Innovative Practice

Innovative Practice

Conjoined Twin Conundrum

By John Carr, CRT, clinical business analyst, Senior-ClinDoc Application Team, Michigan Medicine, Ann Arbor; Heather Somand, Pharm.D., BCPS, director of inpatient applications, Michigan Medicine, Ann Arbor

When you think of conjoined twins, news reports probably pop into your mind with pictures of babies connected in some way or another. You may wonder how the parents hold and nurture their babies in those situations and how difficult it must be to care for them, as well as, the challenges they will face down the road. If you put on your pharmacy hat, you may wonder about the challenges with medication dosing and how the pharmacokinetics may be altered, which are all good questions and considerations. One area we almost guarantee no one thinks about is the electronic health record (EHR) - and rightfully so, since we all expect it will just work as it should. But what does that really mean when it comes to conjoined twins? Should they share a medical record, or should each twin have his/her own record? When you order labs or procedures, what would make the most sense? 

Michigan Medicine recently delivered two sets of conjoined twins, and for those of us in Information Technology, it presented a unique situation that took some thought and planning to ensure it would “work as it should.” While the surgeons and neonatologists planned for the delivery and care of the patients, the teams supporting the EHR met to consider how two patients in a single occupancy room with the same or separate vitals depending on the situation, receiving medications, labs, and radiologic images should have separate medical records, orders and results. In the following paragraphs we describe the questions and considerations we considered in preparing for conjoined twin patients and the solutions we implemented to ensure safe and efficient care was provided. 

Patient monitoring becomes increasingly difficult when your patients share a varying degree of anatomical features and processes. Accurate and relevant vital signs capture and recording is extremely important when making medical decisions for our patients. To this end, we worked with providers and information technology teams to make the decision to create a special patient room that could house these patients while treating them like individual patients with individual charts. Our networking team had to ensure we had enough network ports activated in the room to allow for a second monitor for documenting vitals on each patient. We also worked within the EHR structure to create a second virtual bed in the patient room which allowed these babies to be cared for in one physical location, yet still allowed for the collection of vitals and the normal EHR documentation for each patient separately.

The anatomy of the patients determined whether one or two radiologic exams were ordered; however in either case the radiologist wrote two reports with one for each patient chart. When medications or labs were ordered for the twins we decided that all orders would be placed in baby “A” chart to avoid duplication. However, lab results were entered in both patient's charts, which was completed manually by the lab.

Once the decisions were made and all the pieces were in place, we conducted a “Day in the Life” validation session for these rooms. It is important that this "Day in the Life" validation occurs in situations like this so that workflow anomalies, technical issues and emergency responses can be tested before placing a living patient in a potentially harmful situation. In this validation state, test patients were “admitted” to these beds, patient simulators were connected to the monitors to validate vital sign capture to the correct patient. We validated that each patient in their respective bed was visible in our automated medication dispensing cabinets. Additionally, nursing staff validated that the configurations in place would allow them to care for these patients as they would for any other patient.

Thanks to advanced notice and proper planning with our healthcare partners, we were pleased to report the EHR “worked as it should” in our conjoined twin cases. It was a unique situation for which there is no playbook or build guide to follow, but with proper brainstorming and collaboration, we were able to properly care for our unique patients. 

Posted in: Innovative Practice
Creating Gender-affirming Pharmacy Practice Environments and Services

Nancy JW Lewis, Pharm.D., MPH

adjunct associate research scientist

University of Michigan College of Pharmacy

Consultant, Program Design and Research, Transcend the Binary


Stuart Rockafellow, Pharm.D.

consultant pharmacist

Northern Physicians Organization


Jack Earls

patient advocate and peer counselor

Transcend the Binary


Brayden A. Misiolek

executive director/oo-founder

Transcend the Binary

 The existence of health inequities within the U.S. are well documented.1-3 Such inequities are common among transgender/gender non-conforming (TGNC) individuals.2 who often have limited financial resources, face a scarcity of  competent, gender-affirming providers and have complex health needs.

 The TGNC Community

Defined as persons whose gender identities, gender expressions or behaviors do not conform to that typically associated with the sex they were assigned at birth,4 TGNC individuals compose about  0.6% of the U.S. population.5 They express their gender identities across a diverse spectrum that ranges from, and outside of, male and female. Selected gender identity terms are defined in Table 1.

TGNC individuals often encounter discrimination.6-10 In the 2015 National Transgender Survey (NTS),10 27,715 self-identified TGNC individuals reported discrimination in schools, workplaces, housing situations, and/or public places. High rates of physical and mental abuse, homelessness, low employment and economic hardship were also reported.10

The risk for discrimination extends into healthcare settings.9,11-14 The NTS reported that a third of respondents who saw a healthcare professional in the past year had at least one negative experience related to being transgender.9 A 2016 survey of 316 TGNC adults found that 41 percent of respondents indicated some degree of worry about discrimination with pharmacists.12  Thirteen percent of respondents reported that past experiences of purposeful embarrassment at a pharmacy caused them to avoid seeking healthcare most or some of the time. Experienced discrimination or worry about discrimination in healthcare settings is associated with anxiety, depression and overall poorer self-reported health.12, 15-17

Fear of discrimination within the traditional healthcare system leads some to seek alternative sources of care from other sources.18,19   The prevalence of hormone use with medications obtained outside of legitimate pharmacies is estimated to be as high as 70 percent among studied populations with rates varying based on geographical location and gender identity.14, 18,19

 Pharmacist and Pharmacy Technician Roles in Transgender Healthcare

Given that many (but not all) TGNC individuals seek hormone therapy to affirm their authentic gender (i.e., the gender to which they self-identify), pharmacy staff can play an important role in improving transgender healthcare.20-24  That role can be illustrated by the actions taken by one Michigan pharmacist, Darnell Jones.  In 2013, Darnell began practicing in the Palmer Park area of Detroit. He soon realized he was serving a community of TGNC patients that desperately needed access to medical care. Many patients obtained hormones from black market sources and few knew health providers that offered affordable, gender-affirming care. Darnell educated himself about transgender health, counseled patients about hormone therapy, established a referral process to transgender specialists and co-founded a TGNC advocacy organization, Transcend the Binary. Within a few years, his actions as a pharmacist and ally touched the lives of hundreds of TGNC individuals.

Darnell’s path to care began with researching the literature and discussions with TGNC patients and medical specialists. It is not uncommon for health professionals to have little or no formal education in transgender health. One study found that over 60 percent of pharmacy residents surveyed felt unprepared to provide care to TGNC patients.25 Fortunately, resources are available to assist pharmacy staff gain competency. The World Professional Association for Transgender Health (WPATH) Standards of Care26  is a foundational document for understanding transgender health. Organizations such as The Endocrine Society,27 University of California, San Francisco Transgender Health Clinic, 28 Lorde-Callen Clinic 29 and Fenway Clinic30 have published therapy guidelines. The National Center for Transgender Equality (, Fenway Health ( and Rainbow Health Ontario ( have online health professional educational resources. In Michigan, the Oakland County Pharmacists Association has partnered with TGNC advocates to offer a transgender health continuing education program. Numerous articles discuss appropriate pharmacological care for TGNC adult and/or adolescent patients. 31-38

The most meaningful learning, however, may be gained through interactions with TGNC individuals. Spending time at transgender medical practices, meeting with TGNC community members, and attending advocacy events can provide insight into the daily lives and health needs of this community. These interactions will likely highlight the numerous health-related risks existing within the TGNC community including depression, anxiety, suicidality, interpersonal trauma, substance abuse disorder, smoking and HIV/AIDS. 10, 17, 39-41

The foundation for transgender care is a non-threatening pharmacy environment.  Gender-affirming policies and practices respect the spectrum and fluidity of gender, protect patient confidentiality, engender trust in patient-pharmacy staff relationships and are responsive to patient needs. Table 2 lists actions that support a gender-affirming pharmacy practice and signal to TGNC patients that the pharmacy is a safe place to seek care. A gender-affirming pharmacy experience, however, begins when a patient walks through the building door. Therefore, all store staff should know how to provide gender-affirming service.

Potential services that pharmacy staff can implement to improve transgender care are described in Table 3. Pharmacists and pharmacy technicians wishing to establish gender-affirming practices should do so in consultation with individuals and organizations from the TGNC community so that services reflect an informed, intentional effort to respectful care.


Transgender healthcare requires a skilled combination of evidence-based practice and culturally responsive care. It must understand and respond to the intersecting impacts of medical care, discrimination and social determinates that influence the health of this population. Pharmacists who undertake this challenging responsibility can improve the health of one of our most vulnerable populations.

 Table 1: Common Gender Terms

 Agender: genderless, internally identifies as neither male or female

Authentic gender: self-conception of gender identity

Bigender: gender identity is a combination of male and female

Cisgender: gender identity aligns with sex assigned at birth

Gender fluid: gender identity and presentation shift across gender spectrum

Genderqueer/gender nonbinary:  identity lies along or outside the gender spectrum

Transgender (or trans) female: identifies as female but assigned male at birth

Transgender (or trans) man: identifies as male but assigned female at birth

 (Adapted from references 4,36)


Table 2: Actions for Implementing a Gender-Affirming Pharmacy Practice

 Build bridges

 Post a notice that gender-inclusive care is provided, have LGBTQ-friendly pamphlets in the waiting area, or wear a lapel pin that has LGBTQ colors or indicates your chosen pronouns (e.g., she/her)

Establish a relationship with individual TGNC patients by letting them know that you wish to assist and support them in their therapy decisions

 Connect to the TGNC community by attending local TGNC events to gain first-hand knowledge of the needs and culture of this community

Visit the offices of local transgender specialists. Ask for opportunities to learn about their services and let them know that patients referred to you will receive respectful care

 Establish gender-affirming policies

 Collect and document preferred name and pronouns in the pharmacy profile for all patients and apologize immediately if the wrong name or the wrong pronoun is used

 Ensure that patients receive respectful care even if a specific staff member is uncomfortable dispensing hormone prescriptions for physical, mental and/or emotional alignment

 Create a consistent pharmacy policy about the dispensing of syringes and communicate that with all TGNC patients

 Establish a gender-neutral bathroom or a bathroom use policy that allows people to use the bathroom that is right for them

 Create a safe environment for patient care

 Use private areas for counseling 

 Ask, don’t challenge, patients about doses, dosage schedules or administration instructions that differ from general guidelines. These prescriptions offer opportunities for discussing patient therapy goals.

 Document verification of hormone prescriptions in the pharmacy profile so patients are not re-questioned about therapy appropriateness on future pharmacy visits.

 Avoid unnecessary personal questions that are not pertinent to patient care

 (References 42,43)


Table 3: Potential Services to Offer within a Gender-Affirming Pharmacy Practice

 Information and counseling about hormone therapy effects and side effects for patients who are considering whether such therapy is appropriate for them

 Information, education and therapy management for those prescribed hormone therapy

 Education about hormone injection techniques and assistance/coaching with initial hormone injections

 Assistance with obtaining hormone therapy at an affordable price, especially for those who have high co-payments or who lack prescription insurance

 Counseling about the use and safety of non-traditional health interventions commonly used by the TGNC community

 Referral information for gender-affirming medical providers and other health professionals or service and navigation organizations such as Trans Lifeline (1-877-565-8860), a national suicide and support hotline or Transcend the Binary (, a Michigan-based advocacy and service navigation organization

 Offering of telephone or telecommunication counseling as an addition or substitute to in-pharmacy counseling

HIV screenings, counseling related to HIV pre-exposure prophylaxis (PrEP) and counseling and drug therapy management related to HIV treatment

 Tobacco cessation counseling

 Hepatitis C screenings, counseling and drug therapy management related to Hepatitis C treatment

 Hepatitis A immunizations

 Screenings, brief interventions and referrals to therapy for depression and substance abuse disorders

 (References 12, 20-24)



Nancy JW Lewis, PharmD, MPH




1.        Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report — United States, 2011. MMWR 2011;60(Suppl):1-114.

2.        IOM (Institute of Medicine.) The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press. 2011 (accessed 2017 April 14).

3.        National Academies of Sciences, Engineering, and Medicine. 2017. Communities in action: Pathways to health equity. Washington, DC: The National Academies Press.

4.        American Psychological Association. Definitions Related to Sexual Orientation and Gender Diversity in APA Documents. (Accessed 2019 Feb. 1)

5.        Flores AR, Brown TNT, Herman JL. Race and ethnicity of adults who identify as transgender in the United States. The Williams Institute. 2016. (accessed 2017 Aug. 17).

6.        Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720.

7.        Bradford J, Reisner SL, Honnold JA, Xavier J. Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study. Am J Public Health. 2013;103:1820-1829.

8.        Cruz TM. Assessing access to care for transgender and gender nonconforming people: A consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65-73.

9.        Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M.  Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. (accessed 2017 Nov. 10).

10.     James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. 2016. (accessed 2015 Nov. 14).

11.     Lerner JE, Robels G. Perceived barriers and facilitators to health care utilization in the United States for transgender people: A review of recent literature. JHCPU. 2017;28:127-152.

12.     Lewis NJW, Batra P, Misiolek, B, et al. Transgender/gender non-conforming adults’ worry and coping actions related to discrimination: Relevance to pharmacist care. AJHP (in press.)

13.     Rodriguez, A , Agardh, Oppong Asamoah, B. Self-Reported Discrimination in Health-Care Settings Based on Recognizability as Transgender: A Cross-Sectional Study Among Transgender U.S. Citizens. Arch Sex Behav. (2018) 47:973–985.

14.     Sanchez NF. Sanchez JP, Danoff N. Healthcare utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. Am J Public Health. 2009;99:713-719.

15.     Meyer HH, Brown TNT, Herman JL, et al. Demographic characteristics and health status of transgender adults in select US regions: Behavioral Risk Factor Surveillance System, 2014. Am J Public Health. 2017;107:582-289.

16.     Seelman KL, Colon-Diaz MJP, LeCroix RH, Xavier-Brier M, Kattari L. Transgender noninclusive healthcare and delaying care because of fear: Connections to general health and mental health among transgender adults. Transgender Health. 2017;1:17-28.

17.     Streed CG, McCarthy EP, Haas JS. Association between gender minority status and self-reported physical and mental health in the United States. JAMA Intern Med. 2017;77:1210-1212.

18.     Mepham N, Bouman WP, Arcelus J, et al. People with gender dysphoria who self-prescribe cross-sex hormones: Prevalence, sources, and side effects knowledge. J Sex Med. 2014;11:2995–3001.

19.     Rotondi NK, Bauer, GR, Scanlon K, Kaay M, Travers R, Travers A. Nonprescribed hormone use and self-performed surgeries: “Do-it-yourself” transitions in transgender communities in Ontario, Canada. Am J Public Health. 2013;103:1830–1836.

20.     Bonner L. Pharmacists can be accessible, trusted providers for transgender patients. Pharmacy Times. 2016. (accessed 2018 Feb. 10).

21.     Cocohoba J. Pharmacists caring for transgender persons. Am J Health-Syst Pharm. 2017;74:170-4.

22.     Maxwell E, Salch S, Boliko M, Anakwe-Charles G. Discrepancies in lesbian, gay, bisexual, and transgender patient care and how pharmacists can support an evolved practice. Am J Pharm Educ. 2017;1:1-4.

23.     Newsome C, Colip L, Sharon N. Conklin J. Incorporating a pharmacist into an interprofessional team providing transgender care under a medical home model. Am J Health-Syst Pharm. 2017; 74:135-9.

24.     Radix AE. Pharmacists’ role in provision of transgender healthcare. Am J Health-Syst Pharm. 2017;74:103-104.

25.     Leach C, Layson-Wolf C. Survey of community pharmacy residents’ perceptions of transgender health management. JAPhA. 2016:56:441-445.

26.     Coleman E, Bockting W, Bother M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. Int J Transgend. 2011;13:165–232.

27.     Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal H et al. Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 94: 3132–3154, 2009

28.     Deutsch MB ed. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Center of Excellence for Transgender Health. University of California, San Francisco. 2016.

29.     Callen-Lorde Community Health Center. Protocols for the provision of hormone therapy. Available at accessed 2017 March 11).

30.     Makadon HJ, Mayer, KH, Piotter P, Goldhammer H. Fenway guide to lesbian, gay, bisexual, and transgender health, 2nd ed. Boston: The Fenway Institute; 2015.

31.     Bass M, Gonzalez LJ, Colip L, Sharon N, Conklin J. Rethinking gender: The nonbinary approach. AJHP. 2018;75:1821-1823.

32.     Bishop BM. Pharmacotherapy considerations in the management of transgender patients: A brief review. Pharmacotherapy. 2015;35: 1130-1139.

33.     Chew D, Anderson J, Williams K, et al. Hormonal treatment in young people With gender dysphoria: A systematic review. Pediatrics. 2018;141(4):e20173742

34.     Daniel H and Butkus R. Lesbian, gay, bisexual, and transgender health disparities: Executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163:135-137.

35.     Gabe Murchison, G. Supporting & caring for transgender children. American College of Osteopathic Pediatricians, American Academy of Pediatrics and the Human Rights Campaign Foundation, 2016. (accessed 2019 Feb. 5)

36.     Klein DA, Paradise SL, Goodwin ET. Caring for transgender and gender-diverse persons: What clinicians should know. Am Fam Physician. 2018;98:645-653.

37.     Levine DA, and the Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013:e297-e313. Technical Report.

38.     Shumer De, Nokoff NJ, Spck NP. Advances in the care of transgender children and adolescents. Advances in Pediatrics. 63 (2016) 79–102.

39.     Nuttbrock L, Bockting W, Rosenblum A, et al. Gender Abuse, Depressive Symptoms, and Substance Use Among Transgender Women: A 3-Year Prospective Study. Am J Public Health. 2014;104:2199–2206.

40.     Trujillo MA, Perrin PB, Sutter M, Tabaac A, Benotsch. The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. Int J Transgenderism. 2017;18:39–52.

41.     Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clinical Psychology Review. 2018;66:24–38.

42.     Human Rights Campaign Foundation. Providing LGBTQ-inclusive care and services at your pharmacy: a resource guide for pharmacists and pharmacy staff. June 2016. (accessed 2017 Sept. 15).

43.     Community Conversation: Finding our Strength. (Community Forum Discussion). Transcend the Binary, Ferndale MI. Aug. 30, 2018.


Posted in: Innovative Practice
Advancing Pharmacy Services

By John S. Clark, Pharm.D., M.S, BCPS, FASHP, associate chief of pharmacy, Michigan Medicine, Ann Arbor; clinical associate professor, University of Michigan College of Pharmacy, Ann Arbor and president-elect, Michigan Society of Health-System Pharmacists

What does advancing pharmacy services mean to you? Advancing the professional goals of pharmacists? Advancing the technology in pharmacy? Fancy high tech buildings with palatial spaces? Provision of care to patients? Providing support for other clinicians? Patient counseling? Potentially all of these?

In the spirit of President MacDonald’s theme, “Demonstrating Our Value,” it is imperative that pharmacists and pharmacy extenders consider when we advance pharmacy services, what value is gained from the advancement. Do we improve patient outcomes? Do we free up pharmacist time? What are the pharmacists doing in that newly available time? What value is added for the patients?

All of these questions are critical to the creation of the future of pharmacy practice. However, as the profession’s responsibilities grow in scope, we have a beacon to assure us of our direction. Our patients will guide us to the most critical services they need from the profession of pharmacy.

Do I mean ask patients directly? Only, sort of. Patients should be part of the focused group that suggests services that are needed from pharmacy. Additional input from physicians, nurses, respiratory therapists, PAs, NPs and health-system administration can inform what service weaknesses there are for patients. With a clear focus on what patients need, this well-informed team can suggest, design and assist in implementation of patient care services. After implementation, measurement of impact or value is often neglected. We must measure our changes to enhance our understanding of what services are of value to our patients.

As we consider this, our profession must ask: how are we going to create our future? What is our profession’s moonshot? Our big hairy audacious goal?

It’s our duty to create this in collaboration with all of our stakeholders! Are you up to the challenge? Are you the leader we need? Get involved in your own pharmacy departments and the Michigan Society of Health-System Pharmacists!

This is an exciting time in our profession. Be on the front line of creating the future of pharmacy practice.

Posted in: Innovative Practice
Together We Can Make a Difference – Emergency Preparedness

By Mary Beth O’Connell, Pharm.D., BCPS, FASHP, FCCP, FNAP, AGSF, professor, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit

Every year, disasters and public health threats affect various populations and geographical areas. Since 1953, Michigan has experienced 37 disasters (see Figure 1).1 During disasters and threats, healthcare is needed to meet acute, chronic and preventive health needs. Paid healthcare and government employees coordinate and oversee these healthcare services, but most of the care comes from volunteers for medical, technical, and logistical tasks.  Medications play a critical role in overcoming disasters and public health threats; therefore, pharmacists, pharmacy technicians and student pharmacists are needed at these events. Having a database of volunteers facilitates the engagement of personnel and resources in a timely and organized manner. What follows is information about disasters and public health events and how to join the Michigan Volunteer Registry database. Pharmacy personnel are a critical component of interprofessional healthcare teams to improve the health and well-being of citizens during disasters, so registering with the database is incredibly important. Currently about 325 pharmacy personnel are in the registry, but the goal of MSHP/MPA is to have 1,000 pharmacy-focused volunteers by the end of the year. Non-pharmacy volunteers are also needed, so sign up with a colleague, family member, friend or alone.  Join those of us who have accepted this important healthcare obligation. When you are called on to volunteer, you will make an important contribution to society, but if you are not available at the time you are called, you can always say you are unable to volunteer at this time.

Figure 1. Number and Location of Michigan Disasters1

11 Floods

9 Severe storms

6 Tornados

5 Snow

1 Drought

1 Fire

1 Freezing

1 Hurricane

1 Toxic substances

1 Other


Disasters are common and are classified as natural, technological and man-made. Natural disasters include hurricanes, tornados, fires, earthquakes, floods, etc. Technological disasters can include power grid outages or computer problems. Man-made disasters can be intentional or unintentional including biological terrorism, disease outbreaks, nuclear, radiologic or chemical terrorism, and violence from bombs and mass shootings. As Virginia Zimmerman, Coordinator of the Michigan Volunteer Registry states, “It is not a matter of if but when” a disaster strikes. For example, in 2017 there were four hurricane created natural disasters. During the initial response phases for these four hurricanes, 4,674 personnel were deployed to help 36,370 patients!2 During these disasters people experience trauma or new illnesses, find themselves without their chronic medications due to evacuation or fleeing, or are unable to get more medications due to destruction of community pharmacies. During Hurricane Katrina 68 to 80 percent of shelter evacuees needed replacement medications.3 During Hurricane Sandy, 95 percent of ambulatory care clinics in the affected area needed to close or relocate.4 Only 37 percent of the community pharmacies in that area had a back-up generator; therefore, most pharmacies were not able to operate fully. Seventy-four percent of the pharmacies had damage limiting pharmacy services, and 44 percent of the pharmacy staff had transportation issues getting to work. As demonstrated, during most disasters, temporary community pharmacies are needed with additional pharmacy personnel. Sometimes the need results from the spread of a contagious disease such as the hepatitis A outbreak in the Southeast Michigan area, which required public health events to mass immunize large numbers of citizens at risk of getting the disease. In cases of bioterrorism, a stockpile of medications exists that would require mass dispensing of antibiotics or antidotes quickly. You have the skills and expertise to help during these times.

Can you see yourself helping out? Pharmacy personnel have unique skills that other healthcare professionals do not have that are needed during disasters and public health events. The major categories of pharmacy activities during disasters and public health threats are medication supply, patient management, policy coordination and response integration.5 A recent review of literature has expanded these categories to professional practice, population health planning, direct patient care, legislation and communications.6 So many roles and steps exist, such as setting up an emergency based pharmacy, procuring and storing medications, managing pharmacy volunteers, doing patient interviews to identify and resolve medication related problems, labeling, dispensing and administering medications, counseling and educating patients, answering healthcare professional's drug information questions, providing team care, assisting with computer support, prehospital triaging during mass-casualties, enhancing communications, and decreasing panic and fear with patients, families and providers. Some pharmacy curriculums are even adding emergency preparedness to pharmacy student training. Many pharmacy organizations are adding this type of training to their annual meetings. All pharmacies are encouraged to have a plan for operations during a disaster.

Please join the Michigan Volunteer Registry at Michigan is fortunate to have such a registry. The registry is managed the Michigan Department of Health and Human Services. Dianne Malburg, Michigan Pharmacists Association (MPA) chief operations officer and Farah Jalloul, MPA emergency preparedness coordinator, are administrators for the database. The process required to enroll is done online and can be done in parts. You will need to enter your pharmacy license number and information about immunization, CPR and other types of certifications. The registry is dynamic, which means you can change your ability and responsibilities over time. Enrollment does not commit you to any disaster. If a disaster occurs, they might contact you and you can say “yes, I am available”, “no, I am not available”, or “I need to take care of my family or place of employment first.”

The value of an emergency preparedness database is state personnel can validate licensure to have practice-ready, licensed healthcare professionals they can call upon immediately versus trying to validate personnel during the actual disaster. The database can identify volunteers by skills so the appropriate people are requested by healthcare needs. Outcomes after a disaster are better for states that are ready and have plans and personnel ready to engage.6

Ready to volunteer but have some reservations? Watch the recruitment video that was developed for pharmacy personnel at You can also visit to the website and read the frequently asked questions sections as well as some of the references below. You are also welcome to contact Farah Jalloul, MPA emergency preparedness coordinator, at for any additional information or question. Here are some answers to common concerns.

1)       I don’t know enough. Incorrect. Each of us can assist during a disaster or public health threat by providing skills in the area of management, operations, supply chain, patient education, dispensing, etc.

2)       I don’t have the time. You can volunteer for just a half day or for a couple days or a week – it’s all up to you.

3)       I have a busy life. When they call, you can say sorry, I can’t volunteer this time.

4)       I won’t be able to take care of my family. Incorrect. You can take care of your family first; remember this is a volunteer function that you have the right to say, “sorry, hopefully next time.”

5)       I am uneasy about working with trauma patients or during a chemical or bioterrorism event. You get to choose what type of activities you volunteer your expertise. You can just list immunizations at a public health event and not volunteer for disasters.

6)       I am not trained to do disaster care. At any disaster, medical experts and law enforcement are there to oversee the situation. They direct operations and assignments, so you always have resources and information during a disaster. They have access to safety gear and preventive health medications, if needed.

7)       I’m afraid of liability issues. During disasters state and federal laws exist to cover healthcare professionals, with the coverage varying by profession. Some pharmacy malpractice insurance companies cover humanitarian efforts, so check your plan. MPA is working to get even greater coverage for pharmacy personnel during disasters. The rules are constantly changing. For information about insurance coverage, see reference four, and also the frequently asked questions at www.MiVOlunteerRegistry.7

8)       My employer won’t let me volunteer. You should double-check with your employer to see if you can get release hours from work or could use vacation time. Some pharmacy chains actually set up their own pharmacy units so you might be able to work within your own company during a disaster.

9)       I can’t afford to volunteer. That might be true. During these events you generally have to pay for your own travel, lodging and food. Volunteers are not paid for their services. Generally costs for local events are minimal and less than national events. Sometimes organizations donate food and discount lodging to keep costs affordable.

Using your pharmacy skills and training during a disaster will help save lives and improve healthcare outcomes. Wouldn’t you want the state of Michigan to have a plan to help you and your family in an emergency? In order for that to happen, we have to have pharmacy personnel from all counties in Michigan ready to step up and provide medications and save/improve lives and health outcomes. So please register today at We need you! Recruit others from your practice. Together we can make a big difference!!


1. FEMA. Data Visualization: Disaster Declarations for States and Counties. FEME website.

2. Assistant Secretary for Preparedness and Response. ASPR Year in Review. Public Health Emergency website.

3. Carameli KA, Eisenman DP, Blevins J, d’Angona B, Glik DC. Planning for chronic Disease Medications in Disaster: Perspectives From Patients, Physicians, Pharmacists and Insurers. Disaster Med Public Health Prep. 2013;7(3):257-65.

4. Ford H, Dallas CE, Harris C. Examing Roles Pharmacists Assume in Disasters: A Content Analytic Approach. Disaster Med Public Health Prep. 2013; 7(6):563-572.

5. Arya V, Medina E, Scaccia A, Mathew C, Satrr D. Impact of Hurricane Sandy on Community Pharmacies in Severely Affected Areas of New York City: A Qualitative Assessment. Am J Disaster Med. 2016;11(1):21-30.

6. Alkhalili M, Ma J, Grenier S. Defining Roles for Pharmacy Personnel in Disaster Response and Emergency Preparedness. Disaster Med Public Health Prep. 2017;11(4):96-504.

7. Frequently Asked Questions (FAQ) About Legal and Regulatory Issues Pertaining to the MI Volunteer Registry. website.

Posted in: Innovative Practice
Demonstrating Our Value - MSHP’s Apt Ambition

By Rebecca Maynard, Pharm.D., director of pharmacy, Ascension Borgess Medical Center, Kalamazoo

When asked how we demonstrate our value as health-system pharmacists and pharmacist extenders, most of us would respond with the work we do performing direct patient care on a day-to-day basis. We know that our patients are better off because we are part of their care team, from making sure they have the right medications documented and continued during each care transition, to ensuring they receive evidence-based medication therapy for a variety of disease states in multiple settings. Those who work with us on a daily basis - physicians, nurses and patients - are quick to speak up about how invaluable we are to direct patient care.

But what are we doing to show that value in a way that will enable us to not just maintain our current foothold, but to extend into areas that we have never been before? I think of our newly revised MSHP Vision and Mission Statements:

MSHP’s vision is that all people in Michigan have pharmacy care providers to ensure optimal, safe and effective medication use.


MSHP’s mission is to provide leadership, support, and a collective voice for its members as they practice and advance the pharmacy profession to achieve desired health outcomes through optimal medication use.

If we can’t collectively express our value in a consistent and meaningful way, how can we ever reach our Vision? Our Mission guides our organization to provide what is needed for each of our members to help demonstrate our value, and the theme of this year is aptly ambitious. As care shifts from inpatient to outpatient service models, pharmacy correspondingly is working toward providing the right care, at the right time, in the right setting.

Pharmacists are one of the most underleveraged population health managers according to Lindsay Conway, managing director of the Pharmacy Executive Forum. Preventable medication errors have been estimated to account for $21 billion in healthcare spending every year, and when evaluating numerous publications, it is evident that pharmacists and pharmacist extenders have a variety of opportunities to reduce medication errors through opportunities like inpatient rounding, medication reconciliation and post-discharge education. Because of a lack of reimbursement for pharmacists’ time, however, few health-systems have fully committed to establishing these pharmacist roles. We can work to overcome this through collaborative practice agreements, as discussed in John Clark’s article in the February 2018 MSHP Monitor, and through advocating for pharmacists as providers within section 1861(s)(2) of the Social Security Act.

Many of the MSHP committee charges created this year address ways for us to collaborate and share best practices in a variety of different settings. In the Antimicrobial Stewardship Committee, for example, we are working on revamping the website to include initiatives completed in acute care, long-term care and ambulatory care settings. The call for our membership is to consider what you and your colleagues are doing to demonstrate our value (what initiatives have you completed, what metrics do you use, how do you engage your C-suite and executive leadership in recognizing the role that pharmacists have) and to take that information to the next step. Please reach out to an MSHP Board member or committee chairperson and share what we can do to demonstrate our value so that all people in Michigan have pharmacy care providers to ensure optimal, safe and effective medication use.


  1. Conway L. 5 Things CEOs Need to Know About Pharmacy. The Advisory Board website. Accessed May 6, 2018.
Posted in: Innovative Practice
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