Illinois Council of Health-System Pharmacists

4055 North Perryville Road
Loves Park, IL 61111-8653
Phone: (815) 227-9292
Fax: (815) 227-9294
ichpnet.org

KeePosted
Official News journal of the Illinois Council of Health-System Pharmacists

EDITOR
Jennifer Phillips

ASSISTANT EDITOR
Milena Murray

MANAGING EDITOR
Scott Meyers

ASSISTANT MANAGING EDITOR
Trish Wegner

DESIGN EDITOR
Melissa Dyrdahl

 

ICHP Staff
EXECUTIVE VICE PRESIDENT
Scott Meyers

VICE PRESIDENT - PROFESSIONAL SERVICES
Trish Wegner

DIRECTOR OF OPERATIONS
Maggie Allen

INFORMATION SPECIALIST
Heidi Sunday

CUSTOMER SERVICE AND
PHARMACY TECH TOPICS™ SPECIALIST
Jo Ann Haley

ACCOUNTANT
Jan Mark 

COMMUNICATIONS MANAGER
Melissa Dyrdahl

 

LEGISLATIVE CONSULTANTS

Liz Brown Reeves

Mitch Schaben

 

ICHP's Mission Statement

Advancing Excellence in Pharmacy

ICHP's Vision Statement

ICHP dedicates itself to achieving a vision of pharmacy practice where:

·         Pharmacists are universally recognized as health care professionals and essential providers of health care services.

·         Pharmacists use their medication expertise and leadership skills to optimize the medication use process and patient outcomes.

·         Pharmacy technicians are trained and PTCB certified to manage the medication distribution process.

ICHP's Goal Statements

·         Raising awareness of the critical role pharmacists fulfill in optimizing medication therapy and ensuring medication safety in team-based, patient-centered care.

·         Providing high quality educational services through innovative continuing pharmacy education and training programs, and sharing evidence-based best practices.

·         Developing and nurturing leaders through mentorship, skill development programs, and leadership opportunities.

·         Working with national and state legislators and policymakers to create or revise legislation and regulation critical to pharmacy practice and quality patient care.

·         Urging pharmacy technician employers to require successful completion of an accredited pharmacy technician training program and PTCB certification of all pharmacy technicians.

 

Approved by the ICHP Board of Directors May 30, 2018.

KeePosted Vision
As an integral publication of the Illinois Council of Health-System Pharmacists, the KeePosted newsjournal will reflect its mission and goals. In conjunction with those goals, KeePosted will provide timely information that meets the changing professional and personal needs of Illinois pharmacists and technicians, and maintain high publication standards.

KeePosted is an official publication of, and is copyrighted by, the Illinois Council of Health-System Pharmacists (ICHP). KeePosted is published 4 times a year. ICHP members received KeePosted as a member benefit. All articles published herein represent the opinions of the authors and do not reflect the policy of the ICHP or the authors’ institutions unless specified. Advertising inquiries can be directed to ICHP office at the address listed above. Image disclaimer: The image used in the Pharmacy Tech Topics™ advertisement is the property of © 2017 Thinkstock, a division of Getty Images. Some images are property of © 2020 Adobe Stock.

Copyright © 2020, Illinois Council of Health-System Pharmacists. All rights reserved.

¡Hola! Can you imagine going to a country where the profession of pharmacy like we know it in the United States does not exist?  I am currently writing to you from Antigua, Guatemala where it is 80 degrees and sunny in the beginning of March.  This is my second time coming here for 3 weeks with three 4th year student pharmacists from Southern Illinois University Edwardsville (SIUE).   We work in the clinics of Guatemala counseling on medications, providing immunizations, and screening patients for hypertension and diabetes.  Guatemala is a country with very poor health literacy and people here live on average of about $2 per day.  

What do you mean pharmacists do not exist in Guatemala?  The pharmacy (or in Spanish, la farmacia) is owned by a person that does not require training and medical expertise.   Nurses dispense medications in the Guatemalan government free clinics but the role is focused on dispensing and not counseling.  A fixed amount of free medications is sent to the clinics each month.  Once the medication runs out, it is the responsibility of the patient to go to a pharmacy and buy the medication.  There are no appointments to see the doctors in the clinic; it is first come first serve so the line is long each day when we arrive at clinic.  The patients are first taken to pre-consultation where they are weighed and have their blood pressure taken.  Blood glucose test strips are in short supply, so only patients with known diabetes have their glucose checked in clinic once or twice weekly.  No one has an A1c checked.  Patients do not have blood glucose meters at home. There are no computers in the clinic or pharmacy, so everything is documented by hand.  The patients are given a slip of white paper with a stamp on it to bring to the nurse in the clinic pharmacy.  Many patients sign for the medication with a thumb print because they can’t read or write. The nurse manages all the medications on formulary in the clinic, which includes around 60 medications. 

Something I found inspiring during my time here is how appreciative the patients are that we care for.  Most of the patients have to walk several miles just to see the doctor and patients who live in more rural areas do not see a doctor.  The kindness here is contagious.  I have received more hugs after checking a blood pressure than I can count.  I also am surprised that after waiting so long just to be seen (often hours) by the doctor, not once did I hear someone complain.  Patients genuinely want to learn how to improve their health and this year we were able to spend time teaching patients about hypertension, diabetes, and medication adherence.  This trip gives me a new perspective on life and I would encourage you to find your own way to give back. 

Stepping out of your comfort zone can be a challenge but the bigger the challenge, the bigger the reward.  This experience challenged me to improve my Spanish and learn the Spanish names for all of the drugs!  ICHP has several opportunities where you can
give back.  ICHP provides education to you so you can better care for others.  I encourage you to spread kindness to those less fortunate by sharing your knowledge and time with your patients.

Even though I’m writing this just over a month from its publication, I can only guess how much things will have changed in that short time!  Based on the past 30-days, my guess is, a lot. 

COVID-19 or Coronavirus Disease 2019, the long version, has dramatically altered life as we knew it.  And for the rest of this column, I’m going to call it CV-19 for efficiency’s sake.  Hopefully by the intended publication date of May 1, 2020, we will be able to send you a printed copy of the KP but if not, we’ll have gotten it to you online.  Thank goodness for technology and a top notch staff at ICHP!  We will hopefully be out of the “Stay at Home” mode, too, but still social distancing as much as possible.  I can see the change at movie theaters coming already, if we’re headed back.  Not only will you have to pick your seat, you’ll only be able to choose from the odd or even numbered seats, leaving an empty seat on either side.  Working out at the gym will be a more spacious event but failure to wipe down the equipment will be grounds for membership revocation!  I’m not sure what restaurants and bars will be like, but I suspect they won’t be as crowded (after the first day or two of release) as they were before CV-19 arrived.

For those who don’t know, my son and his wife and child live in Beijing, China and so some of these predictions are based on their experiences, or lack thereof.  They weathered the initial outbreak unscathed, but it has been more than two months - at the time of this writing - since they have seen our daughter-in-law’s grandparents who live on the other side of the city.  At the peak of the outbreak there, my son and another expatriate friend, in an effort to break the lockdown boredom, did a convenience store crawl.  Buy a single beer at one convenience store and then walk to the next through the cold January evening, and then repeat for a couple of more stores.  Not much for entertainment but it did break the boredom.

But all that aside, I think health care professionals learned some very hard lessons from this pandemic.  I’m not sure we can do much individually about them, but collectively through ASHP, APhA, ICHP, IPhA, and many more organizations, health-systems and corporations we can and we will do better!

While planning for disaster has been in place for many years, we are still poorly resourced for a pandemic or disaster of this nature!  While good business practices in the commercial world tout “just in time” inventory, healthcare needs a bigger stockpile or better controls of the inventory when we see disaster approaching.  Hoarding by consumers, individual health-systems, and even physicians of potential medication options is disgraceful and unethical.  We need to identify triggers or alerts that can initiate immediate holds on vital supplies.  And, as individuals, we need to make sure the pantry is filled a little better just in case that disaster hits and the holds are initiated in a timelier manner.  My goodness, just $10 more a pay period and before you know it, you’ll have a year’s supply of toilet paper in your linen closet.  Then, like the good inventory control person that pharmacists are, you rotate your stock and all’s well.

The Pharmacy Practice Act and Rules aren’t flexible enough!  No surprise there.  When you have a Department of non-pharmacists and the Medical Society telling us how we can practice pharmacy, you can’t expect much more.  We need to work with Department attorneys and the General Assembly to give the Board of Pharmacy (made up primarily of pharmacists) more input into the waivers and variances that are needed in the time of a disaster, like the Board of Pharmacy in Ohio has.  They made swift and decisive changes that helped their health care systems work more effectively to fight CV-19.  We can do that with a strong Government Affairs Division, lobbyists, and staff to lead a much stronger grassroots effort from our members long before the disaster hits.

We need to make the Governor, the Director of the Department of Public Health, and the public in general more aware of what pharmacists and certified pharmacy technicians are naturally trained to do and can do every day, not to mention during a disaster!  It’s a shame that the Governor didn’t include retired pharmacists and pharmacy technicians in his encouragement to jump back into duty and help out during the pandemic.  I received calls from retired members wanting to know how they could help.  Heck, I even volunteered to jump back into the fray if needed at one of the hospitals is Rockford.  I hope by the time you’re reading this, I didn’t need to, but will be ready and willing if asked.  And for $150 every two years and 30 hours (20 for certified techs) of CE (most of it can be free home-study from ICHP) maybe we should all keep our licenses until we can’t verify or pull an order anymore! 

Finally, and this one is the toughest, maybe we should try to convince our pharmaceutical manufacturers to produce more of their medications right here in the good old USA.  While we are a part of a global economy, being dependent on foreign manufacturers for raw materials and even a large portion of our generic medication supply is proving to be problematic.  Even before CV-19!  Yes, we will most likely have to pay more for these products, but the supply chain will be more stable and the impact of disaster half-way around the world will have a smaller ripple when it hits here.  Not to mention, our nation could get back into the business of helping other countries out when the feces hits the fan somewhere else.

I certainly don’t know the answers, but even I can see the problems, and admitting you have a problem is the first step towards recovery.  It is my hope that CV-19 won’t be the killer that experts anticipate, not because I want this to just go away but because I don’t want to see so many people suffer and die.  I hope this has helped us learn valuable lessons that we can use to improve our systems so the next problem is at least not as scary. 

Speaking of scary, I don’t think I have been as scared by an event like this since I was in 4th grade during the Cuban Missile Crisis (long time ago - Fall 1962).  If the CV-19 pandemic is still a problem this summer, that might be a good topic for August KP Directly Speaking.  I was pretty young but I remember the thought that we could all be dead at any time back then.  Probably not the same, but I’m sure those of you close to or past 60 years old have been giving it a little thought.

Every year, ICHP elects new members to its Board of Directors.  As existing officers complete their terms, they often move up to higher offices or move on for a variety of reasons not the least being that they’ve completed the highest offices of President-elect, President, and Immediate Past President.  So, every year the ICHP Committee on Nominations searches for new leaders to step up to carry on the business of the Council and lead the organization in “Advancing Excellence in Pharmacy!”  (That’s ICHP’s mission by the way). 

This year is no exception.  With Noelle Chapman completing her term as Immediate Past President and several other offices up for election, there are nine offices that will need two candidates to run for each.  Below is a list of the offices open for election in the Fall of 2020.  All the elected candidates will take office at the 2021 Annual Meeting with the exception of the President-elect, who assumes office immediately.  So each new leader will have almost a year to train for their new job and be coached by our current Board Members.  You don’t have to run that race unprepared!  Job descriptions for each office may be found on the ICHP website at: www.ichpnet.org/about_us/board_of_directors/job_descriptions/.

President-elect

Treasurer-elect

Director-elect of the Division of Government Affairs

Director-elect of the Division of Organizational Affairs

Director-elect of the Division of Professional Affairs

Central Region Director-elect

Northern Region Director-elect

Southern Region Director-elect

NPN Chair-elect

If you are interested in running for an office or you would like to know more about an office before committing to run, you may contact the Committee on Nominations Chair, Noelle Chapman at noelle.chapman@advocatehealth.com or Scott Meyers at scottm@ichpnet.org.   We hope you are ready to help lead the way for ICHP and Pharmacy!

The objective of the program is to encourage the development of new pharmacy practice programs or innovative approaches to existing pharmacy practice challenges in health systems. 

Applicants will be judged on their descriptions of programs and practices employed in their health system based on the following criteria: 

• Innovativeness / originality 
• Contribution to improving patient care 
• Contribution to institution and pharmacy practice 
• Scope of project 
• Quality of submission

The person submitting the application must be the first author and a member of ICHP for a minimum of 90 days prior to the submission deadline and practice in a health system setting.  Co-authors do not have to be ICHP members nor health-system pharmacists.  More than one program can be submitted by a health system for consideration.  

Each entry for the Best Practice Award must include a manuscript prepared as a Word document, double-spaced using Times New Roman 12-pitch type. A header with the paper title and page number should appear on each page.The manuscript should not exceed 2000 words in length (not counting references), plus no more than a total of 6 supplemental graphics (tables, graphs, pictures, etc.) that are relevant to the program. Each picture, graph, figure, and table should be mentioned in the text and prepared as a separate document clearly labeled.

The manuscript should be organized as a descriptive report using the following headings:

• Introduction, Purpose, and Goals of the program
• Description of the program
• Experience with and outcomes of the program
• Discussion of innovative aspects of programs and achievement of goals
• Conclusion

Submissions will only be accepted via online submission form. The manuscript will be forwarded to a pre-defined set of reviewers. Please do not include the names of the authors or affiliations in the manuscript to preserve anonymity.

All applicants will be notified of their status within three weeks of the submission deadline. Should your program be chosen as the winner:

• The program will be featured at the ICHP Annual Meeting. You will need to prepare a poster to present your program and/or give a verbal presentation. Guidelines will be sent to the winner.
• You may be asked to electronically submit your manuscript to the ICHP KeePosted™ for publishing as a continuing pharmacy education home study program.
• You will receive a complimentary registration to the ICHP Annual Meeting, recognition at the meeting and a monetary award distributed to your institution.

For more information, email Trish Wegner at TrishW@ichpnet.org or go to www.ichpnet.org/pharmacy_practice/professional_practice/best_practices/

While some things change others stay the same and this year change has definitely been the theme for health care, but the ICHP Award process is still looking for Illinois Pharmacy’s best and brightest!  The award nominations process for the 2020 ICHP Pharmacist of the Year, the Amy Lodolce Mentorship Award, and the Pharmacy Technician of the Year recipients are open, and it’s your chance to recommend someone you know and respect.  All three awards will be presented at the 2020 ICHP Annual Meeting on October 1-3, 2020 at the Drury Lane Theater in Oakbrook Terrace along with several other important awards.  That is providing we’re back to meeting by then!  But let’s think positive.  

The criteria are different for each award, so let’s start with ICHP’s highest honor, the Pharmacist of the Year. 

• The nominee is a person of high moral character, good citizenship and high professional ideals;
• The nominee has made significant contributions affecting the practice of health-system pharmacy throughout the State; and
• These contributions should be in the form of sustained exemplary service in health-system pharmacy or a single outstanding achievement, or a combination of accomplishments benefiting health-system pharmacy, through it, humanity, and the public health.  

These accomplishments, achievements, or outstanding performances may be in the following areas:

• Health-system pharmacy practice
• Health-system pharmacy education
• Health-system pharmacy administration
• Pharmaceutical research or development related to health-system pharmacy
• Pharmacy organizational activity with a definite relationship to health-system pharmacy
• Scientific or professional pharmacy writing, (e.g., noteworthy articles on pharmaceutical subjects with applicability to health-system pharmacy)
• Pharmaceutical journalism related to health-system pharmacy
• Public and/or inter-professional relations activities benefiting health-system pharmacy
• Pharmacy law or legislation, professional regulations, standards of professional conduct or pharmacy law enforcement as related to health-system pharmacy.

Nominations may be received from Selection Committee members (past recipients of the award), past Presidents of the Council, affiliated chapters of the Council or any six pharmacist members of the Council submitting and signing a recommendation.  Nominators should write a complete nomination letter and submit it along with the nominee’s CV by July 1st, to the ICHP office at scottm@ichpnet.org.  Nominations should include the name of the nominee, name of the nominators, and details describing how the nominee meets the above criteria.  This year’s Selection Committee Chair is last year’s recipient, Jerry Storm.  All nominations will be forwarded to the ICHP office for distribution to the selection committee.

Amy Lodolce was a University of Illinois at Chicago College of Pharmacy faculty member who touched the lives of pharmacy students, residents, and colleagues through her passion for teaching and the profession of pharmacy. Throughout her time at the college, Amy oversaw the training of four PGY2 drug information pharmacy residents, all of whom are currently drug information faculty at various institutions. She worked directly with numerous PGY1 residents and APPE students during their drug information rotations. She also served as a formal mentor to her student advisees and was the advisor of the Phi Delta Chi pharmacy fraternity for many years. As the Assistant Director of the Drug Information Group, Amy served as an informal mentor to other faculty and was quick to help new faculty become oriented and situated. 

Amy approached being a leader and a mentor with an “open door” policy, and she would selflessly pause her work to address others’ needs. Students, residents, and faculty alike would ask her for guidance with career decisions and other professional concerns. Amy was respectful and nonjudgmental in her approach when assisting others whose goals and aspirations may have been different from her own. Her dedication was exemplary in that she worked tirelessly to provide residents and students with quality learning opportunities. She led and coached by example, consciously choosing behaviors that she hoped students and residents would emulate. An active pharmacist member of ICHP, Amy placed emphasis on professional organization involvement and giving back to the profession. Amy’s dedication and generosity to the profession of pharmacy have positively shaped many pharmacists’ careers, and the memory of her will continue to do so. 

• The individual nominated to receive this award must be an ICHP pharmacist, associate or technician member in good standing; 
• The individual should be an exemplary preceptor, professor and/or mentor of students, residents, pharmacy technicians and/or new practitioners;
• The individual should be a positive role model for pharmacists, pharmacy students and/or pharmacy technicians;

In order to be considered for the award, individuals must have been nominated using the approved nomination form below.  More than one person may complete a nomination form for an individual.

• Please provide your name(s), i.e., the name of the nominator(s). (More than one person can nominate a nominee).
• Provide the name of the person you are nominating. In addition, the nominee’s curriculum vitae must be included in the nomination package.

• Is the nominee a member of ICHP?
• In what capacity have you worked with the nominee?
• In what ways do you see the nominee working to advance the profession of pharmacy?
• Give some examples of ways in which this nominee is a model mentor/preceptor.
• Give some examples in which this nominee has demonstrated a service to community (outside of job responsibilities).
• How has this nominee impacted your career?

Completed nominations should be sent by July 1, 2020, to Scott Meyers at scottm@ichpnet.org or to the ICHP office by fax at 815-227-9294 or mail to 4055 N. Perryville Rd., Loves Park, IL 61111.

Award Purpose: The ICHP Pharmacy Technician of the Year Award is established to identify and recognize exceptional performance by a certified pharmacy technician within the State of Illinois.

• Be a current ICHP technician member,
• Be a PTCB certified pharmacy technician for at least two years,
• Demonstrate at least one of the following:
• exceptional contributions to his/her pharmacy worksite
• exceptional contributions to ICHP as a volunteer member
• exceptional contributions to the practice of pharmacy in Illinois

• Be the technician’s supervisor, colleague, or co-worker.  No self-nominations will be accepted.

• Worksite name, address and telephone number.
• Technician name and year certified.
• Describe the technician’s contributions in detail.

Provide the nomination to the ICHP office by no later than July 1st.

Again, the deadline for submissions of all award nominees is July 1, 2020 and they should be forwarded to the ICHP office.

The January 14^th Board of Pharmacy Meeting was held at the Michael A. Bilandic Building, 160 N. LaSalle Street in downtown Chicago. These are the highlights of that meeting.

NABP Update - Board members will be involved in the annual March/April Multi-State Pharmacy Jurisprudence Examination (MPJE) item writing workshop writing new questions for the Illinois portion of the exam.  The Board will also be well represented at the NABP Annual Meeting in Baltimore in May.  Denise Scarpelli, current Board Chair, will be the Illinois delegate to the meeting and Desi Kotis, Board Vice Chair, will serve as the alternate delegate.

2020 Board of Pharmacy Meeting Dates – The Board will continue to meet on the second Tuesday of each odd-numbered month during 2020 with the May meeting to be held in Springfield.

• March 10^th - Chicago
• May 12^th - Springfield*
• July 14^th - Chicago
• September 8^th - Chicago
• November 10^th - Chicago

Department Time – This time is normally provided to allow updates from the Department staff.  Pharmacy Coordinator, Dr. Yash Amin announced forthcoming changes to the Self-Inspection forms.  Please watch for the new forms to appear on the Department website soon.  No details were provided at the meeting. 

At the January meeting the Department staff also fielded questions from the audience regarding the new Sexual Harassment Prevention CE and Pharmacy Working Condition requirements that went into effect on January 1, 2020. 

• Who needs to obtain the Sexual Harassment Prevention CE before license renewal in March?
  Pharmacists and Certified Pharmacy Technician will need to obtain the credit while students, grandfathered and new technicians will not. Student pharmacists who are certified pharmacy technicians will need to obtain the CE credit if they wish to maintain their certified pharmacy technician status on their Illinois license.
  
  
•  Will the Department investigators be enforcing the record keeping requirements for meal and rest breaks right away?
  The Department intends to spend the first three months of 2020 educating pharmacists-in-charge on how to record breaks.  Only breaks for pharmacists must be recorded.  Pharmacists-in-charge should begin working on this requirement immediately. 
  
  
• Do the new revisions to the Act now officially allow pharmacy technicians to administer immunizations?
  Pharmacy technicians and certified pharmacy technicians may administer immunizations if they have been trained using a Department approved training program as long as the pharmacist on duty has reviewed the patient profile to determine appropriateness.  To date no training programs have been reviewed.

Legislative Review – Because the General Assembly has yet to meet this year, two bills passed during the Veto Session were discussed. SB0667 requires insurance providers that cover any of the cost of insulin to limit the patient’s out of pocket costs to $100 or less.  The bill still awaits the Governor’s signature.  SB2104 was the bill which made multiple changes to the Illinois Pharmacy Practice Act including extending its expiration date through December 31, 2023.  Garth Reynolds, IPhA Executive Vice President presented the report.

Audience Comments – The only remaining question for the Board members and Department staff came from Garth Reynolds and asked what the current status on pharmacy investigators is.  Dr. Yash Amin, Pharmacy Compliance Director stated that the Department recently approved hiring two more investigators to add to the existing five.

The March 10th Board of Pharmacy Meeting was held at the James R. Thompson Center in downtown Chicago. These are the highlights of that meeting.

Announcements – The Board will lose two members, Past Chairman, Al Carter and current Vice Chair, Desi Kotis.  Al will become the Executive Director of the National Association of Boards of Pharmacy this summer and Desi will be moving to California to take over the Chief Pharmacy Officer position at the University of California, San Francisco.  We will miss both of them and look forward to working with their replacements.  Board member Ryan McCann was elected by the Board to complete Desi’s term as Vice Chair. 

NABP Update – Board members will be involved in the annual March Multi-State Pharmacy Jurisprudence Examination (MPJE) item writing workshop writing new questions for the Illinois portion of the exam.  The Board will also be well represented at the NABP Annual Meeting in Baltimore in May, if it is held.  Denise Scarpelli, current Board Chair, will be the Illinois delegate to the meeting and Ryan McCann, Board Vice Chair will serve as the alternate delegate.

Department Time – This time is normally provided to allow updates from the Department staff.  Munaza Aman, General Counsel to the Board, announced that the rules relating to meal and rest break records are on hold as the Department will follow the discussion of the Collaborative Pharmaceutical Task Force on these issues for the next couple of months.  Once revised recommendations come from the Task Force, the Department staff will move ahead with draft rules.  Once published in the Illinois Register, the public will have 45 days to provide comments.

Legislative Review – The General Assembly has a variety of bills impacting pharmacy directly and indirectly before them this year.  There are several positive bills and several negative impact bills too.  A more complete description of those bills will appear in the Government Affairs Report.  The Legislative Update was presented by ICHP Executive Vice President, Scott Meyers.

Audience Comments – There were several audience members present representing residency programs across the greater Chicago area.  They expressed concern with the 12-hour shift length limit for residents.  Many programs require 24-hour on call days and there is concern that the new limit will impact residency program accreditation, limiting the number of quality candidates applying for residency positions and eventually continuing to work in Illinois after completion.  Department staff listened and agreed to explore this problem further.  Staff did report that they had received letters of concern from the group and also ASHP and ICHP.

Next Meeting – The next meeting of the Board is scheduled for May 12th at 11:00 am at the Department’s Building in Springfield. This meeting is the only meeting to be held outside Chicago.  Check the IDFPR Website www.idfpr.com for exact room location.  These meetings are open to the public and pharmacists, pharmacy technicians and pharmacy students are encouraged to attend.

Congratulations to our members who are celebrating something big!

Desi Kotis
Congratulations and sad farewell to Dr. Desi Kotis, Director of Pharmacy at Northwestern Memorial Hospital, who is leaving her position to take a bigger one at the University of California San Francisco Health.  Desi will serve as Chief Pharmacy Officer for the entire UCSF Health system, overseeing hospitals, clinics and outpatient pharmacy services.  In addition, Desi will step down from her appointment to the Board of Pharmacy.  She will maintain a residence in Illinois in addition to one in the Bay area, so don’t be surprised if she pops into an ICHP statewide meeting in the future.  Plus we know we’ll see her at ASHP meetings around the country.  Congratulations Desi, we’ll miss you!

Dr. Kliethermes has started a new position at ASHP as their Director of Medication Safety and Quality.  We wish you much success in your new position, Mary Ann!

Jason Alegro
Congratulations to Dr. Jason Alegro at the Roosevelt University College of Pharmacy (RUCOP)! RUCOP was selected as a site for the Midwest integration of the National HIV Curriculum Project. Dr. Alegro, an Assistant Professor at RUCOP, will lead the incorporation of the project into coursework which will provide students with the most up-to-date HIV/AIDS training. 

Baby Julia
Julia Helvi Hamrén was born 3/3/2020.  She came into the world weighing 6 lbs 14 ounces and was 20 inches long.  She was welcomed by proud parents, Rachael Prusi and Jonas Hamrén.  Welcome Baby Julia!  

Please share you major milestones with us! 
Email melissad@ichpnet.org to be featured in our next issue of KeePosted. 

If there is a silver lining with the current pandemic, it is that the Illinois General Assembly is not in session.  One of my favorite Mark Twain quotes is “No man’s life, liberty and property are safe when the legislature is in session”.  Having said this and knowing that the KeePosted is not the most timely source of legislative information, I urge everyone to take a weekly look at the ICHP website “Advocacy” page to see if the session has re-convened and if the problem bills have begun to move.  For right now, I will highlight just a couple of bills so that you will have some bill numbers to focus on.

There are many more bills that will impact pharmacy directly or indirectly but your best bet is to Whitelist e-mails from ichpnet.org and also check the Advocacy page on the ICHP website weekly to stay up-to-date.

Moving on to the Collaborative Pharmaceutical Task Force, which met in February and March this year and has agreed on a few points already.  They are:
Reconfirmed support for implementation of a CQI program for every pharmacy with all internal documents protected for discovery for criminal or civil purposes.
Establishment of a new Task Force focused on new and more appropriate reimbursement models for pharmacist-provided patient care services.

The Task Force will also review problems with implementation of meal break requirements, 12-hour shift length limits for residents, and other pharmacy working condition concerns.  In addition, new topics for the Task Force to consider include:

The next meeting of the Task Force was tentatively scheduled for Tuesday, April 21st, and the May meeting is tentatively scheduled for the 12th.  Each meeting of the Task Force is held in Chicago and Springfield, with exact room locations to be determined by the Department.  Task Force meetings are open to the public with limited input from audience members.

Finally, ICHP has been working on the COVID-19 pandemic and the ICHP office staff have established a COVID-19 Resource page on the ICHP website.  The page includes a variety of documents including:

ICHP staff continue to post new resources nearly daily.

In addition, we are working with Garth Reynolds of IPhA to seek a variety of waivers from the Pharmacy Practice Act and Rules by the Governor, the IDFPR Secretary, and staff.  A joint document from ICHP, IPhA and IALTCPP is posted on www.ichpnet.org.

It’s not new information that our world is facing a new pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for causing coronavirus disease (COVID-19). As our fellow nurses and providers are preparing for an influx of patients, you might be wondering – what more can we do as pharmacists to help our colleagues and patients during this time?

After the attacks on September 11, 2001, the American Society of Health-System Pharmacists (ASHP) published a statement on the role of health-system pharmacists in emergency preparedness.¹ While this document is geared towards responding to natural, industrial, and biological disasters, the same principles can be applied to the COVID-19 pandemic. Pharmacists play key roles in many aspects of emergency and disaster care including:

• Obtaining medications
• Storing, labeling, and dispensing medications
• Developing guidelines for the diagnosis and treatment of affected patients
• Consulting with providers on treatment for individual patients
• Advising the public on the appropriate use of medications in response to disasters

These recommendations may seem like part of your normal daily tasks, and in fact they are! One key fact to remember is that we already have the necessary skills to perform these duties. During pharmacy school, residency training, and in our daily work, we use these skills every day whether we realize it or not.

Want to do more? Here is what else you can do to prepare.

• Educate yourself on your local and institutional plans for emergency preparedness
• Share evidence-based recommendations for treatments with colleagues
• Act assertively to prevent panic and irrational responses to disasters  
• Obtain basic cardiac life support (BCLS) certification through the American Heart Association
• Obtain Pharmacy-Based Immunization Delivery certification through the American Pharmacists Association

Interested in learning more? Check out an excellent review of the treatment of biologic threats available at https://accpjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/phar.2068.2 In the meantime, stay safe and healthy! In the words of Queen and David Bowie – this is ourselves…under pressure. 

ICHP is excited to announce the new Residency Leaders Network (RLN)!  The RLN is comprised of ICHP member leaders in residency programs (i.e, residency directors and residency coordinators) throughout the state. 

 
The mission of the ICHP RLN is to offer networking opportunities to resolve questions, challenges, and issues that residency directors and residency coordinators often face when guiding residents through their program and/or preparing for ASHP accreditation.
 
If you are interested in joining this new network, please contact Trish Wegner at TrishW@ichpnet.org.  

We look forward to networking together!

Hello Fellow Technicians,

We had our inaugural Pharmacy Technician Network call on Tuesday, March 10, 2020. In total, 5 technicians, including myself, as well as the ICHP staff were in attendance. During this initial call we introduced ourselves, discussed network goals for the next year, and brainstormed topics for the Annual Meeting. We also focused on ways to engage the technician membership.

The hope for this new network is to bring health-system pharmacy technicians together to provide ideas for meeting programming “by technicians for technicians” as well as show the value of being a member of ICHP. My goal as Technician Representative-Elect for now and Technician Representative when I am installed at the Annual Meeting is to have a network where technicians feel they can discuss their ideas and where their ideas will be heard and implemented. I would also like the technicians throughout the state to come together either in small groups or a large group and participate in community service projects. Since we have only had one call we are still in the early stages of this network. We would love to have you join if your schedule allows.

If anyone is interested in joining the new Pharmacy Technician Network, we meet on the 2nd Tuesday of each month from 5-6 pm via conference call. Please email me at rohrmund@nm.org if you would like to be included on our next call!

I am the West Central Society President. In this role, I organize the local CPE meetings, manage local funds, and try to engage local members to take part in state wide events.

Where is your practice site?
I am the Anticoagulation Pharmacotherapist Coordinator at OSF Healthcare. The easiest way to describe my job is a medication safety pharmacist with a single focus on anticoagulants. My goal is to ensure our pharmacists and other healthcare providers have the tools and knowledge they need to use anticoagulants safely.

What pharmacy related issues keep you up at night?
Prescription drug pricing and medication shortages are something that has affected my professional life, as it has all pharmacists, but they have also affected my family. My mom has Wilson’s disease and has been taking penicillamine for over 40 years. Prior to about 8 years ago, this orphan drug cost around $350 per month. Her insurance company treated this as a tier 3 medication and she had a very reasonable co-pay. This was one of those drugs that saw a 2700% price increase almost overnight for no apparent reason other than drug company profit. My mom’s reasonable co-pay became completely unaffordable. Additionally, this drug began showing up on and off the shortage list. Luckily, she is a well-educated person with a pharmacist for a daughter. We have been able to jump through the correct hoops, fill out loads of paperwork, contact pharmacy suppliers, and mostly keep her with a regular supply of medication. I am absolutely certain there are patients who require this drug that are unable to maneuver the unreasonable cost increases and drug shortages, and have had to go without treatment. I worry about my mom and the other patients who have been negatively affected by corporate greed. 

What is a challenge that you face in your practice?
One of the particular challenges I faced was helping our health system determine the best formulary choice for the oral Factor Xa inhibitor reversal. On the surface, this would seem like an easy choice. Choose an FDA approved reversal agent or continue using a product off-label. Unfortunately, the choice was not that straightforward. Extreme drug costs, challenging pharmacokinetics, and a complex patient population made the decision all the more challenging. In the end, I believe we made the best choice for our health system by completing a thorough evaluation of safety, efficacy, and cost and selected the non-FDA indicated drug. However, I can say it was the most difficult formulary decision of which I have been a part.

What makes ICHP great?
ICHP is great because it provides an easy way for you to get involved. There are so many opportunities to take a leadership role without feeling like you have committed all of your free time. It’s really easy to start off simply by becoming a site champion. From there you can try out new roles and opportunities.

What initially motivated you to get involved in ICHP?
My co-workers! I saw many of my co-workers getting involved in ICHP, networking with other pharmacists across the state, and gaining leadership experience. I was almost jealous, but realized it was easy for me to be able to do the same.

What advice would you give to student pharmacists?
Pharmacy is such a small world. The bridges you build or burn as a student will impact the opportunities you seek, as you move forward in your career. As the job field becomes more competitive, use your P4 year as a spring board for beginning a successful profession. Before picking rotations, do your homework. What areas of pharmacy do you want to explore? What would truly be a good fit for you? Don’t just pick the rotation that sounds exciting. Pick the one that will give insight into your future job or help you take the next steps. If you want to work in a hospital, check out different settings. Do you like the atmosphere of critical care or critical access? Are you interested in residency? Try to select rotations where you would consider applying for residency or where there are residents so you can ask for their advice. There are so many opportunities in pharmacy, but make your years as a student count!

Do you have any special interests or hobbies outside of work?
I really enjoy cooking (not to be confused with baking). However, with two small children, I don’t get to be as adventurous in my recipe selection as I once was. I do still enjoy trying new things and cooking for my family.

What is the most interesting/unique fact about yourself that few people know?
I really love pizza, but I’m a total pizza snob so I rarely eat it. I grew up in the Chicago suburbs eating real pizza. :)

Direct oral anticoagulants (DOACs) have been utilized in clinical practice over the past decade. These include the direct factor Xa inhibitors apixaban, betrixaban, edoxaban, and rivaroxaban, and the direct thrombin inhibitor dabigatran. The Food and Drug Administration (FDA) has approved DOACs for the prevention of stroke and thromboembolic events in patients with non-valvular atrial fibrillation (AF), deep vein thrombosis (DVT), pulmonary embolism (PE), and the prevention of DVT/PE following total hip/knee replacement.^1,2 Published retrospective cohorts show that more than 56% of DOAC prescriptions are inappropriately dosed.^3-6 DOACs may be under-dosed for fear of increased risk of bleeding. Changes in patient specific factors and lack of provider education may lead to inappropriate dosing which compromises efficacy and safety, putting patients at increased thrombotic or bleeding risk. This is particularly true for patients with AF who are anticoagulated with DOACs.⁶ A multicenter, prospective outpatient disease registry known as the ORBIT-AF II, evaluated over 5,000 DOAC doses among AF patients. Results demonstrated that both under- and over-dosing of DOACs increased rates of hospitalization, all-cause mortality, major bleeding, systemic embolism or stroke, and myocardial infarctions. 

The purpose of this study was to assess the effectiveness of a guideline to standardize the dose and duration of hospital formulary DOACs and to ensure compliance with prescribing information. In this study, a pharmacist-led DOAC guideline was implemented at a 312-bed community teaching hospital in the Midwest. Prescribing practices were evaluated by chart review pre- and post- guideline implementation (Figure 1). The study included education of healthcare professionals, adjustment of doses led by pharmacists, review of inappropriate prescription origins, and evaluation of prescribing practices.

Methods
Creation of a hospital formulary-specific DOAC guideline standardizing rivaroxaban and apixaban doses per anticoagulation indication and duration was approved by the Pharmacy & Therapeutics Committee and the project was reviewed by an Institutional Review Board. Outpatient prescriptions were not evaluated.  Patients were eligible for inclusion in this study if they were treated with apixaban or rivaroxaban, were at least 18 years of age, and were not pregnant. The primary outcome measured the rate of appropriate inpatient prescriptions concordant with package insert labeling. Inappropriate prescriptions were classified as either an overdose or under-dose to determine where healthcare provider education was needed. Secondary outcomes included number of thrombotic or bleeding events during hospitalization, readmissions for bleeds/thromboembolisms, and patients with end stage renal disease.

Data were collected through a comprehensive chart review. Prescriptions ordered, evaluated, and verified in this study came from medical and pharmacy residents in addition to clinical pharmacists, physicians, nurse practitioners, and physician assistants. Pharmacist-led renal dose adjustments allowed for both the increase and decrease of apixaban and rivaroxaban inpatient dosages based on daily laboratory results, without the need to contact the prescriber.

Each pre- and post-guideline period was 45 days which included a set number of orders not to exceed 200, which was chosen to meet a predefined scope and timeline for the residency research project (Figure 1). The pre-guideline time period was July 1- August 15, 2018.  The post-guideline time period was November-December 2018.  Data collected included:  patient characteristics such as age, sex, and weight, corrected Cockcroft-Gault creatinine clearance, prescribed DOAC dose, number of bleeding or thrombosis events, thrombosis, readmission rates, and anticoagulation indication.

Results
A total of 383 orders were included with 200 prescriptions in the pre-guideline arm and 183 prescriptions in the post-guideline arm. Baseline characteristics were similar in age, anticoagulation indication, and about half of all patients in each group had a creatinine clearance of 15 to 50 mL/min. Overall there were more males in the pre-guideline arm (64% versus 46%) and approximately 24% of all patients were above100 kg. No p-values were calculated for baseline characteristics (See Table 1). DOACs were appropriately dosed in 87% (175/200) versus 93% (171/183) of prescriptions pre- and post-guideline implementation, respectively. Evaluation of inappropriate apixaban prescriptions alone identified 16 (10%) pre-guideline compared with 10 (7%) post-guideline. Assessment of rivaroxaban dosing alone identified nine (27%) inappropriate pre-guideline doses compared to two (5%) post-guideline doses. After investigating the 37 inappropriate hospital DOAC prescriptions, it was determined that more than half were due to continuation of a patient’s original home dose upon hospital admission. Missed opportunities were due to both pharmacist and provider hesitation to change established home dosages and from providers denying auto substitutions.  (See Table 2.) 

Bleeding events decreased post-guideline implementation, with no patients being readmitted for bleeds, and one pre-guideline rivaroxaban patient was readmitted for venous thromboembolism. No contraindicated drug-drug interactions were found. There were 23 patients with end stage renal disease on apixaban and none on rivaroxaban.  Numbers of pharmacist-driven renal interventions were similar between the two arms with the majority being associated with apixaban. Pharmacist interventions decreased overall, pre-guideline (n=21) compared to post-guideline (n=18). Most to least documented pharmacist interventions were as follows: renal dose adjustments including pharmacist-led dose adjustments 6 (33%), patient-specific factors for age and weight in apixaban 5 (28%), transitions of anticoagulation 3 (16.5%), dosing frequency 3 (16.5%), and allergies 1 (6%).  (See Table 3.)

Discussion
Study strengths included use of an electronic medical record (EMR) system which contains medication detail, including patients’ external fill history, patient specific information, prescriber documentation, and laboratory results.  This allowed for more accurate assessment of dosing appropriateness and potential for drug-drug interactions. Implementation of pharmacist-led renal dose adjustments allowed for timely administration of appropriate doses based on daily hospital laboratory results. Study limitations include a small sample size and timeframe compared to previously published DOAC studies.^4-6 Some patient information was missing at time of inpatient order verification, which was later discovered during the visit. For instance, anticoagulation indication and appropriateness were unclear for AF patients hospitalized for another indication such as DVT. These occurrences were not excluded, but rather the newest diagnosis was evaluated as the primary anticoagulation indication in the retrospective data collection. Another limitation is that CHA2DS2-VASc scores were not calculated and therefore not used to determine anticoagulation appropriateness in AF patients. Discharge prescriptions were not evaluated in this study. Other barriers include potential drug-drug interactions due to unavailable external medication fill histories and incomplete medication histories. Future studies should evaluate the home DOAC regimen and appropriateness of continuing this on hospital admission as well as upon discharge.

Conclusion
Results suggest underdosing in apixaban patients, especially continuation of home doses upon admission, may require further provider education.  As evidenced by this study, implementation of a pharmacist-led DOAC guideline allowing for renal dose adjustments may improve both FDA-approved concordant prescribing of these medications and decrease rates of bleeding.

1. Eliquis (apixaban) package insert. Princeton, NJ: Bristol-Myers Squibb Company and Pfizer Inc.; 2015.
2. Xarelto (rivaroxaban) package insert. Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2012.
3. Yao X, Shah ND, Sangaralingham LR, Gersh BJ, Noseworthy PA. Non-vitamin k antagonist oral anticoagulant dosing in patients with atrial fibrillation and renal dysfunction. J Am Coll Cardiol. 2017;69(23):2779-2790.
4. Ruiz OM, Muniz J, Rana M, et al. Inappropriate doses of direct oral anticoagulants in real-world clinical practice: prevalence and associated factors. A subanalysis of the FANTASSIA Registry. Europace. 2018;20(10):1577-1583.
5. McAlister FA, Garrison S, Kosowan L, Ezekowitz JA, Singer A. Use of direct oral anticoagulants in Canadian primary care practice 2010–2015: A cohort study from the Canadian primary care sentinel surveillance network. J Am Heart Assoc. 2018;7(3): e007603. https://www.ahajournals.org/doi/full/10.1161/JAHA.117.007603. (accessed 2018 May 27). 
6. Steinberg BA, Shrader P, Thomas L, et al. Off-label dosing of non-vitamin k antagonist oral anticoagulants and adverse outcomes: the ORBIT-AF II Registry. J Am Coll Cardiol. 2016;68(24):2597-2604.
   

In 1985 aspirin, also known as acetylsalicylic acid (ASA), was approved by the Food and Drug Administration (FDA) for secondary prevention of cardiovascular disease (CVD).  Its benefit in reducing CVD morbidity and mortality in patients with occlusive CVD events, including subsequent coronary heart disease (CHD), has consistently proven to outweigh risks of major bleeding associated with its long-term use. However, its role in primary prevention is less clear and necessitates meticulous evaluation and shared decision making to determine realistic benefit-to-harm ratio. Due to lack of clear benefit-to-harm ratio from ASA use for primary prevention, consensus regarding its use also varies. Nonetheless, it has been widely studied and utilized as one of the cornerstone pharmacological interventions for primary prevention of CVD.¹

Long-term ASA therapy, at lower doses in the range of 75 to 100 mg daily, has been associated with a reduction in CV events. The subgroup analyses from the 2002 Antithrombotic Trialists Collaboration (ATTC) meta-analysis indicated that ASA appears to be equally effective for the prevention of CVD at doses between 75 and 325 mg daily.² Hence, for primary prevention, ASA doses of ≤100 mg/day should be used to minimize risk of bleeding. This is in congruence with routine use of ASA 81 mg/day dose in clinical practice.

The most concerning adverse effect of ASA is major bleeding, defined as bleeding which requires hospitalization with or without transfusion. The most common type of ASA-associated bleeding is gastrointestinal (GI) bleeding, and it is rarely fatal.³ Inhibition of cyclooxygenase-1 (COX-1) enzyme increases risk of upper GI bleeding, however, this risk is dose-dependent with ASA therapy and can be minimized with use of lower doses. The incidence of major bleeding is likely to be somewhat higher in the general population than among participants in randomized trials. The U.S. Preventive Services Task Force (USPSTF) report on the use of ASA for the primary prevention of CVD and cancer suggested that increasing age, male sex, and diabetes increased the risk for major bleeding with ASA therapy.⁴ According to 2008 American College of Cardiology/American College of Gastroenterology/American Heart Association (ACC/ACG/AHA) guidelines, risk factors for GI toxicity from non-steroidal anti-inflammatory drugs (NSAIDs) such as ASA include history of ulcer disease or ulcer complication, concurrent use of antiplatelet, anticoagulant, or glucocorticoid therapy, age ≥60 years, dyspepsia or gastroesophageal reflux disease (GERD) symptoms. In patients who have an episode of major bleeding while taking ASA for primary prevention, it should be determined if the risk of recurrent bleeding outweighs the benefits of long-term use.

Identification of individual risk factors, application of atherosclerotic cardiovascular disease (ASCVD) assessment tools, and initiation of evidence-based pharmacotherapy permits clinicians to approach primary prevention effectively in high ASCVD risk individuals. An ASCVD risk score of >20% confers high CVD risk while a <5% confers low CVD risk. Clinicians should use clinical judgement and other tools to sufficiently assess ASCVD risk in this lower risk population (e.g., family history of premature ASCVD, high-sensitivity C-reactive protein [hs-CRP], coronary artery calcium measurement). After a comprehensive CVD risk assessment, it is important to conduct an in-depth discussion and shared decision making about lifestyle modifications and management of other CVD risk factors including dyslipidemia, diabetes, and hypertension.  As an example, for a given patient with ASCVD risk >20%, not on statin therapy, and with > 10 years duration of type 2 diabetes and A1c >10%, the first step would be to optimize control of underlying risk factors.

In order to implement evidence-based guideline recommendations into clinical practice, clinicians should evaluate practice-changing primary literature. Starting in 1988, clinical trials sought to evaluate the potential benefit of aspirin for primary prevention of CVD.⁵ Several meta-analyses have been conducted to collectively evaluate outcomes of major landmark trials published over the past 3 decades (1988 to 2018) to identify the benefits of ASA in primary prevention. The collated evidence from these trials with follow-up range of 3.8-10 years indicated that ASA therapy results in (1) none to very small reduction in all-cause or CVD mortality [high-quality evidence], (2) reduction in non-fatal MI over 10 years [moderate-quality evidence], and (3) none to very small reduction in non-fatal stroke over 10 years.

The three most recent trials published in 2018 (The Aspirin to Reduce Risk of Initial Vascular Events [ARRIVE], A Study of Cardiovascular Events in Diabetes [ASCEND], and The Aspirin in Reducing Events in the Elderly [ASPREE]) are more reflective of modern preventative practices including blood pressure control, smoking cessation, and cholesterol reduction (See Table 1).^6-8  

The ARRIVE enrolled 12,546 patients ≥ 55 years (men) or ≥60 years (women) at a moderate risk of CHD (≥ 3 cardiovascular risk factors: dyslipidemia, current smoker, high blood pressure, positive family history of CVD).⁶ In ARRIVE, ASA use in the intermediate-risk population (~15% in 10 years) did not reduce the composite outcome of first MI, stroke, CV death, unstable angina or transient ischemic attack, while GI bleeding events were more than twice as likely with ASA use.

The ASCEND trial enrolled 15,480 patients with diabetes, age >40 years, and no known CVD.⁷ In ASCEND, ASA use in patients with diabetes led to 12% relative reduction in non-fatal MI, stroke, transient ischemic attack or vascular death (number needed to treat=91) excluding intracerebral hemorrhage, while major bleeds were 29% more likely (number needed to harm=112). Approximately half the excess of bleeding was in the GI tract, with approximately one-third in the upper GI tract.

The ASPREE trial enrolled 19,114 healthy older adults (>70 years old, >65-year-old in Hispanic or African American patients) without a history of CVD, cerebrovascular disease, dementia, or any other chronic condition that would likely limit survival to less than 5 years.⁸ In ASPREE, ASA use in healthy elderly patients showed no reduction in MI or ischemic strokes, however, there was a substantial, progressive increase in major hemorrhage. In addition, there was an increase in all-cause death in the ASA group, mainly due to increased cancer deaths, specifically. 

The updated recommendations from ACC/AHA based on recent evidence is as follows: consider ASA use for primary prevention in adults 40-70 years of age at higher risk of CVD (ASCVD score >10%) but not at an increased risk of bleeding.¹⁰ Routine use of ASA is not recommended in adults >70 years of age or any age with increased risk of bleeding (See Table 2).^10-13 To date, there is lack of evidence to justify use of ASA of primary prevention in patients with the highest CVD risk (>20%), those of African American descent, and those with uncontrolled co-morbidities that increase CVD risk. Therefore, more research is needed to identify patients with high CVD risk and acceptable bleeding risk for whom taking a once daily affordable therapy such as a low-dose ASA is worth considering. The benefits were more pronounced when estimated 10-year ASCVD risk was >7.5%.¹⁴ These findings suggest that the decision to use aspirin for primary prevention should be tailored to the individual patient based on estimated ASCVD risk (See Figures 1 and 2) and perceived bleeding risk, as well as patient preferences regarding types of events prevented versus potential bleeding caused. When aspirin is used for primary prevention, a low dose (<100 mg/day) should be recommended.

1. Miner J, Hoffhines A. The discovery of aspirin’s antithrombotic effects. Tex Heart Inst J 2007;34:179–186.
2. Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71.
3. Selak V, Kerr A, Poppe K, et al. Annual Risk of Major Bleeding Among Persons Without Cardiovascular Disease Not Receiving Antiplatelet Therapy. JAMA 2018; 319:2507.  
4. Whitlock EP, Burda BU, Williams SB, et al. Bleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Review for the U.S. Preventive Services Task Force. Ann Intern Med 2016; 164:826. 
5. Miedema MD, Huguelet J, Virani SS. Aspirin for the primary prevention of cardiovascular disease: in need of clarity. Curr Atheroscler Rep 2016;18:4.
6. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018; 392:1036.
7. ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018;379:1529.
8. ASPREE
9. Raber Inbar, McCarthy CP, Vaduganathan M, et al. The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet 2019;393:2155-67.
10. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. JACC 2019;74:e177-232.
11. ADA. Cardiovascular disease and risk management. Diabetes Care 2019;42(1):103.
12. Bibbins-Domingo, K, on behalf of the U.S. Preventative Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventative Services Task Force Recommendation Statement. Ann Intern Med 2016;164:836-845.
13. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e637S-e668S.
14. Abdelaziz HK, Saad M, Pothineni N, et al. Aspirin for primary prevention of cardiovascular events. JACC 2019;73:2915-2929.
15. Chiang KF, Shah SJ, and Stafford RS. A practical approach to low-dose aspirin for primary prevention. JAMA 2019;322(4):301-302.
    

Before we had to cancel the 2020 ICHP Spring Meeting, we received several outstanding poster presentation submissions.  While we were not able to showcase these presentations at our meeting, we do want to give our members a chance to see the amazing work these students, residents and pharmacists put together.  Below you will find a list of the authors and their presentations.  

“Opinions expressed by authors of Op-Ed articles in the KeePosted are their own and are not necessarily shared by ICHP or its members.  ICHP will publish these articles from time to time to direct you to topics that may be of interest to you and to stimulate discussion on potentially controversial issues of the day.”

What is single-payer?
Single-payer national health insurance describes a system in which one public agency is responsible for health care coverage, but the delivery of health care services continue to be provided by mostly private businesses.¹ This means all payments health care services would come from one agency, but physicians’ offices, hospitals, and pharmacies would continue to be owned and operated by organizations or individuals, as they are in the current system. The two proposed bills for single-payer in the United States are commonly known as Medicare for All. While there are differences between the House bill² and the Senate bill³, both endeavor to provide robust health care coverage – medical, pharmacy, dental, vision, etc. –  for everyone living in the US and to eliminate the private insurance industry’s role in covering health care services included in this legislation. Projected costs vary between analyses⁴, but most show the overall cost of health care services remaining about the same or decreasing, due to minor increases in utilization as more uninsured or underinsured people can afford to seek the care they need, coupled with major decreases in overhead – Medicare spends about 2% on administrative costs compared to private insurers spending up to 18%⁵ – and decreased cost of health care services, including drug pricing.

How would it impact pharmacy?
Perhaps the most obvious change that would impact pharmacy is in drug pricing. Brand name drug prices have increased dramatically in the last decade.⁶ Based on data from Australia and New Zealand, some experts estimate the cost of brand name drugs would drop as much as 50%. While the generic market is less likely to see dramatic price changes, there is greater opportunity for rapid intervention and improved access during drug shortages and for negotiation on prices with both brand and generic manufacturers of “me too” drugs if there is one national formulary.⁷ This is a role some argue pharmacy benefit managers (PBMs) can play, but again, drug prices continue to climb. In scenarios where savings are achieved by a PBM this is often to the benefit of their shareholders or partnering businesses, rather than to taxpayers or patients.⁸ By consolidating negotiating power with a single-payer, there would be greater leverage over drug companies’ asking prices.

Additionally, with a single-payer and the eradication of the PBM model, the idea of “preferred pharmacies” would no longer exist. Patients would be free to fill their prescriptions at the pharmacy that best meets their needs, at no cost. This would mean simplified billing and predictable reimbursement. What would you do with the time you previously spent on the phone trying to understand why an override wasn’t working, or trying to help a patient or physician determine the covered “preferred formulary alternative” when you get a rejection? What if you could spend more time focusing on ensuring therapy is safe and effective, instead of on whether or not your patient could afford it? Would you expand clinical pharmacy services? Would you open your own independent pharmacy, perhaps in an underserved rural area, or in the pharmacy deserts on the south or west sides of Chicago?

We have plenty of evidence from other countries to suggest how patients would respond to a single-payer system. The United States currently has the highest rates of cost-related medication non-adherence (CRMN).⁹ In places where patients don’t need to worry about copays and deductibles, the overall rate of cost-related medication non-adherence is < 3%. Even in Canada, which does not fully cover prescriptions with their single-payer system, rates of CRMN are about half of what they are in the United States. This example highlights the importance of thoughtful inclusion of pharmacy benefits in a single-payer health care coverage plan.

Why do pharmacists need to be involved?
Currently proposed Medicare for All bills in the House and Senate differ in their plans for prescription coverage. The House bill calls for no deductibles and no copays at any point. The Senate bill would allow for up to $200 per year in out-of-pocket prescription costs. This may sound like a small distinction, but has the potential to disproportionately impact low income patients.¹⁰ Pharmacists who have worked with patients with high-deductible prescription plans will immediately recognize this issue. Physicians may not, but they are the primary health care professionals advocating for Medicare for All.¹¹ Most physicians have a limited understanding of the intricacies of pharmacy billing and reimbursement.¹² We don’t know if single-payer will move forward in the next few years, or if it will take several decades, but we do know pharmacists will need to have a seat at the table when the time comes to ensure the changes made are appropriate and sustainable. The best way to guarantee that seat at the table is to get involved in the conversations happening around single-payer now.

To our knowledge, there are less than a dozen pharmacists actively involved in the single-payer movement right now, as compared to the over 23,000 physicians and 1,200 medical students who are members of Physicians for a National Health Plan (PNHP). We know pharmacists are extraordinarily effective advocates when we work for change to improve the lives of our patients and to advance our profession.¹³ We continue to rank among the top professions year after year for honesty and ethical standards.¹⁴ We are trusted experts, and we have the authority to speak on issues facing our broken health care system, particularly when it comes to medications. It’s time to put our expertise to use in advocating for structural change, and to make sure the plans behind it support our patients and align with our goals as a profession.

For those looking to get involved, two Illinois based organizations that focus on this issue are IL Single Payer Coalition (http://ilsinglepayer.org/) and PNHP Illinois (https://pnhp.org/chapter/illinois/). Other ways to take action include contacting your state and federal legislators to ask them to support single payer legislation, writing op-eds or letters to the editor in local newspapers, public speaking, lobbying, and organizing.

1. Physicians for a National Health Program. About Single Payer. https://pnhp.org/what-is-single-payer/ (accessed 2019 Nov 22).
2. Medicare for All Act of 2019, H.R.1384, 116th Cong. (2019). https://www.congress.gov/bill/116th-congress/house-bill/1384/text (accessed 2019 Nov 22).
3. Medicare for All Act of 2019, D.1129, 116th Cong. (2019). https://www.congress.gov/bill/116th-congress/senate-bill/1129/text (accessed 2019 Nov 22).
4. The New York Times. Would ‘Medicare for All’ Save Billions or Cost Billions? https://www.nytimes.com/interactive/2019/04/10/upshot/medicare-for-all-bernie-sanders-cost-estimates.html (accessed 2019 Nov 22).
5. Center for Economic and Policy Research. Overhead Costs for Private Health Insurance Keep Rising, Even as Costs Fall for Other Types of Insurance. http://cepr.net/blogs/cepr-blog/overhead-costs-for-private-health-insurance-keep-rising-even-as-costs-fall-for-other-types-of-insurance (accessed 2019 Nov 22).
6. Wineinger NE, Zhang Y, Topol EJ. Trends in Prices of Popular Brand-Name Prescription Drugs in the United States. JAMA Netw Open. 2019 May 3;2(5):e194791.
7. Gaffney A, Lexchin J; US; Canadian Pharmaceutical Policy Reform Working Group. Healing an ailing pharmaceutical system: prescription for reform for United States and Canada. BMJ. 2018 May 17;361:k1039.
8. The Commonwealth Fund. Pharmacy Benefit Managers and Their Role in Drug Spending. https://www.commonwealthfund.org/publications/explainer/2019/apr/pharmacy-benefit-managers-and-their-role-drug-spending (accessed 2019 Nov 22).
9. Heidari P, Cross W, Weller C, Nazarinia M, Crawford K. Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study. Int J Rheum Dis. 2019 Apr;22(4):555-566.
10. Kaiser Family Fund. Medicaid. The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings. https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/ (accessed 2019 Nov 22).
11. TIME. A New Generation of Activist Doctors Is Fighting for Medicare for All. https://time.com/5709017/medicare-for-all-doctor-activists/ (accessed 2019 Nov 22). 
12. Tseng, C., Lin, G.A., Davis, J. et al. Giving formulary and drug cost information to providers and impact on medication cost and use: a longitudinal non-randomized study. BMC Health Serv Res. 2016 Sep 21;16(1):499.
13. Little J, Ortega M, Powell M, Hamm M. ASHP Statement on Advocacy as a Professional Obligation. Am J Health Syst Pharm. 2019 Feb 1;76(4):251-253.
14. Forbes. America's Most & Least Trusted Professions. https://www.forbes.com/sites/niallmccarthy/2019/01/11/americas-most-least-trusted-professions-infographic/#43777eba7e94 (accessed 2019 Nov 22).
    

The Illinois Prescription Drug Monitoring Program (ILPMP), housed within the Department of Human Services, has existed in some form since 1961.  In its earliest form, the goal of the ILPMP was to collect information on Schedule II controlled substances, monitor multiple-copy (i.e. triplicate) state issued prescription forms, and report prescribing patterns within 30 days of drug dispensing.  Today, the ILPMP serves as an essential tool to ensure the safe use of opioids and other drugs of potential abuse or concern. Utilizing the ILPMP will support clinical decisions and improve patient outcomes while preventing prescription opioid misuse, abuse and diversion. As part of a multi-faceted risk mitigation program (See Table 1), the ILPMP provides invaluable information to prescribers and pharmacists.

Key Questions
How has the ILPMP impacted opioid overdose rates in Illinois?
As the million-dollar question, the impact of the ILPMP on opioid mortality in Illinois may be the most difficult question to answer.  Several studies have shown a direct correlation between the enactment of prescription drug monitoring program laws and opioid prescribing rates.^1–3  Based on the Centers for Disease Control and Prevention (CDC) 2019 Surveillance Report of Drug-Related Risks and Outcomes, Illinois has among the lowest rates of long-acting or extended release opioid prescriptions and among the lowest rate of high-dosage opioid prescribing (defined as morphine milligram equivalents greater than 90 mg daily).⁴  Unfortunately, Illinois ranks 14th in the nation for age-adjusted drug overdose deaths per 100,000 population.  While the ILPMP and other risk mitigation practices has undoubtedly reduced prescription substance abuse and diversion, a swift and unprecedented shift to synthetic and semi-synthetic illicit opioids has driven the steady increase in mortality rates.  However, in 2018, Illinois realized its first decrease in opioid mortality rate with a lookback period of 5 years.

Who has access to the ILPMP?
Access to prescription drug monitoring program data has long been a topic of great contention.  The earliest state drug monitoring programs were housed within various agencies of law enforcement (e.g. California & Hawaii).  The Illinois prescription monitoring program was the first to be housed within a state Department of Health.  This had significant ramifications on the privacy of personal health data and the access to such data by law enforcement. In Illinois, law enforcement may only request indirect access for active cases under investigation. 

All Illinois prescribers and dispensers of controlled substances may register to access the ILPMP, but only prescribers possessing an Illinois controlled substance license (with exception of veterinarians) are required by law to register with the ILPMP.

Prescribers and dispensers may authorize a qualified healthcare professional to access the ILPMP on their behalf for patient care.  The designee may search for a patient by logging onto to the ILPMP website using their own username and password and then provide the ILPMP information directly to the prescriber or dispenser for clinical evaluation.  This increases ease of access to the ILPMP for prescribers or dispensers, especially those who do not have access to the ILPMP through the electronic health record system.  Currently, prescribers and dispensers, in an office or pharmacy practice site, may have up to 3 active designees linked to their ILPMP account at one time. Any prescriber or dispenser assigning designee access is responsible for the designee’s actions while logged on to the ILPMP.   Prescribers or dispensers should strongly consider reviewing the terms and use agreement with each of their designees, namely that the data may only be used for medical purposes when care is being provided to a patient and disclosure or discussion of personal health information is prohibited. You may request designee access at https://www.ilpmp.org/de_registration.php.  Prescribers and dispensers are required to verify searches performed by their designees, at minimum, every 6 months.  Failure to do so will result in ILPMP access revocation for the designee. Prescribers and dispensers are also required to verify continued employment of their designees and to terminate access to the ILPMP when that employer/ employee relationship no longer exists.  If a prescriber or dispenser no longer wants a designee to access the ILPMP on their behalf, they must log on to the ILPMP website and delete them from their account. 

How should I search the PMP?
Utilizing a patient’s first name, last name, and date of birth is a good place to start for most searches.  However, the database is only as accurate as the prescription information uploaded to the system.  For instance, if you were to search Christopher Herndon, you may miss data that was uploaded as Chris Herndon.  For this reason, I usually recommend using the first four letters of the last name and the first three letters of the first name to reduce the risk of missing results due to variations in spelling of the name.  The ILPMP also allows users to simultaneously search other state monitoring programs.  Illinois currently has agreements to share data with 22 other states, including all bordering states (and Missouri’s St. Louis County PDMP).

What information will the PMP display once the patient is found?
Once you verify your search results, the new ILPMP dashboard provides a valuable summary of information such as the total prescriptions, total prescribers, and total pharmacies for that patient within the last year.  You can also quickly identify if that patient currently has prescriptions with a cumulative morphine equivalent daily dose (MEDD) of over 90 mg, currently has overlapping opioid prescriptions or overlapping opioid and benzodiazepine prescriptions, or if a patient has received a long-acting opioid while previously considered opioid-naïve (See Figure 1). A patient may be considered opioid-naïve if they have been on less than 60 mg of oral morphine, or its equivalent, for a duration of seven days or less.   One newer feature that is perhaps the most useful is the “mapping prescriptions” function, which allows for geo-mapping of patient address, prescriber address, and pharmacy address (See Figure 2).  Keep in mind that all this data represents a point on the map and doesn’t necessarily confirm substance abuse or diversion.   Occasionally information in the ILPMP can be incorrect, therefore it is always recommended that prescribers and dispensers confirm the available ILPMP information with the patient.  

Recently, the ILPMP expanded its data to include additional data sets such as naloxone administered by EMS, expanded its functionality to include additional data sets which may assist a healthcare provider when making decisions about utilizing opioid therapy.  You can also see if a patient has filled a prescription for naloxone.  Please be aware that this does not include naloxone dispensed per the state-wide standing order or other corporate-level standing order as the intended recipient may not be the one obtaining naloxone.  Pharmacists should recommend naloxone to patients per the state-wide standing order, when appropriate.  The Illinois state-wide standing order can be downloaded at http://www.dph.illinois.gov/naloxone.

Am I required to search the ILPMP before prescribing or dispensing controlled substances?
In the State of Illinois, a prescriber (or their designee) must document an attempt to access the ILPMP prior to providing a prescription for an initial Schedule II narcotic prescription (720 ILCS 570/314.5).  At this time pharmacists are not required to document an attempt to access the ILPMP.  However, based on the pharmacist’s “corresponding liability” under the Federal Controlled Substances Act, this practice is highly encouraged.  While the law requires accessing the ILPMP only for the initial prescription, in practice, this should be performed (and documented) prior to each prescription from a patient safety and medico-legal standpoint.  The requirement to document an attempt to access the ILPMP prior to issuing an initial Schedule II opioid prescription does not apply to the inpatient setting, patients receiving active oncology treatment, palliative care / hospice patients, or patients receiving a seven day or less supply from an emergency department.

What is the PMPnow Connection?
On January 1^st, 2018, Illinois Public Act 100-0564 mandated that all electronic health record (EHR) systems utilized within Illinois interface directly with the ILPMP on or before January 1^st, 2021.  The integration of the PMP into the electronic health record will enable the prescriber to view the PMP data without leaving their workflow and logging into the ILPMP website. Utilizing this integration, also known as PMPnow, is anticipated to save time and money.  The PMPnow integration can be requested through the ILPMP at no cost to the health-system or pharmacy, although the EHR or pharmacy software vendor may charge the system for upfront costs associated with establishing the ILPMP connection. Currently ILPMP is integrated with approximately 250 pharmacies. Prescribers and pharmacists should work with their EHR and pharmacy software vendor to ensure they are meeting stale law requirements.  The connection between the ILPMP and your respective EHR is encrypted to ensure patient confidentiality.

Does HIPAA allow me to discuss ILPMP results with other prescribers or dispensers without patient authorization?
Yes.  If you are a prescriber or pharmacist   directly involved in the care of a patient, then accessing the ILPMP data and communicating that data with another professional directly involved in the care of the patient would fall under the HIPAA definition of “treatment.”  For instance, if you are a pharmacist and note that one of your patients is receiving alprazolam from his psychiatrist and his primary care physician, calling both prescribers would be considered reasonable under the HIPAA definition.  There is some ambiguity, however, if you do not have an established relationship with the patient.  Perhaps a new patient comes to your pharmacy with a prescription for hydrocodone.  You refuse to fill the prescription due to concerning information on the ILPMP.  Calling the prescribers of this patient may not be covered under the HIPAA definition of “treatment.” 

Case 1
You are a community pharmacist in a large retail chain.  A patient well known to you approaches the counter with a prescription for fentanyl transdermal patch 75 mcg/hour.  You review his prescription profile and note a routine monthly prescription for oxycodone / acetaminophen oral tablets 5-325 mg with instructions to take 1 tablet PO every 8 hours as needed for severe pain.  While you know a prior authorization will be required for the patient’s prescription insurance, you ask your pharmacy student what they would like to do.

Case 1 Discussion
The student recommends first asking the patient if they have been on the fentanyl patch prior and if so, what strength and how long ago.  The patient denies prior experience with fentanyl patches.  You ask your stellar student if this patient is opioid-naïve or opioid tolerant.  The student notes that the patient routinely fills the oxycodone tablets each month, assuming that they use the three allowed doses each day.  This would be 15 mg of oral oxycodone which is equivalent to approximately 20 mg of oral morphine equivalents daily (MEDD).  While the patient has been on this therapy for several years, the MEDD is less than 60 mg, which means this patient should be classified as opioid-naïve.  The safety of the fentanyl patch for this patient should be questioned.  You and your student log on to the ILPMP and note that this patient has been receiving oral controlled release morphine 60 mg dosed every 12 hours from the same prescriber, but it is filled at a different pharmacy.  This would place the patient in the opioid-tolerant category, but the different pharmacy certainly raises a red flag.  You mention this when you call the prescriber.  Before the patient leaves, the student asks, “what about naloxone?” and suggests to the pharmacist that if the patient does not have a dose of naloxone available at home, they should consider obtaining one per the state-wide standing order while providing the standardized procedures for administration.  

Case 2
You are a hospital pharmacist working in the emergency department.  Your hospital has recently integrated PMPnow into your electronic health record.  A patient presents for uncontrolled low back pain due to a fall and is requesting something for severe pain.  You review this patient’s ILPMP record and note that they are routinely using fentanyl transdermal patches.  A urine drug screen is positive for an “opiate.”  The emergency physician comes by on her way to see the patient and stops to ask you your thoughts. 

Case 2 Discussion
First and foremost, the ILPMP should be used to improve patient care, not as punitive action.  You are to be commended for reviewing the ILPMP.  However, because this patient falls under one of the exempt categories, documenting the attempt to access the ILPMP is not legally-mandated should you choose to send this patient out with a prescription for an opioid analgesic.  The other concern is the positive drug screen for “opiate.”  Traditionally immunoassay urine drug screens are not sensitive for synthetic or semisynthetic opioids unless specifically stated.  The first conclusion here would be the patient is using an illicit opioid.  That certainly is a distinct possibility, but an additional consideration could be that this patient received an opioid analgesic in another emergency department or hospital recently.  This would not be reported to the ILPMP.

Conclusions
The Illinois Prescription Drug Monitoring Program is a valuable tool for prescribers, pharmacists, and pharmacy technicians.  Routine review of the ILPMP is essential for improved clinical decision making, safer opioid prescribing, and improved patient outcomes while reducing opioid misuse, abuse and overdose. Both prescribers and pharmacists may designate up to three licensed designees to query the database on their behalf.  Pharmacists should be prepared to discuss ILPMP findings or concerns with both patients and prescribers.  Pharmacy technicians should be prepared to discuss ILPMP findings with a pharmacist.

Clinical Director of ILPMP:
Sarah Pointer, PharmD

Address:
401 North Fourth Street
Springfield, IL 62702

Phone: 217.524.1311

Fax: 217.557.7975

1. Gugelmann HM, Perrone J. Can prescription drug monitoring programs help limit opioid abuse? J Am Med Assoc. 2011;306(20):2258-2259. doi:10.1001/jama.2011.1712.
2. Reifler LM, Droz D, Bailey JE, et al. Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med. 2012;13(3):434-442. doi:10.1111/j.1526-4637.2012.01327.x.
3. Fink DS, Schleimer JP, Sarvet A, et al. Association between prescription drug monitoring programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review. Ann Intern Med. 2018;168(11):783-790. doi:10.7326/M17-3074.
4. Centers for Disease Control and Prevention. 2019 Annual surveillance report of drug-related risks and outcomes — United States surveillance special report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published November 1, 2019. Accessed 2020 Apr 2020 from https://www. cdc.gov/drugoverdose/pdf/ pubs/2019-cdc-drug-surveillance? report.pdf.

Working in a hospital pharmacy has changed my perspective on my career and has given me so many opportunities. I’m still not used to not hearing the phone ring every few minutes and I still expect a line of patients when I walk into an early shift. I’m surprised when I walk by someone and they don’t ask me what aisle the Claritin is in. I have traded my business casual attire for scrubs and I haven’t looked back. Now I work alongside technicians, pharmacists, and even nurses and doctors. As a student, it has been a great experience getting to work in both the community and hospital environments. 

Being able to compare the two environments helped guide me to where I want to be when I graduate. I have been able to learn what I enjoy about both experiences. As exciting as it is to work in a hospital pharmacy, I still reflect on my time as a community pharmacy technician. For example, while working in community, my experiences with counselling patients were all really positive. Being able to describe different side effects and answer questions was really meaningful to me. On the other hand, working in a hospital is providing a chance to learn therapeutic knowledge and I have been able to make connections between the drugs I am filling with the content that we are learning in class. I have been able to grow having had the chance to work in both settings.

Every time I am working, I notice a drug that I happened to learn about in my classes that week. This makes everything come full circle for me. Seeing “Precedex™” print out of the label machine automatically makes me think of all of the reasons that it can be used and helps me to remember the reasons when it appears on exams. Seeing these drugs “in real life” makes me realize that what I am learning is so much more than passing an exam. I will need to have this knowledge with me for the remainder of my career. Whether it is compounding an IV drug or loading tablets into a dispensing cabinet, I am able to make a much stronger connection to what I am learning at school. I am also getting experience with drugs that I hadn’t seen before in the community setting.

Getting to work alongside hospital pharmacists has made me realize that I could see myself in a hospital setting. Yes, it is true we can take all the pharmacy career tests our classes assign us, but you get the best picture of yourself in a career when you have actually been in that setting. Getting exposure to hospital pharmacy has been a great way to narrow down my career choices after pharmacy school and has given me comfort knowing that there is a setting in which I fit well. Getting to hear the endeavors that current pharmacists I work with go through is such a great way to learn about the career and they are always so willing to educate on what they do every day. The pharmacists I work with also make it a point to ask what I am currently learning about in class and try to tie in questions or comments that are relevant to our current patients.

Overall, I have enjoyed my experience so far working in the hospital and I look forward to even more opportunities as a student pharmacist and to my career as a pharmacist. Being able to work in hospital pharmacy has given me more confidence and has made me so excited for my future.

Looking back on our pharmacy school journey, many of my fellow classmates and I agree that the transition from the first year of pharmacy school to the second was quite a wake-up call. The second year of pharmacy school meant new exposure to our initial therapeutic courses such as endocrinology and rheumatology. At the Roosevelt College of Pharmacy, these courses are called Integrated Sequence (IS) as they truly integrate different aspects of disease states such as pharmacology, medicinal chemistry, and clinical presentation. In other words, a lot of information! My personal study routine for the endocrine exam, for example, consisted of frantic cramming with the use of flashcards while stress eating a bag of Doritos™ to prevent a hypoglycemic episode due to skipping meals to study. I was receiving acceptable grades in my courses, but the question remained as to whether this was an efficient study method. Was I truly learning or simply memorizing the information to later regurgitate it during the exam? After going through our second year of pharmacy school, it became apparent to my classmates and I that we could have benefited from resources or guides that could prep us for the intensity of these course during our first year of school.

With that being said, the SSHP has introduced the first IS course preparation workshop for first year pharmacy students this past term. It was an informative presentation that detailed what the IS courses really were. Specifically, how they are structured, what to expect as far as material and quizzes/exams, and how important these courses are for our pharmacy careers. We shared our personal experiences and successes when it came to study habits and understanding the material, as well as answered any questions. We continued to emphasize the benefit of truly understanding the material, rather than memorizing and cramming prior to exams. The IS courses can certainly seem intimidating, however by fine tuning study habits, one can appreciate the information being taught. This will not only help with exams and course grades, but also will result in stronger foundational knowledge that will impact our pharmacy careers. For example, we explained that understanding medication mechanisms of action were an important tool for determining adverse events that may develop from that agent.  Many of the students stated they were nervous and unsure how to tackle these courses, however, after this workshop they were confident in their ability to do well, showing that our workshop was a success!

This past term also included SSHP putting a different spin on our usual winter Journal Club event. Typically during this event, the individuals who present the article are asked certain questions by the audience. However, during this last event, the decision was made to “flip” the setting. The presenters quizzed the audience regarding certain aspects of the article presented. Questions included clinical information, interventions, as well as biostatistics. This innovation made the journal club event substantially more interactive, engaging, and surprisingly fun. Not only were we able to introduce new clinical findings presented in our article, but we also helped reinforce everyone’s literature analysis skills. The ability to break down research articles is an invaluable asset that will continue to help us throughout our pharmacy careers. It is most definitely a skill that can help strengthen our clinical judgement and foundational knowledge which can shape our abilities as students and future pharmacists. We look forward to continuing these “flipped” journal clubs in the future. With that being said, it’s safe to say that biostatistics is pretty significant (no pun intended)!

The Rosalind Franklin University (RFU) student chapter of ICHP has been striving to introduce unique and innovative fundraising ideas. With the vast number of organizations at our interprofessional university, fundraising becomes repetitive and participation declines with time. Our chapter has been working on increasing member engagement as well as sparking greater interest within the RFU community for our fundraisers.

A common fundraising approach for student organizations is to partner with local restaurants or fast food franchises to earn a portion of the profit for that day. There is a smaller margin available to be made with corporate food fundraisers, and they also require little planning and preparation on the organization’s end. However, with the abundance of local food fundraisers, it is difficult to stand out, spark interest, and foster responsiveness with classmates. 

One of our most successful fundraising events we had was making and selling grilled cheese sandwiches and tomato soup during finals week. We knew that we needed something easy to make, yet appealing to stressed graduate students. We finally decided on grilled cheese sandwiches and tomato soup which we could sell in our school’s café. Our fundraiser brought food directly to campus to increase participation and also made it accessible to students studying on campus. With careful planning, we acquired the necessary equipment and ingredients for the event. We sold out within the first hour! This event was a great success largely due to the extensive marketing schoolwide. One platform that we found was the most helpful in spreading the news was Instagram. In addition to social media, we shared the flyers with students from other programs at the university.
   
Another successful event was a t-shirt fundraiser. With the help of our creative executive board, we came up with a great design and made sure to market the shirt to each class in the college. Once designed, the shirts nearly sold themselves. The driving factor was the individuality and quality of our t-shirts. Execution and advertising were vital to student body engagement and the success of the fundraiser.
 
With new fundraising ideas, substantial planning must occur. With no prior guidance or protocols, the planning process can be daunting and time consuming. Advertising should begin well before the event takes place and should be consistent until the event occurs. Advertising on campus can range from distributing flyers, sending college or university wide emails, utilizing social media, strategically placing the event in a high traffic area, and planning an appropriate date and time. 

While new fundraising ideas are challenging, the potential for success is significant and should be pursued. Frequently used fundraisers should still be considered, but the best success often lies with new and innovative fundraisers. Increasing fundraising success allows the chapter to host more events, which increases member participation, engagement, and retention.

As part of the strategic initiative to develop global education opportunities, the SIUE SOP offers unique opportunities for students to travel to countries across the world. One of these opportunities is the Advanced Pharmacy Practice Experience (APPE) in India. Partnering with JSS College of Pharmacy in Karnataka, India, students experience pharmacy in an entirely different environment. SIUE students spend five weeks in India, while JSS students spend a total of eight weeks in the United States. Catherine Gilmore, a student pharmacist from the Class of 2020, has graciously shared her experience of traveling abroad to India through an interview.

Q: Tell us about your experience in India.
A: Traveling to India and experiencing pharmacy practice there was such a wonderful opportunity! We were able to spend 2 weeks at a private, 1800-bed hospital and see how they treated a variety of disease states, such as Dengue Fever, thalassemia, multi-drug resistant tuberculosis, and pediatric endocarditis. Since it was a teaching hospital, we were able to round with attendings, medical residents, medical students, and pharmacy students. We didn’t prepare for rounds each morning because there was only one paper chart available on each patient, so recommendations for changes in therapy came after rounds when chart was available. We then split the next week at a government-run cancer hospital and a government-run HIV hospital. We finished our time at a rural, government-run hospital at a hill station in the mountains, where most people were being treated for COPD. Here, the government supplies all medications free of charge. Pharmacists are involved when it comes to recommending medications on the government’s formulary and obtaining non-formulary medications when indicated. It was such a different experience than a medicine/hospital APPE rotation in America because while the treatment options are more limited the cost is so low.

Q: How is pharmacy different in India than it is here in the United States?
A: The PharmD degree is very new in India. The first cohort of PharmD students graduated in 2014, so clinical pharmacy is growing. Before, students received a Bachelors or Masters in pharmacy (and they still can), with most graduates pursuing a career in industry. They also have a Diploma in Pharmacy, which is an entry-level degree that takes approximately 2 years to earn, and is for those who want to practice more community-based pharmacy. From my understanding, there is not much clinical information taught with this degree and it is mostly how to run your own pharmacy. This degree was necessary for citizens in rural areas to have better access to medications. As the PharmD degree grows and more graduates are seeking advanced degrees, it is the intent of the Pharmacy Council of India to phase out the diploma program.

Q: If you could change one thing about pharmacy in the United States based on what you have learned in India, what would it be?
A: Prescription drug prices. Hands down. Medications are so incredibly cheap! We were in one of the pharmacies at the hospital looking at the various inhalers they had, and I picked up a budesonide/formoterol inhaler. I asked the pharmacy clerk how much the inhaler cost and she said “600 rupees.” I whipped out my calculator and converted that to dollars—it was a little over $8. And that’s the price the patient pays. Having insurance is not as common in India as it is in America, but the cost of healthcare is very low and fairly affordable for all patients. It is crazy that this same branded inhaler is over $300 in America, but is a fraction of the price in India.

Q: Would you recommend students experience this global opportunity to learn more about pharmacy in another country?
A: I would definitely recommend any global opportunity. It helps you to understand what pharmacy practice is like in other countries and how culture and religious beliefs can shape healthcare globally. This experience was unique for me since almost everyone I came into contact with spoke English, so language was not as large of a barrier as it might be with other experiences abroad. I think if students can step out of their comfort zone, even for a month or so, it helps you appreciate the things that we take for granted (e.g., toilet paper, drinking tap water, constantly smelling like bug repellant, etc.). Specifically, India also has SO much to offer! Mysore, the city where we spent most of our time, was home to many yoga studios and schools, as they teach Ashtanga Vinyasa yoga there. The south Indian food was absolutely fabulous, and we never had a bad meal. Mysore is home to the Mysore Palace, a beautiful palace open to the public that happens to be the 2nd most visited place in India. We took full advantage of visiting. There is so much to see and do in India and we were never bored! 

USP 797 is a chapter for sterile compounding requirements produced and published by United States Pharmacopeia and National Formulary (USP-NF) aimed to “help ensure patients receive quality preparations that are free from contaminants and are consistent in intended identity, strength, and potency”.¹ Since a nationwide meningitis outbreak in 2012, many state pharmacy practice laws have adopted USP 797 to require pharmacies be compliant in all settings.² The new revisions for USP 797 will impact the preparation of compounded sterile products in a large way, ultimately increasing sterility and safety of products by increasing the requirements needed for personnel and facilities involved in the preparation of compounded sterile products (CSPs). The new revisions of USP 797 were originally planned to be implemented December 1st, 2019, but have been postponed until a later date due to appeals by individual pharmacies and potential revisions of the material.1 Many hospital systems have been continuing to adhere to the proposed revisions since the original December deadline in preparation for when they become finalized.

However, the updates have come at a cost. The financial and planning burdens of implementing the new standards have been challenging for some hospital-systems that do not have preexisting clean rooms. The new revision of USP 797 requires a clean room with sufficient air exchanges for extended beyond use dates (BUDs) on sterile products which are past 24 hours, a very important feature for maximizing medication usage and decreasing pharmaceutical waste.¹

Our local ICHP chapter reached out to Eva Morrison, PharmD, Inpatient Pharmacy Manager at SwedishAmerican Hospital, a Division of UW Health, to comment on the changes and challenges of implementing the USP 797 revision. Dr. Morrison states that the SwedishAmerican pharmacy department has been working on implementing the USP 797 revision since the beginning of 2018 and the challenges presented to the hospital on implementation have been multifactorial.

The largest and most time-consuming challenge for the hospital was determining the location of the clean room. Dr. Morrison states that the main hospital was not a feasible option for the clean room because of “the high cost of the air handling system that would be required to meet the 797 requirements for air exchanges”. The hospital decided to build the clean room in a nearby facility, the Home Infusion Pharmacy which is one mile away from the parent hospital location.

Implementation difficulties have affected other departments as well. The financial aspect of building a clean room is apparent but Dr. Morrison shared that the changes have affected workflow, too. The new 24-hour BUDs on products produced at the hospital have required new workflow strategies for recurrent continuous medications such as patient controlled analgesics or epidural bags for the labor and delivery floor. The Swedish American Hospital Belvidere campus has had to use some creative solutions “since they can only give CSPs 24-hour BUDs and there isn’t pharmacy staff there on the weekends” says Dr. Morrison.

Overall, Dr. Morrison says that while implementation is difficult and has required problem solving to meet the requirements set forth by USP, the changes are worth while and are a step forward for better patient care. Dr. Morrison states, “I think the stricter requirements are essential to ensure the highest quality environment for sterile product preparation, ultimately improving patient safety and quality care.”

Our chapter mirrors Dr. Morrison’s thoughts towards the new regulation of USP 797. We think that it is important for pharmacies to move forward and provide safer medications to our patients. Our chapter’s P1 liaison, Evan Fetten, has been setting up hospital tours for student pharmacists, particularly those in their first year, to become accustomed to the world of health-system pharmacy. We believe that it is important for students to see how advances in health care impact pharmacies daily and learn how to implement changes so that we can continue to provide quality care. We have tours with SwedishAmerican Hospital as well as Van Matre Encompass Health Rehabilitation Hospital so that students can see how their course work dovetails with clinical practice.

1. Compounding Standards, 2020. https://www.usp.org/compounding (accessed 8 March 2020)
2. What is USP 797 and How to Stay Compliant, 2019. https://www.pharmacyonesource.com/what-is-usp-797-and-how-to-stay-compliant/ (accessed 8 March 2020)
   

Champions Live Webinar
May 21, 2020, 12:00 pm
Topic: Implementation of Best Practices for Asthma
Speaker: Lori A. Wilken, PharmD, BCACP, NCTTP, AE-C
Accredited for health-system pharmacists and pharmacy technicians

2020 ICHP Annual Meeting
October 1-3, 2020
Drury Lane Theatre & Conference Center 
Oakbrook Terrace, IL 

• Abigail Auer
• Michele Averhart
• Nickita Benny
• Nancy Castro
• Kaleia Collins
• Christopher Fontillas - Recruited by Milena Murray
• Jacquelyn Grimm
• Bethany Harris - Recruited by Erin Hatfield
• Lorraine Johnson
• Alexis Leach
• Kassandra Mason
• Edib Mravic - Recruited by Rebecca Ohrmund
• Adam Procento
• Stephen Salisbury - Recruited by Donald Schaeffer
• Syruliah Shah
• Natasha Shea - Recruited by Kristi Stice
• Victora Simmons - Recruited by Julia Schimmelpfennig
• Margo Stone
• Brian Sutton
• Brittany Yang
• Andrew Zouzani

Thank you to all of our PAC contributors!