APhA House of Delegates: Ensuring the power and promise of pharmacy APhA–APPM: Andrew Bzowyckyj APhA–APRS: Ben Urick APhA–ASP: JT Fannin APhA–APPM This year’s American Pharmacists Association (APhA) Annual Meeting featured another exciting session of the House of Delegates (HOD). Pharmacists and student pharmacists from across the country discussed key issues affecting the future of pharmacy. This year’s topBzowyckyj ics didn’t seem to stir up as much debate as previous years but the issues discussed are nonetheless vital to the future of our profession. Below is a summary of the policies that were passed by the 2013–14 HOD from the perspective of APhA’s Academy of Pharmacy Practice and Management (APhA– APPM). The complete wording of these policies is available on the APhA website at www.pharmacist. com/house-of-delegates. Care transitions Our health care system in the United States continues to evolve and respond to paradigm shifts such as the implementation of the Affordable Care Act. Much attention has been placed on cost savings and improved access and quality of care. Additionally, the Centers for Medicare & Medicaid Services has begun to withhold reimbursement for readmissions of patients within 30 days of hospital discharge for certain diagnoses. These changes have prompted health systems and 330 JAPhA | 5 4:4 | JUL /AUG 2 0 1 4

affiliated entities to analyze their care-transition processes. Some groups have welcomed health-system and community pharmacists as active participants in the care transitions processes, but this is often the exception rather than the rule. The policy passed by the HOD provides APhA with the vision and direction to further advocate for integrating pharmacists as critical members on interdisciplinary care teams responsible for ensuring safe and appropriate medication use during care transitions. Those interested in getting more involved with APhA’s initiatives on care transitions should check out the

APhA–APPM Transitions of Care Special Interest Group (SIG), available in the Academy section of Audits of health care practices Claims audits have caused a big stir within the pharmacy profession in in recent years. A process intended to maintain the integrity of prescription claims has morphed into one littered with controversy and obscure rules. Several states have already implemented legislation that sets clear expectations for both parties involved during a claims audit, but there is still much work to be done to ensure that audits are performed fairly, transparently, and professionally. With the 2014 HOD policy in hand, the Association will be able to move forward on this urgent issue as well. Use of social media The use of social media has increased exponentially over the last 10 years. It has transitioned from a platform for networking with peers

The Association Report column in JAPhA reports on activities of APhA’s three academies and topics of interest to members of those groups. The APhA Academy of Pharmacy Practice and Management (APhA–APPM) is dedicated to assisting members in enhancing the profession of pharmacy, improving medication use, and advancing patient care. Through the APhA-APPM Special Interest Groups (SIGs), the Academy provides members a mechanism to network and support the profession by addressing emerging issues. To access a listing of APhA-APPM SIGs, visit www. The mission of the APhA Academy of Pharmaceutical Research and Science (APhA–APRS) is to stimulate the discovery, dissemination, and application of research to improve patient health. Academy members are a source of authoritative information on key scientific issues and work to advance the pharmaceutical sciences and improve the quality of pharmacy practice. Through the three APhA– APRS sections (Clinical Sciences, Basic Pharmaceutical Sciences, and Economic, Social, and Administrative Sciences), the Academy provides a mechanism for experts in all areas of the pharmaceutical sciences to influence APhA’s policymaking process. The mission of the APhA Academy of Student Pharmacists (APhA–ASP) is to be the collective voice of student pharmacists, to provide opportunities for professional growth, to improve patient care, and to envision and advance the future of pharmacy. The Association Report column is written by Academy and section officers and coordinated by JAPhA Managing Editor Honey Fisher of the APhA staff. Suggestions for future content may be sent to [email protected]

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locally to a worldwide network for communication, advertising, sharing of ideas, and much more. The opportunities that social media can present for patient care and public health emergencies have not yet been fully realized. Patient privacy and confidentiality continue to be critical elements that need to be addressed before large-scale use of social media for patient-specific care is achieved. Additionally, the importance of maintaining a professional presence on social media and posting only accurate and appropriate clinical information were also incorporated into this all-encompassing HOD policy. This forward-thinking policy provides APhA and external stakeholders with the profession’s position on the use of social media in a variety of situations as use of this technology evolves. Controlled substances and opioid reversal agents This policy originated as an idea from several members of the APhA– APPM Pain, Palliative Care & Addiction SIG. The increase in the abuse and misuse of controlled substances and other medications with the potential for abuse has increased the incidence of morbidity and mortality as a result of medication toxicities. This APhA HOD policy advocates for enhancements in pharmacist and student pharmacist education regarding this topic, in addition to increasing patient access to opioid reversal agents by better leveraging pharmacists to assist with treatment of opioid toxicities. Electronic cigarettes Electronic cigarettes, or e-cigarettes, present another emerging area of controversy in pharmacy practice. The evidence regarding the health impact and environmental safety remain conflicting and inconclusive. This policy encourages pharmacists to become more knowledgeable about these products and urges the 332 JAPhA | 5 4:4 | JUL /AUG 2 0 1 4

Food and Drug Administration to disclose fully all ingredients found within these products, as well as associated safety data. Getting involved As a member of the APhA–APPM delegation, I enjoyed playing an active role in the APhA policy process. I strongly encourage anyone interested in getting more involved to consider serving as a delegate for your respective state, Academy, or Speaker-appointed seat to get involved in the policy process. Even if you do not have an inherent interest in policy development, who doesn’t love a healthy debate and having a lasting impact on your profession? Andrew Bzowyckyj, PharmD, BCPS, CDE Clinical Assistant Professor University of Missouri–Kansas City School of Pharmacy Gladstone, MO 2013–15 APhA–APPM New Practitioner Officer [email protected]

APhA–APRS The policy-making process is integral to APhA’s continued success. It is through the crafting of policy that the organization hears its membership’s desires and continues to advance the profession. This year’s HOD debated Urick many policies that will help to guide the Association as it advocates on behalf of pharmacy. Some policies passed by the House sought equilibrium between encouraging effective use of audits and social media—and the possible downsides of such areas, encouraged pharmacists to be active on the issue of opioid abuse, and emphasized the role that all pharmacists have in transitions of care. Health care audits and social media Crafting successful policy often reja p h

quires creating language that strikes a balance on tough issues. This is true with policies on auditing practices and social media use passed this year by the HOD. Both audits and social media have positive attributes. Audits can help prevent patient harm and reduce fraud, waste, and abuse, while social media can connect patients with other patients and health care professionals. But both can also be used inappropriately. Audits that rescind payment for small errors in prescription documentation and substantially impede the normal pharmacy work process are a common experience for community pharmacists. Likewise, social media can be used to inadvertently expose protected health information or provide misinformation on clinical topics. The auditing and social media policies passed by the House address the benefits of, and concerns regarding both these areas, as well as provide beneficial guidance to the Association. Controlled substances and opioid reversal agents During sessions of the APhA HOD, new business items can sometimes produce the most interesting pieces of policy. This year was no different. The APhA Academy of Pharmaceutical Research and Science (APhA–APRS) caucus enjoyed spirited discussion related to controlled substances and the furnishing of opioid reversal agents without a prescription. The pharmacist’s duty is to monitor patient’s use of all medications, and controlled substances are no exception. Currently, all states except Missouri have a prescription monitoring program (PMP). However, in many states pharmacist enrollment and willingness to participate in the program are variable.1 It is essential that these programs be used to monitor for patients picking up controlled substances with cash at other pharmacy locations, as pharmacists

Journal of the American Pharmacists Association


need to be aware of this. Prescription opioid use in particular has become an enormous problem and has been linked to a rise in the use of heroin as an alternative when prescription opioids are either unavailable or too costly for the abuser.2 As pharmacists continue to explore additional roles within the health care system, the possibility exists for the pharmacist to be able to furnish opioid reversal agents to people such as family members of addicted persons as a rescue for overdose. Programs to provide intranasal naloxone to first responders have been successful in Boston and New York, and there is a movement towards possession of these products by potential bystanders who have been trained in administering them.3,4 Pharmacy practice regulations in nearly all states would have to change to allow the pharmacist to furnish naloxone without a prescription, but programs to prevent opioid overdoses save lives. Something so good for patients must also be good for the profession. Care transitions The House also passed important policy addressing pharmacists’ roles in transitions of care. Activities related to care transitions are part of the ideal job description for inpatient pharmacists and encompass services such as medication reconciliation and the review of discharge orders. Specific activities related to care transitions are beginning to appear in outpatient and community pharmacy settings as well. The potential for outpatient and community pharmacists to engage in transitions of care through new care models such as accountable care organizations (ACOs) is important. By tying payment to quality metrics, Medicare and private insurers are creating incentives for pharmacists to engage in care transitions. In Iowa, pharmacies are working with patients covered under a

Pioneer ACO to provide medication therapy management (MTM) services in an effort to improve transitions of care, among other things.5 This project, and others like it, will help to define the outpatient and community pharmacist’s role in care transitions in the modern health care system. Sustainable payment systems that reimburse pharmacists directly for the services they provide are needed to secure a place for these roles in pharmacy’s future. Guiding the future of pharmacy As a recent graduate, I have found that the policy-making process of the APhA HOD is reason enough to continue my membership. As a member of APhA–APRS, I see in the policy process the impact of the development of an intranasal delivery system for naloxone and the potential for research on community pharmacists’ roles in transitions of care. Policies on social media use and health care audits also support research to determine what types of audits and social media best accomplish their respective goals and prevent misuse. I look forward to seeing the impact of the 2014 HOD discussions on the practice of pharmacy. Ben Urick, PharmD UI Presidential Fellow PhD Student Pharmaceutical Socioeconomics College of Pharmacy University of Iowa Iowa City [email protected]

References 1. Fleming ML, Barner JC, Brown CM, et al. Pharmacists’ training, perceived roles, and actions associated with dispensing controlled substance prescriptions. J Am Pharm Assoc. 2014;54:241–250. 2. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: summary of National Findings. 2014. NSDUH/2012SummNatFindDetTables/ NationalFindings/NSDUHresults2012. htm#ch5.5. Accessed May 22, 2014.

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3. Rosenberg T. An antidote to overdose, in time to save lives. NY Times. 2014(May 21). 4. Doe-Simkins M, Walley A, Epstein A, Moyer P. Saved by the nose: bystanderadministered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health. 2009;99(5):788–791. 5. University of Iowa College of Pharmacy. Partners launch ACO-MTM model study.‐pharmacy‐partners‐launch‐aco‐ mtm‐model‐study. Accessed May 24, 2014.

APhA–ASP Student pharmacist attendees of APhA2014 unpacked their summer gear for some sunshine and fun in one of the world’s most popular vacation destinations—Orlando, FL. There was no shortage of magical moments and exciting adventures in the home of the Walt Disney World, Universal Studios, and SeaWorld Resorts— all within minutes Fannin of the Orange County Convention Center. The brightest light of the weekend, however, shone on the enthusiastic student pharmacists who debated the important and timely topics on the floor in the two APhA Academy of Student Pharmacists (APhA–ASP) HOD sessions. With the assistance of 2011 Linwood F. Tice Award recipient and APhA– ASP Parliamentarian Michael Moné, chapter delegates voted to adopt three new resolutions and readdress one existing topic as the charge of the 2014–15 APhA–ASP Policy Standing Committee. Pharmacogenomics There are now more than 100 drug products that carry pharmacogenomic information in product labels, and FDA estimates 40% of medications currently in the drug pipeline are targeted therapies. As JU L/A U G 2014 | 54:4 |

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the cost associated with pharmacogenomic testing continues to fall and the results of these tests are increasingly used to improve drugrelated therapeutic outcomes, student pharmacists recognized some of the opportunities and challenges with this developing field. Students emphasized the importance of pharmacists’ roles in clinical pharmacogenomic services, the development of standards and guidelines for practice, and appropriate training for students and practitioners alike. Resolution 2014.1 was adopted as follows: 1. APhA–ASP supports the utilization of clinically relevant, evidence-based pharmacogenomic testing and services to enhance individualization of patient care and improve clinical outcomes. 2. APhA–ASP promotes pharmacists as the primary member of the health care team responsible for pharmacogenomic services, including but not limited to, interpreting and applying test results, developing individualized medication treatment plans in collaboration with prescribers, and serving as a resource to prescribers, patients, and other members of the health care team. 3. APhA–ASP supports continued research, development, and implementation of clinical standards and guidelines regarding the use of pharmacogenomics to improve patient care. 4. APhA–ASP supports ongoing vigilance by all stakeholders with access to pharmacogenomic information to maintain the confidentiality and ensure the appropriate use of the information. 5. APhA–ASP encourages all schools and colleges of pharmacy to incorporate pharmacogenomics throughout the curriculum. 6. APhA–ASP encourages the development of continuing edu334 JAPhA | 5 4:4 | JUL /AUG 2 0 1 4

cation and training programs to support existing practitioner understanding of pharmacogenomics. 7. APhA–ASP encourages all stakeholders, including but not limited to, employers, pharmacies, health systems, and thirdparty payers, to develop a compensation model for pharmacist-provided pharmacogenomic services that is both financially viable and in the best interest of patients. Medications in life-threatening situations Inconsistencies among state regulations create confusion about pharmacists’ authority to dispense and administer medications without a prescription in a life-threatening situation. In addition, the legal protection provided by existing “Good Samaritan” laws varies considerably when “medically trained personnel,” including pharmacists, are involved. In resolution 2014.2, student pharmacists addressed the need for both authority and protection for pharmacists using their professional judgment to act in the best interest of individuals in such situations. Resolution 2014.2 was adopted as follows: 1. APhA–ASP supports pharmacists’ authority to dispense and administer medications, including but not limited to, naloxone, epinephrine auto-injectors, and albuterol inhalers, without a prescription in a life-threatening situation prior to the arrival of emergency medical services. 2. APhA–ASP supports protection from civil and criminal prosecution of medically trained personnel, including pharmacists, for actions taken in the best interest of the patient during a lifethreatening situation. Pharmacist-led clinics Pharmacists continue to be the most accessible health care proja p h

fessional. Clinical evidence demonstrates the role of pharmacistdirected anticoagulation and diabetes clinics in improving patient outcomes and satisfaction. The 2014 APhA–ASP HOD expressed their support for the expansion of such clinics into additional areas of clinical practice and emphasized access to these services for vulnerable and medically underserved communities. Delegates also addressed their desire for curricular improvements in the areas of entrepreneurship, strategic direction, and business management to enhance their ability to establish and manage any of the expanding variety of collaborative practice opportunities for pharmacists. Resolution 2014.3 was adopted as follows: 1. APhA–ASP supports the expansion of pharmacist-led clinics—in collaboration with other members of the health care team—that serve unmet health needs and facilitate increased access to patient care. These clinics may include, but not be limited to, anticoagulation, international travel, tobacco cessation, rural, underserved, and mobile health clinics. 2. APhA–ASP encourages all schools and colleges of pharmacy to incorporate entrepreneurship, business development, and practice management training in the curriculum to provide future pharmacists with the tools to operate and manage financially viable pharmacist-led clinics. 3. APhA–ASP encourages the expansion of residency, fellowship, and other postgraduate training programs within pharmacist-led clinics. 4. APhA–ASP encourages the development of grants or financial assistance programs to aid in the establishment and management of pharmacist-led clinics.

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Drug-abuse epidemic Delegates to the 2014 APhA–ASP HOD recognized the need to revisit a topic related to the continuing epidemic of prescription drug abuse. As states have developed their own prescription drug monitoring programs, challenges in communication across state lines have emerged and remain, as yet, unresolved. Delegates charged the 2014–15 APhA– ASP Policy Standing Committee with renewing our call for the development and implementation of a na-

tionally standardized prescription drug monitoring program to prevent diversion, misuse, and abuse of prescription and nonprescription drug products.

ing action on these items this year under the guidance of the newly elected National Executive Committee and gathering in San Diego, CA, for APhA2015. See you there!

Looking forward to San Diego Students from across the country conducted a spirited and insightful debate on these topics and shared their passion to be the change they envision for our profession. The nearly 34,000 student pharmacists of APhA–ASP look forward to tak-

JT Fannin, PharmD PGY1 Pharmacy Resident Children’s of Alabama Birmingham, AL 2013–14 APhA–ASP Speaker of the House [email protected] doi: 10.1331/JAPhA.2014.14520

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APhA House of Delegates: ensuring the power and promise of pharmacy.

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