Pharmacy News

Entries for May 2020

Pharmacy’s Role in Addressing Stewardship in Dentistry

Elaine M. Bailey, Pharm.D., Executive Director, Michigan Antibiotic Resistance Reduction Coalition

Antibiotic resistance is a serious public health threat requiring a multifaceted approach. Approximately 10 percent of outpatient antibiotics in the U.S. are prescribed by dentists, amounting to nearly 25 million courses each year.1 Approximately 1.5 million additional antibiotic courses are prescribed to patients presenting in emergency departments with dental pain.2. There are increasing reports of inappropriate antibiotic prescribing in dental patients as well as dental patients experiencing Clostridiodes (formerly Clostridium) difficile diarrhea. 3,4. Given these findings, the American Dental Association (ADA) committed to the U.S. Antimicrobial Resistance Challenge by creating and disseminating guidance to help clinicians appropriately prescribe antibiotics. 5 The American Academy of Orthopedic Surgeons (AAOS) also committed to increase awareness of when antibiotics should and should not be used for patients with hip and knee implants who are undergoing dental procedures. (

The ADA guideline for treatment of oral infections addresses many stewardship principles. The guideline encourages a paradigm shift in the use of antibiotics in dentistry from a “just in case” approach to using only when absolutely necessary. For example, when the patient is able to obtain interventional treatment (e.g. pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage) within 24 hours, antibiotics are generally not recommended. The ADA suggests practicing “Delayed Prescribing/Watchful Waiting” in situations where antibiotic treatment is unlikely to be of benefit. If a decision is made to prescribe antibiotics, then the maximum duration is seven days and the patient should discontinue antibiotics after they have been symptom-free for 24 hours. The ADA has also attempted to curb the use of clindamycin, which has been shown to be highly associated with Clostridiodes Difficile Infection (CDI)6, by following the guidance of the CDC in terms of evaluating penicillin allergy and suggesting the use of azithromycin as an alternative to prescribing clindamycin in the face of a true (anaphylactic) penicillin allergy. 

For infective endocarditis prophylaxis in patients undergoing dental procedures, current guidelines support premedication for only a small subset of patients.7 Unfortunately, in the case of patients with prosthetic joint replacements who are undergoing dental procedures, the guidelines developed by the ADA and AAOS have changed over the past 17 years, at times being incongruent particularly related to how long after the implant the patient should continue to receive prophylaxis before a dental procedure. The AAOS Appropriate Use Criteria (AUC) online tool indicates that it is rarely appropriate to prophylax patients who have undergone joint replacement more than one year before the dental procedure. The antibiotics prescribed are generally aligned with the American Hospital Association (AHA) guidelines with the exception of the removal of clindamycin as a choice (Table 2). Unfortunately, several dental providers in Michigan have shared that their orthopedic colleagues are often not in compliance with the AAOS guidance. 

Comprehensive guidelines exist for the development of stewardship programs in inpatient settings but despite the majority of antibiotics being prescribed in the outpatient setting, stewardship guidelines are generally lacking. The CDC include dentists in their list of intended audiences in the Core Elements of Antibiotic Stewardship for outpatient settings. 8 However, guidance is not provided on how to implement the Antimicrobial Stewardship Program (ASP) in the unique setting of dental offices.

Dentists have little opportunity to observe firsthand the adverse events associated with antibiotic prescribing, such as CDI, so they are generally unaware of the impact of their prescribing habits. The majority of dentists are solo practitioners with variably trained support staff and collectively the dental office has limited knowledge of antibiotic pharmacology. 9 Here are just a few suggestions of how our profession can support dentists, their staff and patients, to be better antibiotic stewards:

  1. Talk to all the staff in your dentist’s office about their important role in antibiotic stewardship. Advise them about the resources available through the Michigan Antibiotic Resistance Reduction (MARR) Coalition and other organizations (Table 3).
  2. When filling an outpatient prescription for treatment of an oral infection, insure that it is consistent with the ADA guideline.5 In particular, focus on the duration of therapy and the prescribing of clindamycin. Provide patients with information on how to dispose of unused antibiotics in the event that their symptoms resolve before completing seven days of therapy.
  3. Advise patients with prosthetic devices that in many cases the risk of antibiotics outweigh the benefits of taking them before dental manipulation and therefore they should consider discussing the need for antibiotics not only with their dentists but with their other healthcare providers. In some cases, their general practitioner (GP) may have assumed the responsibility for writing the prescription if the patient is over a year out of their implant and the GP may not be aware of the change in the guidelines. Dentists have shared that referring their medical colleagues to the AAOS AUC tool has been a helpful communication tactic.
  4. Incorporate dental stewardship principles, particularly regarding prophylaxis, in systemwide ASPs. Focus on educating orthopedic surgeons on the increasing incidence of community-associated CDI and the association with dental antibiotics. Policies should be implemented in emergency departments and urgent care centers consistent with the ADA treatment guidelines.
  5. Critically evaluate cases of penicillin allergy since the majority of dental patients with a penicillin allergy are prescribed clindamycin. If the patient’s allergy history is dated, recommend that they discuss with their regular physician.


Given the numerous stakeholders involved, implementing antibiotic stewardship in dentistry is going to be challenging. Pharmacy has an opportunity to positively influence dental stewardship by educating all the stakeholders, particularly the patients. Please review these helpful resources.


  1. Roberts RM, Bartoces M, Thompson SE, Hicks LA, Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148(3) :172-178
  2. Roberts RM, Hersh AL, Shapiro DJ, Fleming- Dutra KE, Hicks LA. Antibiotic prescriptions associated with dental-related emergency department visits. Ann Emerg Med. 2019;74(1):45-49.
  3.  Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, Perez RI, McGregor JC, Evans CT. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open. 2019 May 3;2(5):e193909
  4. Bye M, Whitten T, Holzbauer S. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Suppl 1):S1. Published 2017 Oct 4. doi:10.1093/ofid/ofx162.001
  5. Lockhart PB, Tampi MP, Abt E et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc.2019;150:906-921.
  6. Guh AY, Adkins SH, Li O, et al. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis. 2017 Oct 26;4(4):ofx171
  7. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
  8. Center for Disease Control and Prevention. Core Elements of Outpatient Antibiotic Stewardship. Available at: Accessed 3/28/20.
  9. American Dental Association, Survey Center. 2012 Distribution of Dentists survey. Chicago: American Dental Association, 2011.
Posted in: Professional Practice
Moving Forward with Antiretroviral Therapy for Human Immunodeficiency Virus

Shelbye Rose Herbin, Pharm.D., PGY1 Pharmacy Resident, Detroit Receiving Hospital, Detroit

Almost 40 years have passed since the first case of acquired immunodeficiency syndrome (AIDs) was documented. Throughout this time, great strides have been made with the creation of antiretroviral therapy (ART) for the treatment of the human immunodeficiency virus (HIV), which is the cause of AIDS. Adherence to ART regimens is crucial for patients to maintain viral suppression and reduce the risk of drug resistance.1 However, there are many barriers to adherence such as pill burden and side effects including nausea, fatigue and mood alterations. 2,3 Antiviral therapy with three active antiretrovirals from two different drug classes has been the mainstay of therapy for decades for patients living with HIV. Newer agents that have been introduced have a higher potency and genetic barrier to resistance, which has enabled researchers to revisit the idea of two-drug regimens for the use in patients with HIV.4 Additionally, advances in treatment options have also demonstrated the possibility of monthly injectable treatment regimens.

The two-drug regimens currently approved by the Food and Drug Administration (FDA) as complete antiretroviral regimens are dolutegravir-rilpivirine (JULUCA®), for treatment experienced patients, and dolutegravir-lamivudine (DOVATO®), for treatment-naïve patients. Both of these combinations include antiretrovirals with pharmacokinetic profiles suitable for once daily administration.5,6 Dolutegravir-rilpivirine was approved in 2017 and contains the integrase strand inhibitor (INSTI) dolutegravir with the non-nucleotide reverse transcriptase inhibitor (NNRTI) rilpivirine. Dolutegravir and rilpivirine both have a high genetic barrier to resistance and are stable against common resistance mechanisms for their respective class, allowing them to be used as a complete antiretroviral regimen. Dolutegravir also interacts minimally with hepatic enzymes and therefore has fewer drug-drug interactions compared to other antiretrovirals. The approval of dolutegravir-rilpivirine was based on the results from the SWORD-1 and SWORD-2 trials. These two studies included participants ≥ 18 years old, who were treatment experienced and virologically suppressed (viral load < 50 copies/mL) for at least six months. The primary outcome of SWORD-1 and SWORD-2 was the proportion of patients with a plasma viral load of lower than 50 copies/mL at week 48, which was achieved in 95 percent of the study participants in both treatment groups. This confirmed non-inferiority of dolutegravir-rilpivirine to participants who continued on their current ART regimen (CAR).5

Dolutegravir-lamivudine was approved in 2019 and includes the nucleoside transcriptase inhibitor (NRTI) lamivudine, with the INSTI dolutegravir. The approval of dolutegravir-lamivudine was based on the GEMINI-1 and GEMINI-2 trials. Both studies included participants ≥ 18 years old who were treatment naïve. The primary outcome of the GEMINI trials was the proportion of patients with a plasma viral load of lower than 50 copies/mL at week 48. Virological response was achieved in 90 percent of participants in each group and confirmed non-inferiority between dolutegravir-lamivudine and dolutegravir-tenofovir disoproxil fumarate-emtricitabine.6

Cabotegravir-rilpivirine (CABENUVA®) is not FDA-approved but is currently being tested in phase III clinical trials. Cabotegravir is an INSTI that is structurally similar to dolutegravir and is formulated as an oral tablet or a long acting injectable suspension for monthly administration. There are two ongoing phase-III trials for cabotegravir-rilpirivine the ATLAS trial which involves treatment-experienced patients and the FLAIR trial which includes treatment-naïve patients. The primary outcome in both studies is the percent of patients with virologic failure (HIV-1 RNA > 50 copies/mL) at week 48. Preliminary data has shown non-inferiority of cabotegravir-rilpivirine to the participant’s CAR and dolutegravir-abacavir-lamivudine in ATLAS and FLAIR trials, respectively.7,8

HIV treatment is a life-long commitment that patients must endure with a potential heavy pill burden and adverse side effects. Previous attempts at creating two-drug regimens have failed due to the medications inability to reduce viral loads or overcome resistance mechanisms9. When used in combination as two-drug regimens, the newer and more potent antiretrovirals, such as dolutegravir and cabotegravir have the potential to reduce pill burdens, increase adherence and decrease the long-term effects associated with antiretrovirals.


  1. HIV Treatment Adherence Understanding HIV/AIDS. National Institutes of Health. Published January 15, 2020. Accessed April 26, 2020
  2. HIV Medicines and Side Effects. Understanding HIV/AIDS. National Institutes of Health. Published October 24th, 2019. Accessed April 26, 2020.
  3. Iacob SA et al. Front Pharmacol. 2017;8:831
  4. Cento V et al. J Glob Antimicrob Resis. 2020;20:228-237
  5. Llibre JM et al. Lancet. 2018;391(10123):839-849
  6. Cahn P. Lancet. 2019;333(10167): 143-155
  7. Swindells S et al. NEJM. 2020;382:1112-1123
  8. Orkin C et al. NEJM. 2020;382(12):1124-1135
  9. Corado KC. Drug Design Devel and Ther. 2018;12: 3731-3740
Posted in: Professional Practice
E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI)

Abagail Kirwen, Pharm.D., PGY-1 Pharmacy Resident, Beaumont Royal Oak

E-cigarette, or vaping, product use-associated lung injury (EVALI) has been investigated as a nationwide outbreak since August 2019. Use of e-cigarettes, or vaping, is described as heating a liquid with active agents such as nicotine and tetrahydrocannabinol (THC) as well as inactive ingredients such as flavorings and other additives.1 An algorithm for the diagnosis and management of patients with EVALI symptoms has been created by the Centers for Disease Control and Prevention (CDC) and can be found on their website.2 The most recent update from January 2020 indicates 2,668 EVALI cases have been reported to the CDC. The patients have a median age of 24 years, 66 percent are male, and 82 percent report using any THC-containing product. The majority of cases have been defined as not severe (68 percent) and the mortality rate is currently defined at 2 percent.3

The most common presentation includes respiratory symptoms such as hypoxia and tachypnea as well as gastrointestinal symptoms such as nausea, emesis and abdominal pain.1,4 EVALI remains a diagnosis of exclusion and might co-occur with respiratory infections, so it is important for providers to consider other bacterial or viral causes of the patients’ symptoms. Chest imaging typically reveals ground glass opacities and may appear similar to pneumonia. Bronchoalveolar lavage (BAL) may be performed to collect fluid specimens from patients to aid in diagnosis. BAL specimens were collected from hospitalized patients in August-October 2019 to be analyzed for toxins and active compounds. Of 29 BAL specimens sent to the CDC to be analyzed, vitamin E acetate was detected in all 29 samples.5 Based on this evidence, it was determined that vitamin E acetate is likely associated with EVALI. Although the mechanism for EVALI is not well understood, there are some mechanisms that have been proposed. The heating element used to aerosolize particles may be made of heavy metals known to cause lung disease. It is also noted that e-cigarettes still produce high levels of free radicals, similar to traditional cigarettes, which lead to oxidative stress in the lung and may contribute to pathogenesis of the disease.6 It has also been hypothesized that deposition of oils into the lower airways may be resulting in lipoid pneumonia.4

Management of patients who are diagnosed with EVALI include discontinuation of vaping products, cessation counseling and cautious use of corticosteroids.2 Use of corticosteroids for management of these patients comes with a cautious recommendation due to limited literature. A recently published case series unfortunately did not show a difference in outcomes for patients treated with intravenous corticosteroids transitioned to an oral taper.4 However, another prospective observational cohort believed addition of corticosteroids at moderate doses for relatively short courses led to a more rapid clinical improvement.1

Fortunately, the number of hospital admissions for EVALI peaked during the week of Sept. 15, 2019, and has continued to steadily decline since then.3 The decline in cases may be due to increased awareness of the risks associated with vaping and identification of vitamin E acetate and subsequent removal of this ingredient from products. Despite the steady downtrend in EVALI occurrences, healthcare providers should remain vigilant when patients present with the aforementioned symptoms and a history of e-cigarette or vape use.


  1. Blagev DP, Harris D, Dunn AC, Guidry DW, Grissom CK, et al. Clinical presentation, treatment and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study. Lancet. 2019;294:2073-83.
  2. Algorithm for management of patients with respiratory, gastrointestinal, or constitutional symptoms and e-cigarette, or vaping, product use (12/20/2019). Centers for Disease Control and Prevention. 2019.
  3. Krishnasamy VP, Hallowell BD, Ko JY, Board A, Hartnett KP, et al. Update: characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury - United States, August 2019-January 2020. MMRW. 2020;69(3):90-4.
  4. Kalininskiy A, Bach CT, ENacca N, Ginsbert G, Maraffa J, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med. 2019;7:1017-26.
  5. Blount BC, Karwowski MP, Morel-Espinosa M, Rees J, Sosnoff C, et al. Evaluation of bronchoalveolar lavage fluid from patients in an outbreak of e-cigarette, or vaping, product use-associated lung injury - 10 states, August-October 2019. MMRW. 2019;68(45):1040-1.
  6. Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, et al. Radiologic, Pathologic, Clinical, and Physiologic findings of electronic cigarette or vaping product use-associated lung injury (EVALI): evolving knowledge and remaining questions. Radiology. 2020;294:491-505.
Posted in: Professional Practice
Previewing the 2020 ASHP House of Delegates

Jesse Hogue, Pharm.D., Bronson Methodist Hospital, Kalamazoo, 2019-2020 Michigan ASHP Delegate

The American Society of Health-System Pharmacists (ASHP) will convene its 72nd Annual Session of the House of Delegates virtually (it’s a whole new world!) this June to address an agenda that includes considering 25 policy recommendations and a statement, receiving board and committee reports and considering a variety of other society business items. Your elected delegates this year are Ryan Bickel, Peggy Malovrh, Mike Ruffing and me, with Jim Lile and Dianne Malburg as alternates. The Michigan delegates have already been quite active in 2020. In March, we caucused to consider 15 policy recommendations for the Virtual House of Delegates, and supported all but one policy which we thought needed to be worded more clearly. After voting, 13 of the policies met the >85 percent threshold and were approved and two were deferred for consideration in June. We all also participated in virtual Regional Delegate Conferences in late April and caucused again in early May to discuss which of the 25 policies might be of most interest to MSHP members and/or for which we would like member input. While a full discussion of each of the policy recommendations is beyond the scope of this article, the few we chose to highlight are outlined below.

New Categories of Licensed Pharmacy Personnel. The Council on Public Policy was tasked with considering this issue after several states introduced laws allowing the creation of a “pharmacist assistant.” The Council questioned the need for any new midlevel role. Consistent with the stance MSHP/MPA has traditionally taken, the Council felt the focus should be on reinforcing the importance of and professionalization of the pharmacy technician. The policy recommendation is therefore to oppose the creation of new categories of licensed pharmacy personnel. In support of this policy, many delegates noted that creation of midlevel pharmacist assistants would likely lead to employers cutting back on pharmacists, negatively impacting patient care and making a bad job market even worse.

Funding, Expertise and Oversight of State Boards of Pharmacy. This was an existing policy that the Council on Public Policy reviewed as part of sunset review. The existing policy did a nice job supporting the role and necessary funding of the state boards of pharmacy. After review, the Council has proposed updates to the policy which more clearly identify the need for health-system representation on the state boards of pharmacy, as well as pharmacy technicians. The existing policy also identifies pharmacists competent in the applicable area of practice as the people who should perform board inspections. Some delegates have proposed broadening it to recommend pharmacy technicians as inspectors (see below for proposed language) – your Michigan delegates would like to know if you agree or disagree with this, please let us know your thoughts!

  • To advocate that inspections be performed only by pharmacists and pharmacy technicians competent about the applicable area of practice.

Safety and Efficacy of Compounded Topical Formulations. The Council on Therapeutics crafted this proposed policy to speak to the clinical effectiveness of and issues pertaining to compounded topical formulations. The Council identified a lack of reliable data demonstrating safety and efficacy, lack of standardized composition and concentration and significant increases in insurance fraud with these products. It does not seek to oppose compounded topical formulation, recognizing there is clinical evidence to support their use in some disease states. Rather, it encourages appropriate reimbursement for medically necessary compounded products as well as for hospitals and health systems, with pharmacist leadership, to develop policies and procedures to support informed decision making on these products. The policy includes wording that implies a call for more regulation but that will likely be amended to shift the focus to advocate for internal process that ensure the quality and safety of the products rather than outside regulation. The Michigan delegates support this, understanding that regulation may mean PCAB or similar certification, which would be untenable. We may, however, propose an amendment to ask ASHP to develop a repository of evidence-based formulations that could serve as a resource for topical products compounding for members. If you have strong feelings on these ideas, please let us know!

Residency Training for Pharmacists Who Provide Direct Patient Care. With MSHP’s history of strongly supporting residency training, we thought this policy would be of high interest to our membership. For this policy recommendation, the Council on Education and Workforce Development reviewed two older policies related to residency training and decided they should be updated and combined. The resulting statement continues to support requiring residency training for new pharmacy graduates intending to serve in direct patient care roles, while still recognizing that comparable skills may be attained through years of practice experience for pharmacists previously unable to complete a residency. The old policy included a target of 2020 for this requirement. After considerable discussion, the Council agreed that the need for this is now, and so opted not to include a future target date in the proposed policy statement to underscore the current urgent need for residency training and the expansion of training sites.

Preserving Patient Access to Pharmacy Services in Medically Underserved Areas. Since patient access to care in rural and underserved areas has been a big issue in our state, we thought this proposed new policy from the Council on Pharmacy Management would be of interest to MSHP members. The Council recognized the national trend of low reimbursement rates and decreasing populations in rural and underserved areas resulting in closures of hospitals and clinics and, thus, challenges in recruitment and retention of healthcare professionals. These trends disproportionately affect elderly and low-income populations. The new policy calls for funding and innovative payment models to preserve patient access to acute and ambulatory care pharmacy services in these areas, support for telepharmacy to extend patient care services and enhance continuity of care, advocacy for availability of advanced communication technology to support this care model in rural and underserved areas, and loan forgiveness or incentive programs to aid in recruitment and retention in these areas.

Continuity of Care in Pharmacy Payer Networks. Similar to the previous policy, payer policies and practices that adversely affect continuity of care has been a hot topic in our state. This new policy statement, also from the Council on Pharmacy Management, is very similar to a policy our MSHP caucus in the MPA House of Delegates helped work on earlier this year. This proposed policy would highlight our opposition to provider access criteria that impose requirements or qualifications on participation in pharmacy payer networks that interfere with patient continuity of care or patient site-of-care options.

This discussion merely scratches the surface of the policy recommendations. Many of the other policy recommendations will also be of significant interest to MSHP members, and they all will affect us as health-system pharmacists, so I would encourage you to review the proposed policies and contact one of the delegates with any questions or comments you may have (Jesse:; Mike:; Ryan:; Peggy: I have listed the titles of all the policy recommendations below for your review. Members can view the official language of the policy recommendations at the ASHP House of Delegates website as well as follow online discussions via the House of Delegates community within ASHP Connect. There has already been quite a bit of good discussion on ASHP Connect, feel free to join the conversation!

Policy Recommendations to be considered by the 2020 ASHP House of Delegates:


  1. Credentialing and Privileging by Regulators, Payers, and Providers of Collaborative Practice
  2. Access to Affordable Healthcare
  3. Care-Commensurate Reimbursement
  4. Importation of Drug Products
  5. Public Quality Standards for Biologic Products
  6. New Categories of Licensed Pharmacy Personnel
  7. Funding, Expertise, and Oversight of State Boards of Pharmacy
  8. Dispensing by Nonpharmacists and Nonprescribers


  1. Naloxone Availability
  2. Safety and Efficacy of Compounded Topical Formulations
  3. Postmarketing Studies
  4. Gabapentin as a Controlled Substance


  1. Residency Training for Pharmacists Who Provide Direct Patient Care


  1. Pharmacist’s Role in Health Insurance Benefit Design
  2. Preserving Patient Access to Pharmacy Services in Medically Underserved Areas
  3. Multistate Pharmacist Licensure
  4. Continuity of Care in Pharmacy Payer Networks
  5. Network Connectivity and Interoperability for Continuity of Care
  6. Medication Formulary System Management
  7. Health-System Use of Medications Supplied to Patients
  8. Health-System Use of Administration Devices Supplied Directly to Patients
  9. Staffing for Safe and Effective Patient Care


  1. Role of the Pharmacy Workforce in Violence Prevention
  2. Role of the Pharmacy Workforce in Preventing Accidental and Intentional Firearm Injury and Death
  3. Safe Use of Transdermal System Patches


  1. ASHP Statement on the Use of Artificial Intelligence in Pharmacy
Posted in: Member News
Telepharmacy and E-Prescribing

Stephen Smith, B.S. Pharm., Chief Pharmacy Officer Karmanos Cancer Institute, Detroit and MSHP Treasurer

We are creatures of habit. We enjoy the constancy and consistency of our normal day-in and day-out routine. Introduce any significant change into that routine and “Hey, you moved my cheese.” or “Why did you change something that wasn’t broke?”

We are in the middle of one of the biggest disruptors in our lifetimes, COVID-19. We are required to behave differently, to think differently, and to interact with each other differently. We are now routinely holding meetings where 20-30 of our colleagues interact through Microsoft Teams, ZOOM or other software platforms to hold those meetings where three months ago we had to have a face-to-face interaction. Professional organizations, including MSHP and MPA have held and are planning conferences where 100 – 200 people will interact electronically in various “rooms” deciding issues and formulating policy. What used to be our routine way of doing things is adjusting to our “new normal.”

How can a pharmacy exist without a pharmacist physically present? How can all paper prescriptions be totally eliminated safely? These are questions that are being asked and new solutions and new normal are being explored.

Telepharmacy: Public Act No. 4 of 2020; previously SB 340, Sen. VanderWall (R-Frankfort) defines the practice of telepharmacy. Provisions and definitions of remote pharmacy, parent pharmacy, use of audio and video tools to provide oversight and to interact with patients, minimum distances between sites, requirements for the pharmacists and technicians who work in these pharmacies, limits to the number of prescriptions and retention timelines for audio/video communications are all part of this Public Act. The bill was signed into law by Governor Whitmer on Jan. 24, 2020, and became effective April 26, 2020. Telepharmacy is definitely a new normal from our traditional models of direct face-to-face practice. A major hope for this law is to bring pharmacy services closer to the patients who live in more remote areas of Michigan. Pharmacists embracing this new technology will need to transfer all our normal safety and quality protocols to this electronic space. Time will tell if our hopes for this new technology are realized.

E-prescribing:  HB 4217 / SB 248 / SB 254; Rep. Bellino (R-Monroe), Sen. Johnson (R-Holly) and Sen. Zorn (R-Ida) have submitted legislation which would require prescribers to electronically submit all prescriptions (including controlled substances). Currently, all three bills have been passed out of their respective chambers and are in the opposite chamber’s health policy committee. The bills were introduced to help align Michigan’s processes with upcoming Medicare rule changes regarding the use of electronic prescriptions. As pharmacists, our long time hope with e-prescribing is that information is transmitted clearly between the provider and the pharmacist. No messy writing to interpret; clear concise and accurate directions that are easily communicated between health professionals for the patient’s benefit. Those of us who work in hospitals/clinics realize that these tools have come a long way since their infancy but like any computerized system are subject to human error and incorrect information. The complete elimination of more traditional prescribing methods will continue to be challenging until many of the intrahospital/clinic rules (weight based dosing, drug interactions, dose range checking) are robustly incorporated into e-prescribing. Additionally, access to critical diagnostic information is another safety measure that needs to be available to the external practitioner. So while the concept of e-prescribing philosophically pushes us toward better, safer patient care, there are still some very real challenges that we must work to overcome.

Whether you support these new normals or believe another alternative is better, you need to be involved so that your voice is heard as these changes are being discussed and developed. Consider joining Pharmacy PAC, PART (Pharmacy Advocacy Response Team), participate in an MSHP or MPA committee (Public Affairs or Professional and Legal Affairs); you can explore the MPA website for options open to you. 

Posted in: Member News