skepticism that this increased attention will result in any meaningful changes in how we train students or how we provide care.

Frank North, PharmD, MPA, president-elect of the National Pharmaceutical Association in Houston, shared some similar concerns regarding how meaningful changes look and whether they are effective.

“DE&I is [a] hot topic we see schools implementing, but is it done so in an effective way?” he asked. “Some institutions are wrapping their minds [around] the need for DE&I and the fact that communities of color have different experiences.”

These efforts are wide ranging. Some include steps to create narratives that change how the health industry discusses drug efficacy and disease prevalence, Schmelz said. Other efforts have involved research11 intothe impact of implicit biases—“attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner”11—on pharmacy education.

Cultural Competency: An Outdated Concept?

Education can help create awareness among providers about their own implicit biases while providing strategies to provide more culturally competent care. However, this isn’t a panacea for medication use disparities. According to John, cultural competence—defined as an ability to understand, appreciate, and interact with individuals from cultures different from one’s own

“All patients—regardless of gender or race—want to be provided with care that treats and engages them with respect,” he said. “Understanding the concept of cultural humility will go a long way for people to learn who to improve the health literacy for patients from different backgrounds so that they will be more responsive to medication therapies.

The narrative of cultural competency, while important, has 2 major limitations.

 First, it inadvertently introduces bias and stereotyping by implying that a person can collect information about group of people; and second, it creates the false notion that cultural competence is an area in which a person can become 100% proficient.

A growing body of evidence suggests that cultural competence is on its way to becoming an antiquated concept—perhaps rightfully so. Its origins date back to the ‘60s and ‘70s, an era marked by sociopolitical turbulence.

Cultural humility—a second-generation iteration of cultural competency—first emerged in 1998.13 The term acknowledges the fluidity of culture predomination while recognizing that understanding and honoring one’s culture is a lifelong process that commands reflection and introspection.

Empathy is another critical piece to solving the medication use disparity puzzle, especially when it comes to engaging the patient with practical action points.

“As a pharmacist, I don’t like to take medication myself, so I may not be as adherent to medication regimens if they are too cumbersome,” John admitted. “So, I try to put myself in the patient’s shoes and think [about whether] I could follow through on the recommendation that I am asking them to follow.”

CDC releases second health disparities & inequalities report—United States, 2013. CDC. Reviewed November 26, 2013. Accessed March 24, 2022. 

https://www.cdc.gov/minorityhealth/CHDIReport.html#anchor_1607954179

Risk of severe illness or death. CDC. Updated December 10, 2020. Accessed March 24, 2022. 

https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-illness.html

Wiltz JL, Feehan AK, Molinari NAM, et al. Racial and ethnic disparities in recipt of medications for treatment of COVID-19—United States, March 2020-August 2021. 

2022;71(3):96-102. Doi:10.15585/mmwr.mm7103e1

Lopez III L, Hart III LH, Katz MH. Racial and ethnic health disparities related to COVID-19. 

2021;325(8):719-720. Doi:10.1001/jama.2020.26443

Weida EB, Phojanajong P, Patel F, Chilton M. Financial health as a measurable social determinant of health. 

2020;15(5):e0233359. Doi:10.1371/journal.pone.0233359

Xie Z, St Clair P, Goldman DP, Joyce G. Racial and ethnic disparities in medication adherence among privately insured patients in the United States.

2019;14(2):e0212117. doi:10.1371/journal.pone.0212117

Weiner S. Medical schools overhaul curricula to fight inequities. American Association of Medical Colleges. May 25, 2021. Accessed March 24, 2022. 

https://www.aamc.org/news-insights/medical-schools-overhaul-curricula-fight-inequities

Lawrence E. What doctors aren’t always taught: How to spot racism in health care. KHN News. November 17, 2020. Accessed March 24, 2022. 

https://khn.org/news/racism-in-health-care-what-medical-schools-teach/

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. 

2016;113(16):4296-4301. Doi:10.1073/pnas.1516047113

Across the country, minority populations face significant disparities in medication use. It's time for that to change. 

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