ASHP InterSections ASHP InterSections

March 8, 2019

North Dakota Technician Champions National Certification

This article is part of a series featuring ASHP’s pharmacy technician members and their valuable contributions to the profession. Check out ASHP’s Pharmacy Technician Forum for more information about efforts to advance the pharmacy technician workforce, as well as ways for pharmacy technicians to become more involved in ASHP.

 

Diane Halvorson, CPh.T.

AS A YOUNG ADULT, Diane Halvorson, CPh.T., never intended to become a pharmacy technician. But now, more than 25 years later, she has a gratifying career and is an influential figure in the field. As Lead Pharmacy Technician at Vibra Hospital Pharmacy in Fargo, N.D., Halvorson is a staunch advocate for improving technician certification and education programs.

Successful Technician
Halvorson began working at a hospital pharmacy more than two decades ago. As a single mother, she needed to find a way to support her son. Halvorson was lucky enough to learn the pharmacy technician trade on the job. She didn’t have any experience, but back then the job of a pharmacy technician was “very basic,” she said. She mostly managed the prescription medication stock.

Over time, her boss (the pharmacy director) took notice of her attention to detail and ability to manage her time and work efficiently. “As pharmacy evolved, I evolved along with it,” she said. “I became a sponge and started attending conventions, conferences, and any continuing education I could to expand my knowledge. The support of my peers and leaders gave me the confidence to excel.” When she began serving on the North Dakota Board of Pharmacy in 2011, she realized it was time to become certified.

“I have taken every opportunity to gain the knowledge and understanding of pharmacy and have evolved into the person I am today,” she said

National Standards for Techs
As a member of ASHP and other national and state pharmacy organizations, Halvorson was appointed by the governor of North Dakota to serve a second term on the North Dakota State Board of Pharmacy, with a goal of implementing education and certification programs in the state. The position has provided a forum to speak out about the need for standardizing pharmacy technician training across the nation.

Currently, there is no standard training or certification on a national level to become a pharmacy technician. Education and certification requirements to earn a CPh.T. degree vary by state. Some states may require more training than others, additional exams, or recertification.

But standardization in the profession is needed now more than ever. Pharmacists are now working in more clinical roles, but prescriptions still need to be filled. “Pharmacy technicians should have the credentials and knowledge to fulfill this role safely and accurately,” said Halvorson.

Expanding Tech Education
Halvorson and many of her colleagues would like to see pharmacy technicians undergo the same rigors of training that pharmacists face. “I feel we should have a national standard that establishes a way to ensure all pharmacy technicians have a baseline knowledge when entering the profession,” said Halvorson. “While our education would not be as detailed as the pharmacist, our process should mirror the process of the pharmacist.” The process would include the completion of an exam that verifies the baseline knowledge, she added.

Halvorson is an advocate for improving technician certification and education programs.

Some of the strictest requirements in her field exist in her home state of North Dakota, where pharmacy technicians are required to receive their education from an ASHP/ACPE accredited program. They must take a national certification exam to demonstrate their knowledge of the field, and they may only earn their certification in the state after meeting those requirements.

Hospital pharmacies in North Dakota are also required to have a quality assurance program to track prescription errors. “If you have a near-miss or a mistake that reaches the patient, you need to document it,” said Halvorson. “Was this an isolated incident? Was there a product problem or process problem or personnel problem?”

Technician Advocacy
Donna Kisse, CPh.T., is a pharmacy technician who has gotten to know Halvorson through their service together in North Dakota’s Northland Association for Pharmacy Technicians. Kisse and other colleagues admire Halvorson for the advocacy work she’s taken on toward a goal of consistent, national certification requirements for pharmacy technicians.

“Since pharmacists are taking the lead in clinical patient care roles, pharmacy technicians must be leaders in supporting standardized qualifications to ensure pharmacies are safe, efficient, and have productive work environments,” said Kisse.

Halvorson became involved with ASHP through the Pharmacy Technicians Stakeholders Consensus Conference steering and advisory committee. “For me, being a member of ASHP has elevated my overall knowledge and fundamental understanding of the opportunities of expansion of the scope of practice that a pharmacy technician can achieve,” she said.

The ASHP Pharmacy Technician Forum, which launched last year, has also been integral to her efforts. She currently serves on the forum’s Patient Care Quality Advisory Group committee.

Halvorson began her technician career more than two decades ago and currently serves as the Lead Pharmacy Technician at Vibra Hospital Pharmacy.

Reducing Prescription Errors
Halvorson hopes that all states will move toward following strict training guidelines like those in North Dakota. By not standardizing pharmacy technician training, Halvorson said the profession is putting the safety of patients in jeopardy. “The consumer believes that any person behind the pharmacy counter has education, that those people know what they’re doing, and that they have a minimum education.”

She recalled an incident that made headlines years ago. It involved Emily Jerry, a three-year-old girl in Ohio who died in 2006 as a result of a hospital pharmacy technician error. At the time of the toddler’s death, Ohio didn’t register pharmacy technicians or require any training or licensing to do the job. In 2009, Emily’s Act was signed into law. The legislation requires that pharmacy technicians be at least 18 years of age, register with the State Board of Pharmacy, and pass a Board-approved competency exam. It also includes requirements related to technician training.

“Humans make errors, and that’s why in a pharmacy you have a check and balance,” Halvorson said. That safety net wouldn’t exist without Halvorson and other passionate pharmacy technicians.

By Jessica Firger

 

# # #

December 18, 2018

ED Pharmacists Keep Opioid-Naive Patients Naive

ED pharmacists Zachary Brent, Pharm.D., BCPS, and Julie Bennett, Pharm.D., MBA, BCPS, discuss opioid metrics.

IN THE EMERGENCY DEPARTMENT (ED) of Baptist Memorial Hospital in Memphis, Tenn., an innovative opioid stewardship program is showing real promise in keeping opioid prescriptions to a minimum while making sure patients are comfortable and pain-free. The program’s primary goal is to keep opioid-naive patients naive.

Opioids in the ED

“Opioids are an increasing problem in the ED, not because pharmacists are seeing so many more overdoses — those are often treated by EMTs — but because the ED is often where a patient is first exposed to opioids,” explained Julie Bennett, Pharm.D., M.B.A., BCPS, a pharmacist who works in Baptist Memorial Hospital’s bustling ED. “We realized that if we could find a way to eliminate that first exposure, then we could make a significant impact on the opioid crisis.”

With the full support of Baptist Memorial’s ED physicians and leadership, Dr. Bennett and Zachary Brent, Pharm.D., BCPS, also an ED pharmacist at Baptist Memorial, set out to create an opioid stewardship program that offers opioid alternatives to patients.

The two pharmacists, both members of ASHP, began the project in January 2017 by collecting data on opioid usage in Baptist Memorial’s ED. They chose milligrams of morphine equivalents per 100 emergency department patient visits as the primary metric. The data showed that in January 2017 the ED staff was giving 120 mg morphine equivalents per 100 ED patient visits. “This was sobering,” said Dr. Brent. “We were giving a dose of opioids to one out of every four patients in the ED.”

Opioid Alternatives

To reduce opioid dispensing, the hospital’s pharmacy team created an opioid stewardship program based on a program implemented at the Swedish Medical Center in Englewood, Colo. First, the Baptist Memorial pharmacy team identified five conditions that are typically treated with opioids: chronic abdominal pain, headache/migraine, renal colic, extremity fractures/joint dislocations, and musculoskeletal pain. The team then provided physicians with non-opioid alternative treatment options for each condition.

Dr. Bennett orders medications from an automated dispensing system.

“Treatment options are broken down into first-, second- and third-line options,” said Dr. Brent. “For example, first-line treatment for headache/migraine might include a liter of saline plus oxygen, ketorolac, ketamine, or lidocaine injections. A physician might choose one, two, or even three of these options.”

He noted that many of the first-line options are common OTC pain medications, but in IV form. “All of the treatment options are built into our computer physician order entry system so our physicians can easily access and order these alternative pain medications,” said Dr. Brent. “Most of the alternative options are also stocked in our automated dispensing cabinets in the ED to allow for quick retrieval by nurses.”

If an opioid is needed, then the pharmacy team will try to use the lowest effective dose. “If patients come in on opioids, that’s fine, but it doesn’t necessarily mean that we are going to give them opioids while they are in our ED,” said Dr. Brent. “The alternative medications we use tend to work quicker and more effectively to alleviate patients’ pain.”

For example, Dr. Bennett recalled a recent situation where a patient who used morphine and oxycodone at home for a certain condition wanted a prescription from the ED pharmacist to alleviate pain caused by her shoulder bursitis. “She already had topical lidocaine patches and creams and every other alternative I could think of at home,” said Dr. Bennett, who ultimately recommended a nonsteroidal anti-inflammatory drug called ketorolac. The patient remembered that she received ketorolac for a dental procedure and that it had really helped with the pain.

Communication and Education

Soon after rolling out the new opioid stewardship program, the pharmacists experienced a bit of pushback from physicians who were used to ordering opioids and from patients who expected to get them. The pharmacy team used a combination of communication and education to demonstrate why opioid alternatives can often be a better option.

ED physician Katrina Hutton, D.O., and Dr. Bennett talk about opioid alternatives for a patient being discharged.

On the patient side, the pharmacy team assisted nurses with answering patients’ questions about the alternative medications and made sure that patients’ pain needs were always being met. “There were many times when I was called to a room to explain to a patient how the alternative medication works and why it is better than an opioid,” explained Dr. Brent. “Sometimes the patient was satisfied with the explanation, and other times they weren’t.” He believes the conversations with patients helped them understand that the providers in the ED were trying to do what was best for them, instead of just defaulting to using opioids.

Although the physicians were excited about the change and enthusiastic about providing more appropriate care for their patients, “it was still difficult for them to curb their opioid use, since it was a habit for them to order opioids,” said Dr. Brent. “Once our providers knew they had support [from hospital leadership], and we provided them with the order sets and educated the nurses about opioid alternatives, they were all in.”

Satisfied Patients, Satisfied Providers

As a result of implementing the opioid stewardship program in the ED at Baptist Memorial, opioid use decreased by 73 percent. Where previously one out of four patients received a dose of an opioid in the ED, the number has now dropped to 1 out of 10. Patient satisfaction with how they felt their pain was being addressed increased by around 30 percent.

Dr. Brent believes the entire team of ED pharmacists, physicians, and nurses at Baptist Memorial has done a great job of communicating to the patient why they are being given an opioid alternative. “We are all focused on taking care of patients effectively and efficiently,” said Dr. Brent. “Through the opioid alternative program, pharmacists are providing physicians and nurses with the support to do that. ED pharmacists are in the perfect position to partner with our providers to give them the tools needed to take care of patients appropriately.”

 

By Ann Latner

 

# # #

August 31, 2018

Pharmacy Technician Untangles Knots in the Supply Chain

This article is part of a series featuring ASHP’s pharmacy technician members and their valuable contributions to the profession. Check out ASHP’s Pharmacy Technician Forum for more information about efforts to advance the pharmacy technician workforce, as well as ways for pharmacy technicians to become more involved in ASHP.

 

AS A PHARMACY TECHNICIAN WHO WORKS AS A  SUPPLY CHAIN CONSULTANT for McKesson Pharmacy Optimization, Cindy Jeter, CPh.T., solves problems. She uses 20 years of pharmacy expertise, her Lean Six Sigma training, and specialized interviewing techniques to help hospital pharmacies across the country optimize workflow, reduce drug expense, and maintain optimal medication inventory levels.

 

Cindy Jeter, CPh.T.

Super Sleuth

On one assignment, Jeter was asked to use her supply chain knowledge to solve a mystery at a large teaching hospital in Texas. More than half of the IV bags prepared in the hospital’s pharmacy were being sent back to the pharmacy at the end of the day. “This meant that roughly 400 bags of IV solution were unused, resulting in thousands of dollars’ worth of medication being thrown in the trash every day,” explained Jeter. “In addition, pharmacy technicians spent four to five hours every day updating the computer system to make sure patients weren’t being charged for unused IV medication.”

After conducting an in-depth analysis, she identified one major cause, observing that when patients were moved to a different area of the hospital, their IV medications weren’t moving with them. The medication was being reordered once the patient was on the new floor and the IV medications on the old floor were then returned to the pharmacy. With more than 250 intensive care unit beds, the number of transfers among floors each day was substantial.

Once Jeter identified the problem and the causes, pharmacy leadership revised their processes and reduced IV bag returns to the pharmacy by 91%. “Consequently, they saved a lot of money, and staff morale increased because technicians didn’t have to spend so much time at the computer updating patient charges,” said Jeter. The pharmacy staff appreciated that I did the investigative work and removed the problem from their plates so they could concentrate on patient care.”

 

Why Pharmacy?

The satisfaction that comes with solving problems is one of the reasons why Jeter went into pharmacy. Jeter, who resides in Springdale, Ark., has a bachelor’s degree in general science from West Texas A&M University. She landed a job as a pharmacy technician at a community hospital pharmacy in 1998. “I didn’t know anything about pharmacy,” she recalled “But they were willing to teach me and invest time in my development for a six-month trial period.” She passed the National Pharmacy Technician Certification exam and, with her aptitude for business, she found her niche in supply chain pharmacy.

Reflecting upon her career accomplishments, Jeter is most proud of winning an innovation award for a McKesson competition in October 2017. The award will fund an online training course for pharmacy buyers, inventory coordinators and supply chain. It is comprised of courses in key areas that are pertinent to pharmacy purchasing such as inventory management, drug shortages, purchasing analytics, emergency preparedness, and pharmacy regulations. “There is a lack of formal training for this vital staff position,” she said. “The world of pharmacy purchasing has increased in complexity over the last decade and requires more skills than before to navigate the challenges associated with pharmacy purchasing.”

 

Inventory Control

In addition to solving supply chain mysteries, Jeter finds fulfillment in helping pharmacy purchasers with inventory management. “In a hospital pharmacy, it’s imperative that you have needed medications in stock,” she said. “You also need to be prepared to treat many patients at the same time. This differs from retail pharmacies, which don’t have to be equipped with products for emergency situations such as a mass shooting or traffic accidents.”

By helping hospital pharmacies control inventory costs, Jeter believes she saves pharmacy jobs. She explained that there are generally three expenses in a hospital pharmacy: medications, staff compensation, and automation expenses. When hospitals are struggling financially, they either have to cut drug costs or employees. “It’s rewarding to help customers more efficiently manage inventory so they can maintain a full staff,” she said.

Jeter is also passionate about being an advocate for pharmacy purchasers. She noted that purchasers have a difficult job trying to manage drug shortages and provide for patient needs. “It takes a lot of dedicated time and effort to keep the hospital pharmacy supplied with the right drugs at the right time,” Jeter said. “Pharmacy purchasers do not always receive training or professional development opportunities.”

She added that being a purchaser is a complex, complicated, and demanding job. Purchasers have tremendous responsibility in providing for patients and do not have the option of simply being out of a medication or a product. Bringing awareness to the position is critical.

 

Advanced Opportunities

With pharmacists taking on more direct patient care roles, there are more advanced opportunities for pharmacy technicians than ever before. Examples include being a supply chain consultant like Jeter, a pharmacy purchaser, a data analyst, a business manager, or a quality assurance specialist.

According to the Bureau of Labor and Statistics, there will be a 12% job growth rate for pharmacy technicians between now and 2026. “It’s an exciting time for pharmacy technicians to find their niche,” Jeter said. Her best advice for technicians is to be an advocate for yourself, make a plan to reach your goals, and let your manager know what you’d like to achieve.

 

ASHP Endeavors

Jeter, an ASHP member since 2003, finds the organization’s education and networking opportunities invaluable. “Being able to present to my peers about projects I have worked on has helped me increase my leadership skills,” she said.

From 2010 to 2014, Jeter served on the Section Advisory Group on Pharmacy Support Services. As chairwoman of the group from 2011 to 2012, she advocated for the development of new opportunities for pharmacy technicians. She is excited about ASHP’s Pharmacy Technician Forum, which developed from these discussions, and the future of pharmacy technicians as integral members of ASHP.

More recently, Jeter served from 2015 to 2017 on the Pharmacy Technician Certification Board Task Force for Advanced Technician Certification, which is working to advance opportunities for technicians to become certified in expanded roles.

“There has never been a more exciting time to be a pharmacy technician and involved in ASHP,” Jeter concluded. “There are practically endless ways technicians can help patients and provide important care.”

By Karen Appold

 

# # #

March 27, 2017

ASHP’s 75th Anniversary: Celebrating the Past, Creating the Future

Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP

ASHP TURNS 75 THIS YEAR, and we have a yearlong campaign filled with surprises and exciting events for our members to celebrate this significant milestone. The last 75 years have been marked by so many ASHP-led advances in pharmacy practice, including: the creation of postgraduate residency training, clinical pharmacy, enhanced recognition of pharmacists as vital members of the interprofessional team, the largest gathering of pharmacists in the world — the ASHP Midyear Clinical Meeting — and so many more.

Although much has been accomplished over the last 75 years, our focus remains on the future, and ensuring that more and more people have access to the direct patient care services of pharmacists. Therefore, the theme of our yearlong celebration is Celebrating the Past, Creating the Future.

The founders of ASHP were visionaries who understood and learned from the past but realized that pharmacists must transform their practices. They worked hard to create a practice future designed to dramatically improve the care of their patients. These leaders included legends such as Gloria Niemeyer Francke, ASHP’s first CEO; Harvey A.K. Whitney, ASHP’s first president; and Donald Francke, ASHP’s second president; and, of course, Joseph A. Oddis, ASHP’s CEO for over 37 years. These are just a few of the great leaders who realized very early that pharmacists must do so much more than dispense drugs, and that ASHP should be the organization that makes it happen on behalf of patients.

Prior to the 1920s, hospital pharmacy was not a strong, well-organized component of the profession. In 1936, a subsection of hospital pharmacists in APhA was formed and, for the first time, hospital pharmacists had a voice on the national pharmacy stage. In 1942, the American Society of Hospital Pharmacists was formed with 153 charter members who worked exclusively in hospital settings.

Today ASHP has nearly 45,000 members who treat patients in every healthcare setting, including in ambulatory clinics, hospitals, and throughout the entire continuum of patient care. ASHP members are involved in all facets of pharmacy practice and include inpatient pharmacists, ambulatory care pharmacists, clinical specialists and scientists, informatics experts, practice managers, student pharmacists, residents, new practitioners, pharmacy technicians, and others.

We owe our success to our dedicated members, which is why we would like you to help us celebrate our diamond anniversary. We have a number of special activities scheduled throughout the year, culminating in a grand finale celebration at the Midyear Clinical Meeting in Orlando in December. We also are planning significant activities for key ASHP events including the Summer Meetings in June, the Preceptors Conference in August, Policy Week in September, and the Leaders Conference in October.

Thank you so much for being a member of ASHP, and for everything you do for your patients. With your help, we can continue to improve patient care and support you in your professional endeavors.

Please join us in celebrating this important anniversary — and stay tuned for more details as we roll out our 75th anniversary celebration.

Sincerely,

Paul

June 14, 2011

Informatics and the Health-System Pharmacist

AMONG THE SIGNIFICANT TRANSFORMATIONS in hospital pharmacy practice that have pushed the profession toward more direct, safe, and effective patient care, the emergence of informatics ranks near the top. When they are well-designed and properly implemented, the complex technologies that constitute pharmacy informatics can reduce medication errors, streamline medication-related processes, monitor patient status, and provide pharmacists, physicians, and nurses with instant access to critical information at the point of care.

“The precision and safety we can provide to the medication system has been astounding,” said Leslie Mackowiak, R.Ph., M.S., director of clinical information systems at Vanderbilt University Medical Center in Nashville. Vanderbilt’s integrated medication system supports electronic transfer of medication information from physician ordering, through pharmacy verification, to nursing bar-coded medication administration and documentation.

The system verifies the dispensing authority of the caregiver and the patient’s identity; matches the identity with the medication profile from the pharmacy information system, which has checked against alerts or reminders; and then records the action in the electronic medication administration record.

Hospitals considering this type of new technology must weigh the equation of patient safety and quality of care, according to Karl Gumpper, R.Ph., BCNSP, BCPS, FASHP, director of ASHP’s Section of Pharmacy Informatics and Technology.

“Is this technology going to prevent a bad outcome and add a level of patient safety? Will caregivers be able to take better care of patients?” he queried. “In most cases, the answer is yes.”

ASHP Leading the Way

ASHP continues to be at the forefront of this special field, offering members a special section, continuing education and information resources, and practice documents like the Statement on the Role of Pharmacists in Informatics.

The Society also ensures that key elements of informatics and technology are rolled into every major Society initiative. For example, at ASHP’s Pharmacy Practice Model Initiative Summit in Dallas in November 2010, participants noted that key elements of pharmacy informatics are “important enablers” in developing optimal pharmacy practice models.

These elements include:

• Computerized physician order entry (CPOE)

• Automated dispensing/robotics

• Electronic medical records (EMR) systems

• Bar code technology during medication administration

• Clinical decision support systems (CDSS) integrated with CPOE

• Systems that capture and report pharmacy metrics and outcomes data, among other kinds.

According to ASHP practice surveys, 18.9 percent of hospitals used combined CPOE and CDSS, up from 10.4 percent in 2007, and 17.8 percent of hospitals reported the adoption of information technology (IT) to some degree by 2007.

Informatics creates a better safety net by removing stumbling blocks scattered throughout paper-based systems, such as prescription transcription errors and overreliance on memory, which too often result in medication errors, according to Gumpper.

“The ability to document a pharmacist’s intervention at the bedside into the medical record by laptop or tablet gives pharmacists the tools to actually do what they were trained to do in school and their residencies,” he added.

Informaticists as Liaisons

Enhanced patient safety is just one potential benefit of pharmacy informatics, according to Gumpper. He noted that technology that processes and verifies patient medication orders on the ward or in the clinic creates better work-flow efficiency and greater satisfaction among nurses and patients.

But technology cannot stand alone. Pharmacists who implement and manage pharmacy informatics systems consistently identify one factor as crucial to successful outcomes: translating clinical necessity into information technology (IT) systems and processes.

Without question, pharmacists, not IT professionals, are best suited to play that role, said Chris Urbanski, R.Ph., director of pharmacy informatics and medication integration at Indiana University Health in Indianapolis.

These pharmacy informaticists “bridge the gap and act as liaisons and interpreters between the purely IT and the clinical realm,” said Urbanski. “We have the clinical training, and I can much more easily teach information technology to a clinician than I can teach an IT person the clinical side.”

Pharmacists are obviously not computer scientists, added Mackowiak, who cultivated her expertise by working closely with IT experts. “You’ve got to know how to manage a database and envision how information will look on a computer screen. Those aren’t skills taught in pharmacy school.”

William Churchill, M.S.

Demand for pharmacists with IT credentials will only keep rising, according to William Churchill, M.S., chief of service in the department of pharmacy at Brigham and Women’s Hospital in Boston. “As the profession grows, we’ll need more individuals with strong pharmacy backgrounds who also understand information systems,” he said. “These are pharmacists who can sit at the table and talk the language of informatics with software developers, systems analysts, and informatics managers.”

Finding those unusual skill sets isn’t easy, and pharmacy schools lag well behind the curve in filling this yawning knowledge gap. “There is not an abundance of people trained appropriately in health care informatics coming out of pharmacy schools ready to fill our needs,” Churchill said, adding that the profession must find new ways to prepare pharmacists for a future in which familiarity with informatics will be mandatory.

The Future of IT and Pharmacy

That future will see more connectivity among the assorted components of medical informatics. Ideally, the right information will flow more freely to clinicians precisely when and where they most need it, but without interrupting their work flow (persistent alerts for inconsequential drug interactions, for instance, only annoy and distract users). Caregivers, said Mackowiak, should not have to look from chart to chart or wait until they visit a patient’s room to obtain the most up-do-date case information, such as lab values or pain scores.

“In the past, you would have to query a few charts, search around, or go to the floors to find the patient record,” said Christine Beuning, Pharm.D., BCPS, pharmacy informatics application analyst with MultiCare Health System, which is based in Tacoma, Wash. “Now we can generate a report within our electronic health record in 30 to 45 seconds that includes specific clinical information from a patient’s chart. Pharmacists have always been in a contest with other providers for the paper chart, and now we’re more able to share the information.”

The reach of informatics will inevitably extend beyond individual hospitals and hospital networks. For instance, a specialist in Seattle outside of the MultiCare network will, with the patient’s permission, be able to call up relevant information from the patient’s EMR, seamlessly preserving continuity of care. E-prescribing will enable pharmacy informatics systems to capture prescriptions filled at retail pharmacies, bringing clinicians a step closer to complete medication reconciliation for patients who are moving between outpatient and inpatient care.

“Right now, we’re focused on what’s going on inside the four walls of the hospital,” said Gumpper. “Informatics gives us the opportunity to move beyond that and think about the care of the overall population of patients we serve. We’re going to take a much bigger view.”

Powered by WordPress