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November 13, 2020

Pharmacists Take the Lead in Providing Vaping Interventions

Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, with PGY2 residents Becca Wytiaz and Mara Rubin.

AN INCREASE IN THE USE OF E-CIGARETTES AMONG adolescents in the U.S. is erasing recent progress in reducing overall tobacco use in this population, according to alarming statistics from the Centers for Disease Control. Some 27.5% of high schoolers and 10.5% of middle schoolers reported current use of e-cigarettes, the CDC reported in a recent issue of the Morbidity and Mortality Weekly Report, creating an immense opportunity for pharmacists to get involved.

Vaping and COVID-19

In 2019, there was a surge in E-cigarette or vaping product use-associate lung injury (EVALI) which was particularly noted in adolescents and young adults. Interestingly, there was an observed decrease in EVALI cases early in 2020, explained Kimberly Novak, Pharm.D., BCPS, BCPPS, FPPA, an advanced patient care pharmacist in pediatric and adult cystic fibrosis at Nationwide Children’s Hospital in Columbus, Ohio. “This was originally attributed to increased public awareness of vaping and strategies aimed at reducing marketing and access of flavored vaping products of preferred by this population,” said Dr. Novak. “However, this decrease also corresponded with the initial surge in COVID-19 cases and many state-mandated stay-at-home rules as well as increased implementation of work-from-home and virtual school policies.”

As many of these policies were loosened in the summer months, health care practitioners have noted an increase again in EVALI cases, perhaps due to less supervision as parents returned to onsite work, she added.

Pharmacist roles

In general, e-cigarette usage in adolescents “has blown up among this population way more than people suspected, particularly because it’s so easy to hide, and it doesn’t smell,” said Dr. Novak. “This snuck up on us as a society with very little regulation, and now we’re working backward, trying to catch up to this epidemic that got out of the bag before we got a hold on it.”

Kyle Mays, Pharm.D., BCPPS, discusses cessation options with a teenage patient.

Pharmacists can play several important roles in patient care regarding e-cigarette usage and related lung injuries, said Dr. Novak, an ASHP member since 1998. In teaching hospitals like hers, pharmacists provide continuity where attending physicians and residents may change over. They also can monitor trends in nicotine usage, and, because patients view pharmacists differently than their physicians, they may share more information about medication histories with them.

Typical agents prescribed to help curb nicotine cravings, like varenicline (Chantix) and bupropion (Zyban, Wellbutrin), are not indicated for people under the age of 18, noted Justin Reinert, Pharm.D., BCCCP, a clinical assistant professor at the Ben and Maytee Fisch College of Pharmacy at the University of Texas at Tyler. This doesn’t mean physicians aren’t prescribing them for this population, he said, but pharmacists can employ motivational interviewing techniques and assess patients’ readiness to change.

Interventions to reduce usage

In addition, pharmacists can use their medication expert hat to advise primary care teams on different vaping products used by teens, said Kyle Mays, Pharm.D., BCPPS, a critical care pharmacist with SSM Health Cardinal Glennon Children’s Hospital in St. Louis. When his hospital saw a recent surge in illnesses among patients using THC-related vaping compounds, some of his colleagues weren’t aware these products were linked to lung injuries because of the solvents and vitamin E they contained. If patients are admitted with severe lung illnesses and are intubated and can’t speak, Dr. Mays and colleagues play detective, eliminating potential causes or ordering urine toxicology screens.

Justin Reinert, Pharm.D., BCCCP

In an effort to address e-cigarette usage in his area, Dr. Reinert is directing a two-fold intervention. Pharmacists and doctoral pharmacy students are providing educational in-services and assemblies in local schools, as well as surveying high school students about their use of nicotine products. Then, beginning this fall, pharmacy students will provide nicotine cessation programs in schools, targeted to high schoolers who may have violated a tobacco or nicotine use policy.

Among over 100 students they surveyed so far, about 78% reported using these products, said Dr. Reinert, an ASHP member since 2013. “Students are primarily into vaping, but it’s important to be cognizant of other things out there,” he noted. “Kids are still smoking cigarettes, they’re still using cigar wrappers for marijuana. The addictive component of the devices remains nicotine.”

Dr. Reinert tries to use shock value to educate the students, asking how many of them who drive and pump gas would stick the gas nozzle into their mouths and inhale. “There are components in these vaping cartridges that are identical to components of unleaded gasoline—lead, mercury, nickel, cadmium and heavy metals, etc.,” he said. “The students have no idea, which is terrible, but it also highlights the need for targeted education at this age group, which I think pharmacists are uniquely positioned to accomplish.”

Strategies for pharmacists    

The pharmacists offered advice on working with adolescent patients and their families:

  • Take an objective yet compassionate stance. “Don’t tell them they’re [doing something] wrong,” Dr. Novak said, as that can cause the patient to shut down and not disclose information. Instead, acknowledge that they may have made an unhealthy choice but keep the lines of communication open. “Your job is to treat the patient and make them better, not ridicule what they were doing that brought them in,” added Dr. Mays, an ASHP member for the past 10 years.
  • Put your message in terms relative to adolescents. Dr. Reinert’s cessation curriculum discusses the financial, health and psychosocial ramifications of nicotine use at a level appropriate for adolescents, not adults or younger children.
  • Offer resources for quitting. Educate adolescents that, similar to cigarettes, it’s hard to quit cold turkey, Dr. Mays noted. Encourage them to seek appropriate help through their pediatrician or another primary care provider, and work with them to develop a plan.
  • Try to talk to the patients without their parents. Patients may not want to fully admit to using these products, especially if their parents are present, Dr. Mays said.
  • Keep current on your knowledge. People tend to think JUUL devices are the e-cigarette of choice for teens, but new ones are popping up all the time, said Dr. Mays. “You have to stay trendy with what’s going on in a teenager’s mind,” he added.

Patient impact

Vaping devices essentially are nebulizers that deliver a drug, Dr. Novak said. But they haven’t yet been adequately studied to determine what products should go in them, what the safety margins are, or if chemicals put into them are altered by heat that the devices generate. Hopefully, with time, she said, the medical community will learn better safety information about these devices and their related products.

Meanwhile, pharmacists should stay involved, such as working with ASHP to advocate for more regulation around vaping and nicotine products. “The more we can do this on an individual level, whether in our own institutions, providing education or working with poison centers, we can make a pretty positive impact wherever our patients are,” said Dr. Novak.


By Karen Blum


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November 12, 2020

ASHP’s Standardize 4 Safety Initiative Helps Pharmacists Reduce Medication Errors

Nathaniel Sims, M.D.

ASHP released its recommended list of concentrations and dosing units for intravenous continuous medications for pediatric patients in November 2020, representing the culmination of a multi-year, multidisciplinary effort to improve medication safety for children and adults nationwide.

The Standardize 4 Safety (S4S) initiative, funded by the U.S. Food and Drug Administration (FDA) and helmed by ASHP, is the first national, interprofessional effort to standardize medication concentrations to reduce errors resulting from confusion over non-standardized drug concentrations and errors that result from concentration differences when patients transition their care from one setting to another. Expert committees with the program previously released two lists—standardized concentrations for adult continuous infusions and compounded oral liquids.

ASHP standardization leadership

Many health care systems have developed their own local standardized concentrations, or formularies, for how drugs are mixed or compounded for administration, and have shared these widely, said Nathaniel Sims, M.D., a cardiac anesthesiologist and medical device developer at Massachusetts General Hospital (MGH) in Boston. Dr. Sims served on the expert committee to develop the MGH intravenous continuous medications for pediatric patients. However, the S4S initiative is “special in that it arose as a project of the FDA,” he said. Because the FDA does not have authority to mandate such lists, it partnered with ASHP and other entities with high credibility. “The S4S initiative is exceptionally well-positioned to influence clinical practice,” Dr. Sims said.

For over a decade ASHP has supported the creation of nationally standardized drug concentrations for adult and pediatric medications, but the work began in earnest in 2015, when the FDA awarded ASHP a three-year contract to develop and implement lists of such concentrations for intravenous and oral liquid medications. That contract, which was later renewed, was part of the FDA’s Safe Use Initiative—an effort to reduce preventable harm from medications by fostering and facilitating public and private collaborations within the healthcare community.

Through these efforts, ASHP gathered a variety of pharmacist, physician, and nurse experts from across the care continuum and partnered with national patient safety organizations such as the Pediatric Pharmacy Association, the Institute for Safe Medication Practices (ISMP), and the Association for the Advancement of Medical Instrumentation, as well as regional and local health care organizations.

Although additional lists are planned, finalization of the first three lists is timely. Concurrent with many hospitals launching ambitious initiatives to integrate drug infusion pumps with their clinical information systems for automatic programming. Dr. Sims noted that since smart IV pumps will not accept auto programming instructions unless there is a perfect match between the concentration in the pump’s drug library and the pharmacy order, hospitals including MGH are working hard to create compatible systems using the ASHP standard lists as a benchmark.

Benefits of standardization

Standardization is helpful in many ways, said Rachel Meyers, Pharm.D., B.C.P.S., B.C.P.P.S., F.P.P.A., a pediatric pharmacy specialist at Saint Barnabas Medical Center in Livingston, N.J., who served on the committee for the pediatric continuous infusion list. It can simplify medication ordering for providers; enhance efficiency for pharmacies, who can then purchase less stock; and streamline production and allow for the formulation of premixes.

Rachel Meyers, Pharm.D., B.C.P.S., B.C.P.P.S., F.P.P.A.

“It might sound meaningless, caring what concentrations other hospitals use,” said Dr. Meyers, also a clinical associate professor of pharmacy practice administration at Rutgers University’s Ernest Mario School of Pharmacy. “But it’s actually really important, because we often transfer our patients between hospitals. It helps a lot if we’re all using the same concentrations.”

Having a standardized library for syringe pumps also is beneficial, she noted. “When you think about smaller hospitals who might not have a pediatric pharmacist on staff, then when they get a pediatric patient admitted to the Emergency Department, they’ll have a syringe pump ready to go already programmed with the appropriate concentrations,” Dr. Meyers said. “It just makes this whole process that much safer for the patient, so we can fully utilize tools at our disposal to their maximum effect.”

In the pediatric population, wide variations of weight range, dosing units, and fluid tolerance need special consideration, Dr. Sims cautioned. These factors may require multiple concentrations. Out of about 43 unique drugs in the ASHP pediatric concentration list, approximately 10 have three recommended standard concentrations and 30 have two recommended standard concentrations.

The key benefits of ASHP’s lists are several-fold, Dr. Sims said. The ASHP standard concentrations were created by many health care system experts using a disciplined consensus process informed by best practices for all patient groups, from “micro-preemies” in the neonatal intensive care units to adults. They also include stability data and other information essential to validate the safety of these standard concentrations. ASHP can use its broad network to publicize the lists, as well as additional educational materials, including an online course directed by Dr. Sims. Launched in November, it covers a comprehensive overview of syringe pumps and considerations for use at low flow rates. The online course offers free continuing education credits for pharmacists, nurses, and physicians, emphasizing the importance of ASHP’s standard concentrations for the safe use of infusion pumps.

Pharmacists at the helm

Pharmacists, as the “original safety champions for drug safety,” are primed to help lead efforts to adopt these lists at their home institutions, said Jared Cash, Pharm.D., M.B.A., B.C.P.S., F.P.P.A., director of pharmacy at Intermountain Primary Children’s Medical Center, in Salt Lake City. “Pharmacists are both the production crew as well as the clinical crew involved with communication of medication information and assuring the correct dose.”

Jared Cash, Pharm.D., M.B.A., B.C.P.S., F.P.P.A.

Pharmacists can employ various strategies to help push for adoption of these lists at their hospitals and health systems, Dr. Sims said. For example, they can leverage a “sentinel safety event” to convene a discussion about adoption of S4S.

A second approach is to combine a discussion about the ASHP standards with a local initiative, such as a planned revision of infusion pump drug libraries. Additionally, pharmacists can create a multidisciplinary initiative within a hospital or health system to validate and benchmark the ASHP standard concentrations against what they already are doing. They could use the ASHP lists as a prompt to “spring clean” the infusion pump drug libraries, Dr. Sims suggested, or run queries in electronic medical record systems to capture utilization of each of the medications, and learn the range of real-world dose rates clinicians program into infusion pumps to see whether resulting flow rates match patient needs.

“Be aware of the lists as you’re reviewing your formularies and EMR product selections,” Dr. Cash added. “Many places are already compounding these items and to change their compounding to the specific concentration is strongly encouraged.”

Process improvements

Some hospitals have already adopted a list of standard concentrations for neonatal drug infusions that was published several years ago by the Vermont Oxford Network, a nonprofit voluntary group of healthcare professionals, and the ISMP, Dr. Meyers said, so there is a precedent. ASHP’s working group was conscientious to include considerations of that previous list in their own work, Dr. Cash noted.

“The ASHP list is bigger, and I think it’s important for pharmacists to stress the safety of standardizing those concentrations,” Dr. Meyers said. “It not only makes transfer between hospitals easier, but if you’re part of a health system, it can help make all processes of care safer, from your EMR to your syringe pumps.”

Experts working on the S4S standards hope that the work may motivate drug manufacturers to produce some of the recommended standard concentrations, Dr. Meyers added.

“One thing we really struggle with in pediatrics is we have to compound so many of these medications,” she said. “By making this list and selecting standards, we’re hoping some drug manufacturers will pick up on this and say it may be worth it to make these items, because we know that commercially available products are safer.”

While pediatrics may have the most to gain from standardized lists, Dr. Cash said, there is still a lot of medication safety the lists can improve for adults, too. “The amount of compounding within the adult population is more significant than people recognize, and having standardized concentrations for any of that compounding reduces risk,” he said.


By Karen Blum

# # #

Tips for Students: Getting the Most Out of the 2020 Midyear Meeting

Marissa Chow, a fourth year Pharm.D. candidate at St. Louis College of Pharmacy

WITH SOME ADVANCE PLANNING AND PREPARATION, students will find this year’s virtual Midyear Clinical Meeting as enlightening and productive as the in-person meetings of previous years. The meeting is loaded with student programming, so attendees like Marissa Chow, a fourth year Pharm.D. candidate at St. Louis College of Pharmacy, are getting down to work preparing for a few jam-packed days of education, networking, and interviews.

“Since in-person meetings will most likely not happen due to safety concerns during the COVID-19 pandemic, it will be even more important to chat with the right people at this year’s Midyear,” said Chow.

Preparation is key

Her preparation includes looking through the ASHP Midyear’s student-specific programming, which will be offered both in on-demand and simu-live formats. Residency-focused student sessions will cover all aspects of residency applications and interviews, ranging from navigating the PhORCAS application system to understanding the Match Algorithm. Professional development student sessions will aim to help students of all classes explore post-graduate opportunities and personal success topics like branding and financial guidance.

As with every year, the ASHP virtual residency showcase will give students a chance to interact with residency programs, learn more about what they have to offer, and narrow down their options prior to applications. Additionally, the Personnel Placement Service (PPS), free to all fourth-year student registrants through advance sign up, will provide an opportunity for dedicated interviews and one-on-one time.

Chow said she is already researching programs that are participating in this year’s residency showcase and writing down criteria and questions ahead of time to help her evaluate programs.

Advice for first-timers

One piece of advice Chow had for students attending the Midyear for the first time is to map out where they want to go ahead of time and to read and learn about the virtual platform prior to the meeting, “so you aren’t scrambling to find the next item to attend and there are no technical errors.”

“And consider finding a “Midyear Buddy” to support each other for meetings, residency talks, and even PPS,” Chow said.

Elizabeth King, Pharm.D.

Students should also work with their preceptors and professors ahead of time to make sure they can dedicate time to the meeting, said Elizabeth King, Pharm.D., who graduated from pharmacy school in 2018 and is now a hematology/oncology pharmacist at Mayo Clinic, Rochester, Minnesota.

“When we attend in person, there is a natural separation from other responsibilities so we can focus on the meeting, but this may not be the case in the virtual setting,” Dr. King said.

Students should carve out a time and space with minimal distractions and dress as if they were attending the conference in person, “to get yourself in the right mindset,” she recommended. “And just like in person, you will need breaks so don’t be afraid to walk away from the screen,” she added.

Although the meeting is chock-full of student programming, Dr. King suggested attending at least one new practitioner session and one pharmacist session.

“If students have a clinical area they’re interested in, it’s a great idea to attend some of the clinical sessions on that topic to hear about how clinical practice is changing,” she said, noting that the virtual format means attendees can spend more time viewing posters and listening in on sessions and less time “shuttling between locations.”

Another reason to venture outside of student programming is to get a better sense of the faculty at an institution where one might apply for a residency, Dr. King said.

“You can get an idea of what the people you will be learning from are like and what their academic passions are, which also gives you talking points for interviews,” she said.

Dr. King recommended actively participating in sessions by asking questions. If there are private messaging options, contacting others to network can help you connect with people who have similar interests, she added. “Also make sure also to build up your profile on ASHP and PPS so that others can find you based on your interests and reach out to you,” Dr. King said.

Residency search

Younger students interested in learning about the residency process should attend the PhORCAS session to find out what programs are looking for in residency candidates, Dr. King said.

“Knowing this can help you set your priorities so that you end up getting to where you want to be academically,” Dr. King said. “The earlier you can start thinking about and preparing for residency, the better.”

For residency applicants, it’s a good idea to formulate a set of criteria that can help decide on a program and also to formulate questions tailored to that specific institution, Dr. King advised.

Nelly Adel, Pharm.D., BCOP, BCPS, supports her student during an ASHP Midyear meeting poster presentation.

“These questions can help you understand the culture of the institution, the educational offerings they have, or explore key non-negotiable items that you want in a residency,” she said.

As a residency recruiter herself, Nelly Adel, Pharm.D., BCOP, BCPS, chair of the department of pharmacy practice and associate professor in oncology, Touro College of Pharmacy, New York, appreciates when residency candidates distinguish themselves from others in the candidate pool.

“Ask questions that are not answered on the program’s website,” she recommended. “For example, I like to be asked about projects that I have worked on with students or residents and that have made a difference.”

Dr. Adel also recommended highlighting co- and extra-curricular activities and volunteer work. “I speak with 20-30 candidates a day and it’s sometimes hard to remember each one.  This can help to separate you from your peers,” she said.

Virtual etiquette

One thing Dr. Adel emphasized is to approach the Midyear with professionalism. “Even though the meeting is virtual, the same rules as in-person meetings hold,” she said. She encouraged students to wear professional attire, find a room without visual distractions in the background, smile when speaking to others or presenting a poster, and to not be “sitting or lounging at your bed.”

“There’s also no reason to be late for a meeting or a presentation, particularly when it’s virtual,” she said. “So become familiar with the platforms you’ll be using by playing around with them ahead of time. This could help avoid technical glitches and delays.”

Having attended and hosted numerous virtual meetings herself, Dr. Adel said student presenters and residency applicants should look straight into their computer’s camera rather than at the picture on the monitor.  “This helps you connect better with the person in front of you,” she said. Another technical consideration to keep in mind is the possible lag time during remote conversations, Dr. Adel added.

“Avoid interrupting the other person by waiting for the end of their sentence,” she said. “If you want to interject, find the right moment and know how to interrupt without being offensive. That holds true whether it’s a live or a virtual meeting.”

Despite the checklist of considerations that students should keep in mind prior to this year’s Midyear, Chow, the student pharmacist, is enthusiastic about the potential of the meeting.

“I’m excited to attend this year’s meeting!” she said. “Although this is not the traditional format or the format that most people would have wanted for the Midyear, as the pharmacy profession as a whole has shown, we are good at adapting to change.”


By David Wild

October 29, 2020

Virginia Mason Kirkland Medical Center Wins ASHP Board of Directors’ Award of Excellence

AN EFFICIENT PRACTICE WORKFLOW, allowing pharmacists and other clinicians to perform at the top of their licensure, and a culture of respect are three of the principles rooted at Virginia Mason Kirkland Medical Center in Washington. These factors have contributed to high job satisfaction among clinicians and helped the medical center become one of two recipients of the 2020 ASHP Board of Directors’ Award of Excellence.

Promoting Well-being

Richard Furlong, M.D

“The Virginia Mason Kirkland Medical Center implemented initiatives to support well-being and resilience and reduce burnout for its patient care providers,” ASHP said in a formal announcement. “These initiatives have been selected by the National Academy of Medicine to promote pharmacists as part of an interprofessional team to address clinician burnout and promote resilience.”

The medical center is one of nine locations for the Virginia Mason Health System, each with one or more primary care pharmacists. The Kirkland location is an outpatient clinic with 30 full-time clinicians, including two pharmacists, which since 2002, has embraced a team-based structure built around professional development and workflow optimization.

“This work, like almost all process improvement at Virginia Mason, leveraged our management method called Virginia Mason Production System (VMPS), modeled after the Toyota production system. It optimizes care delivery by eliminating waste, standardizing processes, and spreading the work to the right operators,” said Richard Furlong, M.D., section head and medical director of the center.

Promoting Engagement, Contentment

Well-being is promoted in several ways. One is the physical structure. The building is set up in two concentric circles. The inner ring has exam rooms while the outer ring has clinician workstations. Patients are brought immediately to an exam room when they arrive; there are no waiting rooms. Integrated care teams include pharmacists, advanced registered nurse providers, physician assistants, physicians, and medical assistants who able to move among the teams as needed. All employees are encouraged to submit ideas on improving processes, with suggestions reviewed weekly by leadership. Leaders promote a culture of engagement, teamwork, and respect for people, which includes making time for professional development.

Contentment is also promoted through pharmacists and other clinicians working to the full extent of their education and training systemwide.

“When pharmacists and other teammates help, and the work is evenly spread, it creates a collegial atmosphere that engages people and reduces burnout,” Dr. Furlong said. Pharmacists in the state have provider status and can bill for medication management appointments. They see some of their own patients between provider visits, answer all patient questions about medication, and have the authority to make changes to therapy.

Expanding Pharmacist Roles

In the early days, the pharmacist’s role was limited to anticoagulation management, noted Dr. Furlong. The team then started to look at other clinical conditions that could use pharmacists’ help, such as lipids and hypertension. They created a Heart Attack and Stroke Prevention clinic.

“We convinced our doctors that it was in everyone’s best interest to refer our patients for lipids and hypertension management to our pharmacists,” he said. It didn’t take long for data to accumulate, indicating their quality metrics were higher than other clinics not employing pharmacist management, so they continue to expand the pharmacists’ role.

Roger Woolf, Pharm.D.

Now, the health system’s 22 clinical pharmacists—all board-certified in ambulatory care— manage patients in additional areas such as chronic opioid therapy, hyperlipidemia, behavioral health management, anemia management, and smoking cessation. Practicing under the state’s collaborative drug therapy agreement, pharmacists can manage multiple conditions at once, easing provider workload by helping with direct and indirect patient care, said Jenny Park, Pharm.D., BCACP, a clinical pharmacist with the medical center.

“We refer to it as skill task alignment,” said Roger Woolf, Pharm.D., administrative director and chief pharmacy officer for the Virginia Mason Health System, of the team-based care model. “Our pharmacists manage drug therapy. They can prescribe, they can change doses, order labs and other diagnostics to ensure the patient’s medications are being used with the right intent or getting the desired outcomes. If you’ve got a full spectrum of patients coming in, some of whom need in the weeds medication management, who’s the best person? The majority of the time, that’s going to be the pharmacist.”

Adds Dr. Furlong, “What makes people feel engaged is not just giving a pat on the back or a reward, because eventually, if the work they’re doing is not meaningful, that reward will feel hollow. You respect people when you help them to develop professionally and to work at the top of their abilities.”

Increased Job Satisfaction

Jenny Park, Pharm.D., BCACP

Through this process, pharmacists have been able to help the health system achieve certain quality measures, Dr. Park said. For example, a few years ago, Washington State had depression management rates of less than 40%. Investigating, Dr. Park and colleagues discovered that some patients would abruptly stop their medications because of side effects or because they felt the drugs weren’t working fast enough. The health system began a process through which pharmacists would follow up with any patient started on medication for anxiety or depression after two weeks through a telehealth visit to assess side effects or reassure them to allow more time. From there, they reassess every six weeks, noting improvements in medication adherence and patient-reported outcomes.

The Kirkland workday also incorporates mandatory pauses. Pharmacists see patients for 20- to 40-minute visits throughout the day. They have one built-in 20-minute pause in the mornings and one in the afternoons that they can use to catch up on documentation or other indirect patient care tasks without feeling frenzied. Additionally, leadership supports activities like team discussions on being inclusive and honoring diversity, and quarterly workshops about empathetic communication skills. A Joy at Work team arranges outings to bowling alleys or potluck meals.

With all of these items in place, job satisfaction has been high, Dr. Furlong said. In a 2018 employee satisfaction survey, 93% of clinicians reported they were content or engaged.

Winning the ASHP award has been gratifying, he said. “It feels good, especially for the pharmacists who do so much work, to share this award with them.”

“I love my job, I love my profession, and I love bragging about Virginia Mason and sharing all that I do,” Dr. Park added. “To be able to do that on a bigger level nationally is amazing. The possibilities are endless for what pharmacists can do.”

Drs. Furlong and Park were part of a team that presented information on their model through a national webinar in January sponsored by the National Academy of Medicine (NAM). ASHP is an original sponsor of the NAM Action Collaborative on Clinician Well-Being and Resilience and is proud to represent pharmacy in interprofessional efforts to address the critical workforce and patient care issue of well-being and resilience.

By Karen Blum


# # #

VA Clinical Pharmacy Practice Office and Pharmacy Residency Program Office Win ASHP Board of Directors’ Award of Excellence

Anthony Morreale, Pharm.D., M.B.A., BCPS, FASHP

WHEN ANTHONY MORREALE, PHARM.D., M.B.A., BCPS, FASHP, started working for the Veterans Health Administration (VA) in 1985, only a few pharmacists had advanced practice prescriptive authority in the ambulatory care setting, and the majority of their clinical practices were in hospital-based acute care. As the VA evolved into more of an ambulatory care-based system, the role of clinical pharmacists continued to expand.

Prescriptive Privileges

Now, a decade after the VA and Dr. Morreale launched a dedicated Clinical Pharmacy Practice Office (CPPO), the health system has a highly interactive, supportive infrastructure to engage pharmacy leadership, share best practices, and promote the role of clinical pharmacy specialists (CPSs) system-wide. Over 4,500 CPSs, about half of all pharmacists in the VA. have prescriptive privileges as part of their advanced practice roles managing patients in primary care, pain management, mental health, acute care, and antimicrobial stewardship.

It’s a primary reason why the VA Pharmacy Benefits Management CPPO and Pharmacy Residency Program Office (PRPO) were among two recipients of the 2020 ASHP Board of Directors’ Award of Excellence.

“The VA CPPO and PRPO developed and implemented comprehensive strategies to expand advanced clinical practice excellence and post-graduate pharmacy residency training,” ASHP said in a formal announcement. “These innovative efforts resulted in greater patient access to care, improved patient safety, identification and treatment of substance use disorders, and enhanced care coordination.”

According to Dr. Morreale, the CPPO work started in primary care with the VA’s system-wide adoption of the team-based care medical home model, which embraced pharmacists with prescriptive privileges playing key roles in those teams.

“That just happened to be a natural marriage that really helped expand the role of clinical pharmacy specialists in ambulatory care,” he said. “Having pharmacists embedded in all of those teams really launched a number of initiatives.”

Boot Camps for Pharmacists

The pharmacists initially helped manage patients with core diseases like diabetes and hypertension, said Dr. Morreale. Then the CPPO created clinical boot camps in different geographic regions to train primary care pharmacists on additional conditions they would encounter in ambulatory care, including osteoporosis and pain management, utilizing a train-the-trainer model where they would go back and teach their colleagues. In 2015-2016, with the approval of better drugs for hepatitis C, CPPO held national boot camps to train hundreds of pharmacists, who eventually managed over 30% of all hepatitis C patients, resulting in nearly 100% of those patients having a clinical cure from the disease.

More recently, CPPO, in conjunction with the Office of Rural Health, has held boot camps focused on expanded primary care, mental health, and pain management efforts to fill an identified gap in comprehensive medication management in the veteran population. In this project, over 180 CPSs were hired across 63 VA medical facilities focused on improving veterans’ access to comprehensive medication management in rural settings.

“The physicians really appreciate the comprehensive medication management support, because many of those disease states have either complex pharmacotherapy or require a lot of hand-holding of the patients, and they may not have the time or bandwidth to do it,” Dr. Morreale said.

Additionally, CPPO holds leadership trainings for pharmacy champions, conducts site visits with VA center leadership to promote the role of clinical pharmacists, and operates a coaching and mentoring program through which new clinicians and pharmacy leaders are paired with seasoned pharmacists. It’s been a multi-pronged approach to expanding roles for CPSs that was built one step at a time, said Dr. Morreale.

“We obviously don’t do all of this work to win an award—we’re doing it to do the right thing and take care of the Veterans,” he said. “But it’s always nice, after 10 years of hard work with some major successes, to have the recognition of ASHP and national attention to the program. Maybe as a result, there will be more programs that will start to implement the same type of strategies.”

Innovation in Residency Training

Lori Golterman, Pharm.D.

The VA also was recognized for its work in post-graduate pharmacy residency training. The VA operates the largest pharmacy residency program in the country, said Lori Golterman, Pharm.D., National Director of Residency Programs and Education for the PRPO, with some 272 residency program directors, and 628 residents and fellows. About 60% of residents are recruited into full-time positions with the VA when they complete training.

“We’re extremely innovative with our programs,” Dr. Golterman said. Residents have trained in a variety of areas including mental health, rural health, pain, neurology, and oncology. “We are the leaders in psychiatric training, with approximately 77 residents trained annually, as well as pain, neurology and other specialties such as ambulatory care. We were recognized with this award for our latest expansion of pain residencies. We are training 15 residents a year, and it continues to grow as former residents are eligible to become residency program directors.”

Besides monthly calls with residency program directors and residents, PRPO supports teaching and preparing for accreditation visits, responses to surveys, preceptor development, resilience, and much more, Dr. Golterman said. “PRPO supports its trainees throughout the year, with a variety of learning opportunities. The residency year starts with a project design and statistics course, a learning program for presenting articles and evaluating literature, quarterly leadership presentations, monthly conference calls, resilience training, and periodic surveys to check on well -being,” she explained.

The Federal Resident’s Council —a group of 25 residents that include VA and Indian Health Service residents (next year it will include the Department of Defense)—provides information to residents nationally through several committees such as a professional development committee; research committee; networking committee; and an IT committee. The Council works with the Residency Advisory Board to support issues like virtual interviewing and mentoring.

Promoting Resilience

The program also dedicates a lot of time to resilience. “We were among the first to identify stress, anxiety, and depression among

Virginia Torrise, Pharm.D.

residents and report it to ASHP,” Dr. Golterman said. PRPO brought in a psychologist to help with these issues and promoted using mental health resources offered through the VA’s employee assistance program. And, with the start of the COVID-19 pandemic, the residency program quickly adopted virtual training methods for situations where residents could not be on-site.

Dr. Golterman noted that receiving the ASHP Board of Directors’ Award of Excellence is a reflection on the entire team. Her residency advisory board has a combined 240 years’ experience in pharmacy. “They are the heartbeat of the program, and they spend a lot of their own time to support the residency program directors and preceptors and strive toward excellence,” she said.

Virginia Torrise, Pharm.D., deputy chief consultant of Pharmacy Benefits Management professional practice for the VA, added, “Drs. Morreale and Golterman have ensured that the VA has highly qualified, advanced pharmacist-practitioners serving our veteran patients on interdisciplinary teams to meet VA priority needs in primary care, mental health, and pain specialty.  Their work has ensured VA expanded clinical pharmacy telemedicine services to our Veterans who reside in rural health settings and addressed difficulties commuting to a VA clinic. I couldn’t be prouder of their leadership, foresight, and dedication to advancing residency training and clinical pharmacy practice in the VA.”

By Karen Blum


# # #



October 26, 2020

ASHP Continues to Expand Engagement Opportunities and Advocacy Impact

Filed under: From the CEO — Amy Erickson @ 9:05 pm

Dear Colleagues,

ASHP is always striving to develop the best tools, resources, advocacy, and education so our members can provide optimal care to their patients and grow, develop, and advance their pharmacy careers.

I would like to highlight a few recent examples of how ASHP supports leadership development and facilitates meaningful connections so that our members can continue to thrive in today’s rapidly evolving healthcare landscape.

Opportunities in our Newest ASHP Sections

Recently ASHP launched the Section of Community Pharmacy Practitioners, providing a distinct membership home within ASHP for pharmacists, student pharmacists, pharmacy residents, and pharmacy technicians who practice in community/ambulatory pharmacy-based settings and who are involved in direct patient care, leadership and management, and implementation of advanced practice models and education. The new Community Pharmacy Section is currently accepting applications for the inaugural Executive Committee, which will play a pivotal leadership role in shaping the future of this important new membership group. This is an exciting new opportunity for ASHP members to further advance care at the community level, and to help improve continuity of care for patients in and across all patient care settings. Executive Committee members will provide major leadership, guidance, and advice to ASHP on ways to better meet the needs of community-based practitioners and leaders. The deadline for applications is Nov. 2. I encourage you to apply as we hope to further engage you in ASHP!

This week is National Health Education Week. I’m pleased to share that the Executive Committee for our recently launched Section of Pharmacy Educators will be conducting its first meeting on Friday. Pharmacy educators have played critical roles in ASHP for many years. The idea to create this new section came directly from our pharmacy educator members and reflects ASHP’s strong desire to further support them in developing more seamless and bidirectional communication and engagement between pharmacy education and hospitals and health systems. The Executive Committee is chaired by Dr. Marie Chisolm-Burns, Dean and Distinguished Professor of the University of Tennessee Health Science Center College of Pharmacy and Professor of Surgery in the College of Medicine, who will lead this initial meeting to help establish the tone and strategic direction for the section. I am looking forward to attending the meeting and engaging with this impressive new group. I am confident that the section will get off to a strong start.

Recent Engagement Opportunities

ASHP’s virtual Conference for Pharmacy Leaders, celebrating a milestone silver anniversary, concluded earlier this week. ASHP held the first conference 25 years ago with 150 attendees to emphasize leadership development for the profession. This year’s conference was an overwhelming success, bringing together 500 attendees with strong representation from hospital and health-system pharmacy administration and leadership residents. Attendees participated in virtual roundtable discussions and breakout sessions to connect, strategize, and exchange ideas on telehealth, women in pharmacy leadership, COVID-19 business recovery, and multi-hospital pharmacy services. Our keynote speakers, Deb Boelkes, M.B.A., B.S., and Bryan K. William, DM, shared leadership strategies and solutions that dovetail with ASHP President Tom Johnson’s inaugural themes of transformation, servant leadership, and acting on your truth. Thank you to the current and aspiring leaders who attended this exceptional event.

Our virtual National Pharmacy Preceptors Conference kicks off tomorrow. The agenda is rich in education and networking opportunities to help attendees stay current with the latest accreditation standards. If you haven’t already registered for the National Pharmacy Preceptors Conference, there is still time. I encourage you to take advantage of the many networking opportunities, training tips, and advice that have been developed to help preceptors of residents and students learn and apply best practices.

Rounding out ASHP’s efforts to provide members with leadership and engagement opportunities is our inaugural ASHP Pharmacy Executive Leadership Alliance (PELA) Summit, which will be held next week. ASHP created PELA earlier this year as a new engagement opportunity to provide distinctive, interactive, and highly productive networking, strategic planning, and professional development activities for pharmacy executives in complex hospital and health-system settings. PELA provides a venue to address the increasing demands for integrated strategic decision-making to ensure we are advancing medication use that is optimal, safe, and effective for all people all of the time across our nation’s multi-hospital health systems and integrated health networks. More than 170 pharmacy executives representing multi-hospital health systems and major hospitals and academic medical centers are participating in the event, which is focused on business recovery and rebuilding in response to the COVID-19 pandemic.

ASHP continues to create new engagement opportunities to meet the needs of our members who hold a wide array of leadership positions within their organizations. Whether you are a clinician, preceptor, mentor, new manager, or seasoned pharmacy executive, ASHP has a wealth of exciting new programs and opportunities for service, networking, knowledge-sharing, and personal development. We hope you continue to take advantage of these exceptional opportunities. Be on the lookout for new and innovative programming as we continue to enhance our offerings in support of our diverse membership.

The Latest ASHP Advocacy Efforts

ASHP is engaged in a wide array of advocacy on your behalf. I would like to highlight a few key recent ASHP efforts. ASHP called on policymakers to provide transparency into the quality of drug manufacturing as part of our legislative objectives developed with the American Hospital Association, the American Society of Anesthesiologists, and the American Society of Clinical Oncology to address drug shortages. The Food and Drug Administration (FDA) recently announced new programs that focus on drug manufacturing quality. These programs align with our legislative objectives, and we applaud the FDA for launching these programs to improve the transparency of drug manufacturing quality.

ASHP and our partners — 340B Health, America’s Essential Hospitals, the American Hospital Association, the Association of American Medical Colleges, the Catholic Health Association, and the Children’s Hospital Association — are advocating on your behalf to support the 340B Drug Pricing Program. We launched a digital advertising campaign opposing pharmaceutical manufacturers’ actions that threaten to undermine this program. The campaign targets policymakers and has been viewed 8.6 million times. ASHP is also coordinating with our partners to promote messaging on social media about how 340B benefits hospitals, health centers, clinics, and your patients using the hashtag #Protect340B.

We’re also continuing to engage on multiple fronts to advocate for an effective vaccine rollout plan. Most recently, we shared key insights from ASHP’s Principles for COVID-19 Vaccine Distribution, Allocation, and Mass Immunization during Friday’s Department of Health and Human Services (HHS) National Vaccine Advisory Committee public meeting. We requested that details related to the storage and handling of any approved vaccine(s) be made available as early as possible to assist our members in planning for Phase 1 allocation and distribution.

Tomorrow, we are participating in HHS’s Office of the Assistant Secretary for Preparedness and Response’s Operation Warp Speed COVID-19 Vaccine Distribution Strategy briefing for a discussion on distribution logistics, security, and planning assumptions related to the COVID-19 vaccine. We look forward to providing you updates on that briefing. We also submitted comments and will be attending the FDA Vaccines and Related Biological Products Advisory Committee meeting tomorrow to provide guidance as the agency continues to plan for the approval and authorization of COVID-19 vaccine(s).

We are actively working with many other leading healthcare organizations as well to support clear guidance and leadership on vaccine preparedness efforts. Most recently, we united with 19 other health organizations to form the National Associations’ COVID Vaccine Leadership Council to complement the efforts of the Centers for Disease Control and Prevention, HHS, and Operation Warp Speed, and support state-level efforts. Additionally, we continue to update our dedicated COVID-19 Vaccine webpage, which includes tools, resources, and other support that I hope you will leverage as we work to support you through this public health crisis.

Finally, I’d be remiss if I didn’t mention that this week is National Pharmacy Week. Please view a short video message from me. I am so proud of the extraordinary responsiveness, resilience, and camaraderie shown by ASHP members during this extremely challenging year.

Thank you for being a member of ASHP and for everything you do for your patients and our profession during these very challenging times.



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