Pharmacy News

Entries for June 2017

What is Your Number: The Importance of INR

By Carla R. LaMarr, CPhT, LTC project specialist, PharMerica; Reviewed by Amanda Moulton, Pharm.D., pharmacist, PharMerica


INR, which stands for international normalized ratio (INR), is an important lab value to obtain when you are being treated with Coumadin (warfarin), a medication that is known as an anticoagulant.  Various disease states that require anticoagulation therapy include heart attack, blood clots and an irregular heartbeat known as atrial fibrillation. Anticoagulants are essential in the treatment of the previously listed disease states since they will slow blood clotting and prevent the formation of blood clots. INR levels measure the amount of time it will take for your blood to form a clot. The lower the level, the higher the risk for your body to form a blood clot; the higher the value, the longer it will take for your body to form a clot, thus increasing your risk for a bleed.  If INR levels are either too high or too low, a dose adjustment of your medication is necessary.  


A normal INR level is 0.8-1.2 for a healthy individual. When a person is being treated with an anticoagulant such as warfarin, the targeted level should be 2.0-3.0 or 2.5-3.5, depending on diagnosis.  Warfarin is a medication that interacts with certain foods, medications and alcohol due to its mechanism of action.  Due to these interactions, INR levels may potentially be affected.  Please note that certain antibiotics, vitamins, over-the-counter supplements and foods such as green, leafy vegetables may alter the effectiveness of warfarin and in turn INR values. It is also good to remember that if you are taking an anticoagulant and you have an injury that causes bleeding, contact your primary care provider or emergency services immediately as this medication thins the blood and increases the time for bleeding to stop.


Another lab value that may be required for monitoring in addition to INR levels when on warfarin may include a PT (prothromin time), but INR’s are the standard when determining dose adjustments.  It is very important to communicate to your healthcare provider any new medications or vitamins that you take, as well as any dietary changes that occur since all of these could impact your treatment and health.



1.       University of Rochester Medical Center.  Health Encyclopedia. International Normalized Ratio. Accessed April 2017.

2. What is normal INR level. Accessed April 2017.

3.       American Association for Clinical Chemistry. Prothrombin Time and International Normalized Ratio. Accessed April 2017. 

Posted in: Professional Practice
Technician Spotlight

Amanda Hamp began working in the pharmacy after high school. She needed a “grown up job” and something that would provide her with the benefits she needed, and at that stage, she still wasn’t sure what direction she wanted to take in life. She applied at a locally owned family pharmacy despite having had no experience in pharmacy at that point. The staff provided her with on the job training, and the pharmacist she trained with provided priceless training, values and confidence, describing it as “the good old days.”


Amanda says she tried to step out of pharmacy and work in some administrative roles, but always found herself back in the pharmacy. Outside of her first job, she has held several roles within the pharmacy. She first began at Chelsea Pharmacy as a pharmacy technician. This is where she learned the core values of how to treat patients, customers and coworkers. The goal here was quality customer services while still having fun. She also spent time at CVS pharmacy where she experienced a much more fast-paced, high volume pharmacy and introduced her to the chain retail pharmacy environment. She also spent time at Meijer Pharmacy, where she says she learned how provide customer services to, at times, difficult customers. Currently she is at the Center for Family Health as the lead pharmacy technician and works on 340B referrals. She has been able to use all the skills from her previous work experiences to be successful in this current role.


This role, she says, is completely different than her retail experience. She says, “It is my job as the 340B Referral Specialist to ensure we are properly using our 340B inventory for federally qualified patients only by meeting Federal Guidelines put in place by the Health Resources & Services Administration (HRSA). Every claim that we bill to 340B inventory using a specialist doctor outside our covered entity must meet the appropriate guidelines. It is my job to prove we have met all these guidelines and have the appropriate supporting documentation to close the 340B loop and be compliant with the laws.” This role requires a lot of investigation and at times problem solving. Amanda says she is always searching for information and trying to find all the different pieces that are needed to close the 340B compliance loop. She says, “It’s like a jigsaw puzzle. I love that.” She says she loves learning new things and that there are more administration roles for pharmacy technicians.


Amanda lives in Grass Lake, Mich. with her two children and husband. She enjoys Michigan’s seasons and spending time with her family. She likes to get away up North and spend time on the Ausable River kayaking and spending time near the Mackinac Bridge.

Posted in: Member News
2017 ASHP House of Delegates

By Jesse Hogue, Pharm.D., pharmacy education coordinator, Bronson Methodist Hospital, Kalamazoo, MSHP immediate past-president

The American Society of Health-System Pharmacists (ASHP) convened its 69th Annual Session of the House of Delegates in Minneapolis in June to consider 28 policy recommendations and a resolution, receive board and committee reports and consider a variety of other society business items. Your elected delegates this year were Gary Blake, Mike Ruffing, Paul Walker, and myself. In addition to attending the two official House sessions, the other Michigan delegates and I participated in Regional Delegate Conferences as well as during other forums and caucuses during the Summer Meeting to fully understand all the issues voted upon to consider possible language amendments, new business items and recommendations of other delegates. While a full discussion of each policy recommendation is beyond the scope of this article, I would like to highlight a few that I felt were of greatest interest to Michigan Society of Health-System Pharmacists (MSHP) members.

Any Willing Provider Status for Pharmacists and Pharmacies. This policy was of particular interest considering MSHP’s focus this year is on “Gearing Up” for advanced practice. I can’t summarize it any better than the stated rationale in the ASHP Board of Directors report, so I have copied it here: “Historically, any willing provider statutes have primarily been a concern for pharmacists in the traditional retail or community pharmacy practice settings, but as hospitals and healthcare organizations have become more engaged in developing ambulatory care service lines, pharmacists working in those settings increasingly find themselves excluded from payer networks. As pharmacists obtain provider status in a number of states, they recognize the infrastructure required to implement direct, independent patient care and billing for provider-based services. Including pharmacists and pharmacies as providers in any willing provider statutes will improve patient access to pharmacists’ care by allowing pharmacists to access payer networks, assuming those pharmacists can fulfill the terms and conditions required by payers.”

Ready-to-Administer Packaging for Hazardous Drug Products Intended for Home Use. Although at first glance you might not think it, I believed this policy was also of acute interest to MSHP members as we increasingly see these medications brought into the hospital as “patient supplied” medications and because we are becoming more actively involved in transitions of care. This policy urges ASHP to advocate that pharmaceutical manufacturers be required to provide hazardous drug products intended for home use in ready-to-administer packaging whenever feasible, and that pharmacists be involved in providing education regarding safe handling of the products. This would be expected to minimize patient, caregiver (including pharmacy staff and nurses while the patient is hospitalized), and family exposure to hazardous drugs, promote patient adherence and enhance safe medication use.

Collaborative Drug Therapy Management. This was a policy amending the existing ASHP policy 1217 of the same name. I highlighted this policy for a couple reasons. First, I think this policy closely relates to our MSHP theme for this year because it pushes for federal and state laws that recognize our advanced practice roles. Second, it recognizes that pharmacists practicing in advanced roles must be responsible and accountable for medication-related outcomes. The main amendment to the existing policy was to add a clause advocating for laws and regulations that would also allow pharmacists to transmit prescriptions electronically, which I think is very important. However, the proposed language dictates that this be done under collaborative drug therapy management protocols, which is something MSHP successfully opposed in the MPA House of Delegates policy recommendations in February because restricting us to protocols actually narrows the scope of our practice in Michigan. I have volunteered to work on amending language to address this, with broad support from many other delegates, and there is also a push to amend the policy to use the broader “collaborative practice agreement” phrase rather than the narrow “collaborate drug therapy management” phrase.

Pharmacist Participation in Medical Aid in Dying. I expected this policy to be the most controversial one we considered this year. Two years ago, the ASHP House of Delegates approved a policy opposing pharmacists’ participation in capital punishment, affirming that we, as healthcare providers dedicated to achieving optimal health outcomes and preserving life, should not participate in capital punishment. A recommendation was made after that to evaluate the ASHP position of neutrality on health professional participation in assisted suicide, and subsequently the ASHP Committee on Resolutions proposed a policy amendment strengthening that policy to one of opposition for consideration at the 2016 House. The House voted to refer the motion for further study, and the ASHP Board convened the Council of Pharmacy Management, Council on Pharmacy Practice, and the Council on Public Policy as a Joint Council Task Force to study and consider the issue. The Task Force noted in their rationale that many healthcare professionals and organizations, including the American Medical Association, the American College of Physicians, and the American Nurses Association, hold that death is not an acceptable therapeutic goal. Others, however, such as the American Academy of Hospice and Palliative Medicine and the American Psychological Association, have a neutral position, with the view that medical aid in dying has as its goal the relief of suffering through a compassionately hastened death while recognizing the risks of such a practice. They also noted that “medical aid in dying” is the currently accepted terminology, rather than “assisted suicide.” After researching and discussing the issue, the Task Force proposed a position of studied neutrality on whether pharmacists should participate in medical aid in dying. They define studied neutrality as “the careful or premeditated practice of being neutral in a dispute … to foster a respectful culture among people of diverse views and to guide action that does not afford material advantage to a [particular] group.”1 The Task Force cited a desire to promote patient autonomy and access to care and to protect pharmacists’ professional integrity and comity as the rationale for this stance. The recommended policy also reaffirmed that a pharmacist’s decision to participate is one of individual conscience, and that participation or refusal to participate should not result in retribution, which is similar to the existing ASHP policy. There appears to be significant disagreement among delegates whether to approve the Task Force’s policy recommendation, or to amend it to delete the third clause and add a first clause expressly opposing pharmacist participation in medical aid in dying. This may come down to individual delegate conscience when the vote is taken, but I would welcome input from ASHP members in Michigan on this debate. I have included the Task Force’s proposed amendment to ASHP policy 9915, ASHP Position on Assisted Suicide, below for your review (underscore indicates new text; strikethrough indicates deletions).

To affirm that the a pharmacist’s decision to participate or decline to participate in the use of medications in assisted suicide medical aid in dying for competent, terminally ill patients, where legal, is one of individual conscience; further,

To reaffirm that pharmacists have a right to participate or decline to participate in medical aid in dying without retribution; further,

To remain take a stance of studied neutrality on the issue of health professional participation in assisted suicide of patients who are terminally ill legislation that would permit medical aid in dying for competent, terminally ill patients; further,

To offer guidance to health-system pharmacists who practice in states in which assisted suicide is legal.

Since this discussion merely scratches the surface and all of the Policy Recommendations, I would encourage all of you to review the actions taken at the House Session which can be found here. If you have additional questions or comments, please contact one of your Michigan delegates: Jesse Hogue:; Paul Walker:; Mike Ruffing:; Gary Blake: For more information about policy recommendations considered at the 2017 Session, click here


1. Johnstone M-J. Organization Position Statements and the Stance of “Studied Neutrality” on Euthanasia in Palliative Care. J Pain Symp Manag. 2012;44:896-907.

Posted in: Professional Practice
Pearls for a Successful Year in Pharmacy School

By Jacenta M. Gabriel, Pharm.D., University of Michigan College of Pharmacy, Ann Arbor, 2017 Graduate

Pharmacy school is a whirlwind journey. As a recent graduate from the University of Michigan College of Pharmacy, I can happily say that I now have the opportunity to reflect on the four-year expedition that has brought me to where I am today. When I look back, I am reminded of all the steps I took to integrate into the pharmacy field of this generation. Knowing what I know now, I thoughtfully mull over the actions I took that positively contributed to my student pharmacist experience and consider what I could have done differently. By sharing this newfound wisdom with the incoming classes, my hope is that students are able to make the most of their upcoming school year.

As a P1, you are full of optimism for the new life you are beginning. Adjusting from being an undergraduate student to a graduate student can be overwhelming, but pushing through the adaptation period and putting forth your best effort is important to succeed during the first semester. It is the ideal time to build up your GPA, as the classes only get more difficult as each semester passes. You will have the most leisure time this year, therefore, you should get involved in student organizations and college events. This will get the leadership ball rolling for your future years and start up the networking process. I would also encourage you to get to know your classmates and make some friends early on; sharing this experience with others that are going through the same thing makes for an irreplaceable support system.

Pharmacy school starts to ramp up during P2 year. Your workload will seem unbearable some days, but the content will be more relevant to pharmacy practice. The most valuable skill you will learn is time management. Prioritizing your work according to deadlines and level of importance will help you manage your time appropriately. Writing out a daily checklist will ensure no exam or assignment is forgotten. I would recommend not focusing too much on grades, but rather focusing on truly understanding the concepts you are taught, as it is more likely the material will be committed to memory and be readily recalled in the future. I also suggest shadowing pharmacists in a variety of settings during this year. Exploring the different facets of pharmacy will give you a better idea of where your interests lie, or at least help you figure out what you do not like.

As P3 year comes around, you have a couple years of knowledge under your belt. The material you learn is complex and takes more time to understand. It is important to carry on the good habits you formed in previous years to keep the momentum going and avoid decreased motivation. You will be ranking your P4 rotations; therefore, you should continue to discover your interests in order to narrow down your potential Advanced Pharmacy Practice Experiences (APPE) options. Faculty, residents, upperclassmen and peers may all be useful resources to guide you through the process, so ask as many questions about preceptors and rotations as you can before finalizing your rank list. This is key to making the next year an enjoyable experience.

At last, you are in your final year of school. You are not expected to know everything while on P4 rotations, so do not be afraid to ask countless questions and take every learning opportunity you can. Even if you are on a rotation that is not your first choice, it is essential to keep an open mind and have a well-rounded experience. Form positive relationships with the preceptors and colleagues you work with as they may one day help you land your dream job. This is the perfect time to be curious, make forgivable mistakes and mold your own learning experience, so try to make the most out of this year!

Lastly, I urge you to remember that pharmacy is a small world. Be sure to act professionally at all times throughout your four years to keep the doors of opportunity open. Also remember to make time to go out and enjoy your hobbies; it is important to maintain school-life balance to keep your mind sharp and avoid burn out. Best of luck in the upcoming school year!

Posted in: Member News
Utilizing the ASHP Ambulatory Care Self-Assessment Tool

By Malak Abbas, Pharm.D. candidate 2017, Wayne State University and Amber Lanae Martirosov, Pharm.D., BCPS, clinical pharmacy specialist, ambulatory care, Henry Ford Hospital, Detroit, and clinical assistant professor, Wayne State University,


In 2014, the American Society of Health-System Pharmacists (ASHP) held a summit for the advancement of ambulatory pharmacy services.  Pharmacy leaders and experienced practitioners from around the country developed recommendations aimed at advancing patient care and optimizing pharmacists’ roles in ambulatory care settings.1 Since that time, the ASHP Foundation has expanded the Pharmacy Practice Model Initiative (PPMI) to include more pharmacy practice settings. The PPMI was also rebranded the Practice Advancement Initiative (PAI). The overarching goal of the PAI is to “significantly advance patient health by developing and disseminating futuristic practice recommendations that support pharmacists’ roles as direct patient care providers.”2 The PAI is comprised of five pillars that maximize the pharmacist’s role in patient care in acute and ambulatory care settings. The key recommendations from the PPMI and the Ambulatory Care Summits lay the foundation for practice advancement in the acute and ambulatory care settings, respectively.


Given that ambulatory care is the largest growing area in pharmacy, Michigan Pharmacists Association (MPA) has utilized the PAI to expand resources and opportunities for pharmacists who practice in outpatient settings. Recently, the Michigan Society of Health-System Pharmacists (MSHP) Ambulatory Care Committee developed an Ambulatory Care Toolkit to provide Michigan pharmacists with tremendous resources for starting and advancing their ambulatory care practice. Find that toolkit here. Additionally, the Committee reviewed the ASHP Ambulatory Care Self-Assessment Tool. This assessment tool was developed by an expert panel to promote ambulatory practice alignment with the Ambulatory Care Summit recommendations.


The ASHP Ambulatory Care Self-Assessment Tool is designed to identify possible gaps in the ambulatory practice site and aid in identifying resources to improve adherence to practice standards. The tool includes two different assessment tracks: system track or practitioner track. The system track is designed to provide those with administrative roles, including supervisors, an outlook on operations beyond a single ambulatory practice setting; whereas the practitioner track provides a perspective for a single practice site.3 There are a total of eight sections to be completed including: (1) Demographics, (2) Program Development & Sustainable Business Models, (3) Pharmacist Training & Credentials, (4) Program Planning, (5) Patient-Care Delivery & Integration, (6) Health Information Technology, (7) Pharmacy Technicians and (8) Outcomes Evaluation.3 Once the assessment is completed, pharmacists are given the opportunity to develop an action plan that focuses on individualized practice or health-system priorities. A list of resources are provided with the action plan to help the user implement practice changes.


To gain the most from the self-assessment, ASHP recommends that ambulatory care pharmacists complete the action plan immediately following the self-assessment, utilizing the resources provided. The tool also provides comparative reports for multi-site health-systems and states. This allows users to see how their action plan compares to others. Additionally, users can determine how their individual answers compare to aggregate data from other assessments to further advance their practice models. Pharmacists are encouraged to revisit the assessment regularly or annually to assess advancement progress.


The benefits of the Ambulatory Care Assessment Tool are numerous and include: (1) providing an internal benchmark for practice advancement in ambulatory care, (2) showcasing alignment with recommendations provided during the ASHP Ambulatory Care Summit, (3) providing resources to develop or expand upon existing opportunities, (4) creating an action plan post self-assessment evaluation that identifies priorities based on feasibility and impact, (5) contributing to the strategic planning of department or affiliated health-system and (6) identifying both strengths and areas of improvement for a practice site.4,5  The tool can also be used to discuss recommendations from the Ambulatory Care Summit with pharmacy students and residents. Additionally, it can help state pharmacy organizations understand the priorities for clinical pharmacy services and identify opportunities for practice advancement.5

As of October 2016, Michigan ranks second nationally for utilization of the Ambulatory Care Self-Assessment, with over seven completed System assessments and 19 completed Practitioner assessments.4 Since the tool provides a framework and support system for advancing ambulatory care practice, we encourage all Michigan pharmacists who practice in outpatient settings to complete the tool. By increasing utilization of the tool, we can transform how pharmacists care for patients in ambulatory settings throughout Michigan. 



1. American Society of Health-System Pharmacists. Ambulatory Care Summit: Recommendations of the Summit. Am J Health Syst Pharm. 2014;71(16):1390-1391.

2. American Society of Health-System Pharmacists. ASHP Practice Advancement Initiative. ASHP website. Accessed May 2017.

3. American Society of Health-System Pharmacists. ASHP Ambulatory Care Self-Assessment Tool. ASHP website. Accessed May 2017.

4. Maroyka EM. Practice Advancement Initiative: Pharmacist Roles in Public Health (webinar). Accessed January 2017.

5. Boyle J. The ASHP Ambulatory Care Self-Assessment: Putting Practice Advancement into Action (webinar). Accessed May 2017. 

Posted in: Professional Practice
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