NewApproachesforAntiviralMedication

DispensingDuringaPandemic:
Collaborationsthatutilizesthecommunity
pharmacist
LisaKooninMN,MPH
CentersforDiseaseControlandPrevention
AnitaPatel,PharmD,MS
CentersforDiseaseControlandPrevention
MitchelRothholz,RPh,MBA
AmericanPharmacistsAssociation
GillianSteelFisher,PhD,MSc
HarvardSchoolofPublicHealth

DevelopmentandSupport
ThiswebinarwasdevelopedbytheAmerican
PharmacistsAssociationandsupportedbya
CooperativeAgreementprovidedbytheCentersfor
DiseaseControlandPrevention(CDC).Theopinions
expressedinthisprogramdonotrepresentthe
viewpointsoftheCDC.

Disclosures
MitchRothholz, declaresthathiswifeisanemployeeof
Merckandheservesontheadvisorycommitteefor
MerckandPfizer.
GillianSteelFisher,PhD,MSc,declaresherhusbandisa
consultantforEliLilly.
LisaKoonin,MN,MPH, AnitaPatel,PhamD,MS,and
APhAs editorialstaff declaresnoconflictsofinterestor
financialinterestsinanyproductorservicementionedin
thisactivity,includinggrants,employment,gifts,stock
holdings,andhonoraria.Forcompletestaffdisclosures,
pleaseseetheEducationandAccreditationInformation
sectionatwww.pharmacist.com/education.

AccreditationInformation
TheAmericanPharmacistsAssociationisaccreditedbythe
AccreditationCouncilforPharmacyEducationasaproviderofcontinuingpharmacy
education(CPE).Thisactivity,NewApproachesDuringaPandemicforAntiviral
MedicationDispensing Collaborationthatutilizesthecommunitypharmacist,is
approvedfor1.5hoursofCPEcredit(0.15CEUs).TheACPEUniversalActivityNumber
assignedbytheaccreditedprovideris:20200012248L04P.
ToobtainCPEcreditforthisactivity,participantswillberequiredtoactively
participateintheentirewebinarandcompleteanonlineevaluationandCPErecording
formlocatedatwww.pharmacist.com/educationbySeptember28,2012.
TargetAudience:Pharmacists
ACPEActivityType:KnowledgeBased
LearningLevel:2
InitialReleaseDate:September19,2012

LearningObjectives
Discussthegoalsforanantiviralmedication
distributionprogramduringapandemic
Describethecurrentmodelandproposedmodelfor
distributionofantiviralmedicationsandthevarious
providerswithinthesystem
Articulatethevalueofincorporatingcommunity
pharmacistswithinanewmodelofantiviral
medicationdistribution/dispensingduringa
pandemicevent.

LearningObjectives
Discussthelearningsfrompharmacysimulations
conductedbyCDCthatidentifiedsuccessfactorsfor
thenewmodelofantiviralmedicationdispensing
Identifystrategiesforovercomingbarrierstothe
implementationofacollaborativepractice
agreementanddiscusscomponentsofa
collaborativepracticeagreementneededto
successfullyimplementthenewmodelforpatient
evaluationandantiviralmedicationdispensing
DescribethelearningsfromaHarvardUniversity
surveyofpharmacistsandhowtheresultsinformed
theproposedmodelofcaredelivery.

SelfAssessmentQuestion#1
1.Thepurposeofexploringanewmethodof
pandemicantiviraldistributionanddispensingis
to:
A. Improveaccesstoantiviralsduringaninfluenza
pandemic
B. Increasetheburdenonpublichealthduringa
publichealthemergency
C. Provideantiviralsforfreetothepublic
D. EnsureeveryAmericanhasadoseofantivirals

SelfAssessmentQuestion#2
2.CDCspharmacysimulationexercisesprovided
informationthat:
A. Pharmaciescanprovidemedicinesduringan
emergency
B. Pharmaciescanincreasethenumberofpatients
servedduringafuturepandemic
C. Usualstandardsofaccuracyandqualitycontrol
canbemaintainedwhendispensingantivirals
duringapandemic
D. Alloftheabove

SelfAssessmentQuestion#3
3.CollaborativeDrugTherapyManagement
(CDTM)encompassesthefollowing:
A. Itisateamapproach
B. Mayinclude,butisnotlimitedtoinitiating,
modifying,andmonitoringapatientsdrug
therapy
C. Canbeutilizedinnonemergencyanddeclared
influenzasituations
D. Alloftheabove

CDCsAlternativeAntiviralDrug
DistributionandDispensingExploratory
Project
Lisa M. Koonin MN MPH
Lead, Pandemic Medical Care and
Countermeasures Task Force
Influenza Coordination Unit
Centers for Disease Control and
Prevention

TimelyAntiviralTreatmentDuringanInfluenza
PandemicDependsUponSuccessAtEveryStep
Antiviral susceptibility and
effectiveness

Supply Available

EUA/Regulatory issues

Distribution from
SNS/Commercial supply
chain
Provider Acceptability

Patient access to Rx
Pharmacists acceptability

Public acceptance
Access to medication

Timely administration

CDCAntiviralDistributionandDispensingProject
AVProjectDates:May2011 May2013
AVProjectKeyPartners:ASTHO,NACCHO,AmericanPharmacists
Association,NationalAssociationofChainDrugStores,National
CommunityPharmacistsAssociation,RxResponse
AVProjectGoal:Toimprovetheavailabilityandaccesstoantivirals
duringaninfluenzapandemic
AVProjectKeyActivities:
Explorethefeasibility,acceptability,cost,andimpactofleveraging
existingsystemsbysendingSNSantiviralstopharmaceutical
distributorsandpharmaciestodistributeanddispense
Developprocessestoalignwithusualcommercialsystem
practices(inventorycontrol,pharmacyordering,tracking,billing)
Exploreinnovativefinancingmechanisms:
Explorehowdispensingfeescouldbecoveredfor
uninsured/underinsured

CURRENTMETHOD:AntiviralDistributionand
DispensingDuring2009H1N1Pandemic
Dispensing Locations
PH Clinics

SNS

SHD

Various
methods

LHD

Various
methods

Hospitals
Nursing
Homes
Med Offices /
Clinics

Antiviral
Manufacturers

Pharmaceutical
Distributors

Pharmacies

PROPOSEDMETHODFORTESTING:
FuturePandemicAntiviralDistributionandDispensing
DispensingLocations

X%

PH Clinics
Targeting
underserved
populations

LHD

SHD

Tribal nations?
Prisons?
Other?

Y%

Large Pharmacy
Chains

SNS

Chain, Big-Box,
Grocery Pharmacies
Independent
Pharmacies
Nursing Homes

Z%

Distributor(s)
Med Offices/Clinics

Hospitals

TimelyDispensing

AmountofRelease
TriggersforRelease

KeyAreasofExploration
WhatproportionofSNSAVDsshouldbesentto
SHDsandwhatproportiontodistributors?
Leveraginginherentstrengthsofkey
participants:
Publichealthsuniquereachtounderservedand
otherpopulations
Distributorandpharmaciesreach
Specificusesforstate/localstockpiledantivirals?
Distributionstrategies:primethepump,per
capita,demandbased,mixedmodel?

Financing:
Howtoassurethatcost/paymentisnotabarrier?

Acceptability,feasibility,cost,reliability?

AlternativeAVDDistributionandDispensing
PlanMustbeFeasible andAcceptable
New
Approach
drafted

LearnfromH1N1

Feasible?

Acceptable?

Legalbarriers

YES

PossibleNew
Policy

NO

Backtothe
drawing
board!

PublicHealth

Explorepossible
solutions

Mathematical
modeling>
supply/demand

FeedbackfromPH
andotherpartners

Commercialpartner
interest(RFI/RFP)

Distributors
Pharmacyexecs
Pharmacists

Retailpharmacy
throughput/simulations

Providers

Reachtonon
pharmacylocations

Public

Accessforuninsured
Abilitytotrack
assets/informationflow
Costanalysis

Assumptions
Rapidaccesstoantiviraldrugsiscritical
Stockpiledassetswillbetheprimaryresourcefor
AVDsintheUS
PublichealthcontinuestohaveakeyroleinAVD
distributionanddispensing
Thissystemwillbescalable
Systemruleswillbetransparentandadaptas
needed
Informationexchangeiscriticalforallpartners

ScriptedSurge:PreliminaryFindingsfrom
CDCsPharmacyThroughputSimulations
AmericanPharmacistsAssociationWebinar
September 19,2012

AnitaPatel,PharmD,MS
HealthScientist
DivisionofStrategicNationalStockpile
OfficeofPublicHealthPreparednessandResponse
CentersforDiseaseControlandPrevention

ExercisePurpose
Simulateapandemicscenarioatapharmacy
toassesstheimpactofdispensing
governmentprovidedantiviralmedicationsin
additiontonormalpharmacyprescriptions
duringanemergency
Thesedrillswillhelptoassessthroughputin
pharmacysurgesituationsandidentify
bottlenecksintheprescriptiondrugdispensing
process

1
9

Scripted Surge: When and

Where?

MattsMedicineStore,
IndependenceMO
PharmacySimulation1:
Independentpharmacy
March11,2012

Walgreens, Chicago, IL
Pharmacy Simulation 2:
Traditional chain pharmacy
June 24, 2012
2
0

ExerciseObjectives
1. Determinetheaveragetimerequiredforacommunity
pharmacytodispenseprescriptiondrugsinapandemicsurge
situation
2. Determinenumberofpatientsservedandscriptsfilled/hour
andassessaccuracyofprescriptionsfilled
3. Identifyspecificbottlenecksinthedispensingprocess
4. Examinethequalityofthedispensingexperiencefor:

Eachpharmacypatientduringtheexercise
Pharmacystaffduringtheexercise

2
1

ExerciseDesign
Useofnormalpharmacyprocesses,systemsand
materials
Dispensingundertraditionalpharmacypracticeprinciples
Pharmacyoperatingatanticipated surgelevels
Mirrornormalprescriptionenvironment
Howprescriptionsenterpharmacy
Hardcopy,called,faxed,electronic
AntiviralRxplusregularRx
Ratioofinsurancerelatedproblems
Estimatesofpatientrelatedproblems

2runthroughs
Approximately90minutesinlengtheach

SettingtheStage
TheScenario
TheUSisatthepeakoftheworstinfluenzapandemic
indecades
Anewpandemicvaccineisstillbeingmadeandisnot
yetavailable
Antiviraldrugsaretheonlytreatmentfortheinfection
TherearetwoantiviraldrugsTamifluandRelenza

Commercialsuppliesofantiviralmedicationshave
beendepleted
Aproportionofthefederalstockpileofinfluenza
antiviralmedicationshasbeendistributedtolocal
pharmaciestodispensetopatientswithaprescription

WhatHappened?
27actorsforeachdrill
Each was given patient
profile cards
Personal
information
Information about
their insurance, name
of their doctor, and
the medications they
have been
prescribed

2
4

PatientProfileCard

Back of Card
2
5

Volunteers
PatientCards
Alongwithprescriptions',patientshandedoneormoreofthe
followingcardstopharmacystafftohelppresentamorerealistic
scenario

Greencards=Usedforpayment
Bluecards=Insurancecoverage
Orangecard=Problem(affixedtogreenorbluecards)
Redcard=Timedactor

Normalpharmacyprescriptionerrorswerealsoincludedforpharmacy
stafftocatchaspartofnormaldispensingprocesses
Dosingerrors,patientallergies,druginteractions

2
6

WhatHappened?(cont.)
Pharmacistsfilledprescriptionsasonanormal,butbusydayatpeak
ofaninfluenzapandemic
Patientspresentedwithprescriptionsandscenarios
Pharmacistsfilledallprescriptionsandprovidedservicesasthey
normallywould
ExceptNOREALMEDICATIONSWEREHANDLEDORUSED

TheSimulationCell(SimCell)
Problemsrequiringa3rd partytoresolveweresimulated
byControllersstaffingphonesattheSimCell
Problemswiththepatient
insurance
Problemsassociatedwiththe
methodofpayment
Missing/incorrect
informationonprescription
Interactionswithphysicians
toverifyprescriptionsas
needed

2
8

Objective1 Determinetheaveragetimerequiredfor
aforcommunitypharmacytodispense
antiviraldrugsduringsurgescenario
Timedrandomlyselectedactors
atfourdifferentpoints inthe
pharmacy
1.
2.
3.
4.

entrytothepharmacy
dropoffoftheprescription
prescriptionpickup
exitingthepharmacy

25.4

Independence, MO

Objective1:TimeResults

Dropofftopickupof
prescriptions
(Mean=23.8minutes)

Time (minutes)

Objective2a
Determinenumberofpatientsservedand
scriptsfilled/hour
Summaryofpeopleservedandprescriptionsfilledinbothdrills
(Run1andRun2)
Durationofrun(minutes)
Numberpeopleserved
Numberpeoplepickedupmultiplescripts
Throughput(numberpeopleservicedperhour)
Numberscriptsfilled
Throughput(numberscriptsfilledperhour)

MORun2
90

CHIRun1
90

CHIRun2
90

29

41

35

35

11

20.7

27.3

23.3

23.3

MORun1
84

34

55

44

45

24.3

36.7

29.3

30.0

Objective2b.Accuracy
Assessingaccuracy
VolunteersturnedinprescriptionstoQA
evaluatorsafterleavingthepharmacy
Criteriaexamined

PatientName
Medication
Dose/Strength
Quantity
Instructionsfordruguse

Objective2b.
AssessingAccuracy:Independence,MO
Overallhighlevelaccuracyobserved
Patient
Name

Medication

Dose/
Strength

Quantity

Instructions

Overall
Correct
Prescriptions

99%

98%

100%

99%

98%

Run1(n=34)
Correct
Prescriptions

100%

100%

100%

100%

97%

Run2(n=55)
Correct
Prescriptions

98%

96%

100%

98%

98%

Objective2b.
AssessingAccuracy:Chicago,IL
Overallhighlevelaccuracyobserved
Patient
Name

Medication

Dose/
Strength

Quantity

Instructions

Overall
Correct
Prescriptions

99%

98%

99%

99%

96%

Run1(n=34)
Correct
Prescriptions

98%

98%

100%

98%

95%

Run2(n=55)
Correct
Prescriptions

100%

98%

98%

100%

96%

Objective3.Bottlenecks
Bothdrills
Topbottlenecksperceivedbypharmacystaff
1. Counseling
2. Inputtingprescriptioninformationintothe
computer
3. Takingdoctorcalls
4. Takinginprescriptionsfrompatients
5. Other
Technology Printers,computers,registerissues
Attainingaccurateprescriptionsfromprescribers

Objective 4. Quality of the dispensing experience for each pharmacy patient during
the exercise
Independence,
MO

Chicago, IL

KeyPreliminaryObservations
Pharmacieswereabletodispense1.52.5xmorescriptsthannormalscript
peak rate
Usingnormal surgestaff

Solutionstobottlenecksmayneedtobeimplemented
Adjustnormalpractice

Increasestaff
Clarityoneachstaffrole
Adjustflowofpatientsorscriptdispensingprocess
Useofadvancedtechnology(eScripts,novelwaysofprocessingRx{tablets),video
counseling)

Keyartificialities/limitationsoftheexercise:
Learningcurveondiseaseanddrugscouldnotbeaccountedforinaoneday
drill
Abilitytocopewithsurgemayimproveovertimefromstartofpandemictopeak
couldntreplicatethatindrill
Familiaritywithdisease,drugs,dosage,contraindications,druginformationwilllikely
improve
Pharmacystaffneedtoimplementappropriateinfectioncontrolmeasures

Resilienceofstaffovertimecouldnotbeaccountedfor
Anxiety/fearofstaffandpatientscouldnotbesimulated

ThankstothePharmacy
SimulationTeam!

ASTHO/NACCHO/CDC
IEMConsulting,Inc.
Participatingpharmacies
NationalAssociationof
ChainDrugStores
NationalCommunity
PharmacistsAssociation
RxResponse
StateandLocalHealth
officialsandEmergency
Managementofficials
Volunteers
Manyothers!
3
8

3
9

The Voice of Pharmacists:

A Poll about Alternative Methods for Antiviral
Distribution During a Pandemic Influenza
September 19, 2012

Gillian SteelFisher, Ph.D., M.Sc.

Robert J. Blendon, Sc.D.
Mandy Brule, M.A.
Harvard School of Public Health
Harvard Opinion Research Program, February 24 - April 23, 2012

Methods Summary

Mail and online poll

Conducted February 24 to April 23, 2012

Nationally representative sample of 1,076 Pharmacists who work in

community pharmacies (retail settings)

Quick summary statistics on sample:

60% pharmacists; 38% managing pharmacists; 1% district managers
67% full-time (35+ hours)
73% staff (vs. float)
54% male; 46% female
81% married
37% are parents of children 18 and under

Questions after brief description of scenario & alternative delivery effort

Technical note: Some summary statistics do not add to 100% or the sum of the subsets due to rounding and/or 41
categories not shown (e.g., refused/skipped)

Harvard Opinion Research Program, February 24 - April 23, 2012

Key Research Questions

What do pharmacists think of this idea overall?
Will they participate?
What concerns might prevent them from participating?
Do they have relevant experience that might impact
participation?
Do they think their pharmacies will participate?
Do they work in pharmacies that might impact their
participation?
42

Harvard Opinion Research Program, February 24 - April 23, 2012

Overarching Reactions

43

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Reactions to
Proposed Antiviral Distribution Effort
Just based on the information so far, do you think it would be
a good or bad idea for the government to distribute antivirals through
pharmacies in this way?

7% 5% 3%

85%

a good or bad thing for the pharmacist profession?

84%

Good

Neither

Bad

11% 3%2%

Don't Know

44

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Views on The Impact of This

Initiative
Please indicate whether you agree or disagree with the following statements:
Participating in this effort would strengthen

The role of pharmacists during public health emergencies

18%

78%

(96%)

Relationships with patients

(93%)

28%

65%
Relationships with your local public health department

37%

46%

(84%)

Relationships with your state public health department

40%

38%

(78%)

Relationships with physicians

28%
Strongly Agree

(76%)

49%

Somewhat Agree

Harvard Opinion Research Program, February 24 - April 23, 2012

45

Predictions about
Pharmacist Participation

46

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Views on Pharmacist Participation

Would you favor or oppose participating in such an effort personally?

81%
Favor

Neither

Oppose

8% 6% 6%
Don't Know

Do you think the other pharmacist(s) who work in your pharmacy would favor or oppose
participating in such an effort?

65%
Favor

Neither

Oppose

4% 8% 2%
There no other pharmacists

21%

Don't Know

47

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Predictions: Coming to Work for

Normal Shifts During a 12-Week Outbreak
How likely is it that you would come to work for your regular hours for all 12 WEEKS of the
outbreak? (Assuming you are not sick yourself)

Very likely

91%
Somewhat likely

6%
Not very likely

1%
Not at all likely

1%
48

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Willingness to Come In for

Extended or Additional Shifts
In order to support the increased prescription volume, how likely is it that you would come to work
for extended or additional shifts [at routine pay rates / if you received a higher pay rate or received
comp time for those shifts?

Very likely

46%

79%

Routine Pay
Somewhat likely

33%

Very likely

67%
Higher Pay Rate/
Comp Time

91%

Somewhat likely

24%
49

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Comfort Levels in Giving Antivirals

Only to High-Risk Groups
In any emergency there is a chance that there would not be enough medicine at the time patients
needed it. If there were a shortage of antivirals in your pharmacy and community, how comfortable
would you be with only filling prescriptions for those identified as high-risk following CDC
guidelines on high-risk groups?
Very comfortable

39%

80%
Somewhat comfortable

41%
Not very comfortable

16%
Not at all comfortable
50

3%
Harvard Opinion Research Program, February 24 - April 23, 2012

Concerns

51

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Worries About Participating

Facing antiviral
shortages

33%

Carrying influenza
back to family

29%

41%

(71%)

Personal exposure
to influenza

20%

39%

(59%)

Managing usual
patients

19%

40%

(59%)

Keeping order
in the pharmacy

16%

Personal legal
liability
New billing
process

21%

11%

(58%)

42%

(57%)

36%

15%

Managing
antiviral patients

(81%)

47%

31%
33%
Very worried

(45%)
(44%)
52

Somewhat worried

Harvard Opinion Research Program, February 24 - April 23, 2012

Experiences that Could

Impact Participation

53

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Experience Compounding

Medication
In the last five years, have you compounded medication to make them appropriate for children,
adults with swallowing problems or those who need special dosing?

Yes, I have

78%

No, I havent

22%

Dont Know

<.05%

54

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Experience with

Collaborative Practice Agreements
Do you personally have any experience with a collaborative practice agreement? (Collaborative
practice agreement means a written and signed agreement between a pharmacist and one or
more physicians for the purpose of medication therapy management (MTM) of patients, based on a
protocol or protocols authorized by the physician(s).)
Yes

37%
No

58%
Dont Know- I am unfamiliar with this term

2%
Dont Know- Not sure if Ive experienced this

3%
55

Harvard Opinion Research Program, February 24 - April 23, 2012

Frequency of Contact between Pharmacists and

their State or Local Health Departments
In the past year, in your capacity as a pharmacist, how many times have you had contact with any
staff of your state or local public health department?
1

3-5

6-10

More than 10

9%
5%
6%
2%
3%

None

68%
56

Harvard Opinion Research Program, February 24 - April 23, 2012

Predictions about
Pharmacy Participation

57

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Views on Pharmacy Participation

Do you think your pharmacy would participate in such a program if their really were a pandemic
influenza outbreak?

Yes, my pharmacy would participate

82%

No, my pharmacy would not participate

1%

Dont Know

16%
58

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Reactions to
Proposed Antiviral Distribution Effort
Just based on the information so far, do you think it would be

good or bad for business in your pharmacy?

79%

Good

Neither

Bad

9% 4% 8%

Don't Know

59

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacies Abilities to Handle 20% Increased

Prescription Volume for 12 Weeks
If the pharmacy only had its routine number of pharmacists, student pharmacist interns and
pharmacy technicians, do you think the pharmacy could handle 20% more prescriptions all of
which were antivirals, or do you think the pharmacy would not be able to do this [for 12 weeks]?

Yes, could handle increased volume

63%

No, could not handle increased volume

27%

Dont Know

10%
60

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacies Abilities to Handle 2-3 Week Surge

of Prescription Volume
If the pharmacy had only its routine number of pharmacists, student pharmacist interns and
pharmacy technicians, do you think the pharmacy could handle an increase of [50% or 100%] more
prescriptions--all of which were antivirals--for 2-3 weeks, or do you think it would not be able to do
this?

Yes, could handle surge

34%
14%
No, could not handle surge

53%

50%
72%

100%

Dont Know

13%
13%
61

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacy Features
that Could Impact
Participation

62

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacists Internet Access

While they work, do the pharmacists or pharmacy technicians have full access to the Internet,
do they have restricted access to the Internet, do they have access to ONLY the companys system
software (intranet), or do they have no Internet or intranet access at all?
Full access to the Internet

35%
Restricted access to the Internet

31%
Access to ONLY the companys system software (intranet)

32%
No Internet or intranet access at all

2%
63

Harvard Opinion Research Program, February 24 - April 23, 2012

Pharmacies Customer Service Options for

Patients
Does your pharmacy have a drive-thru
window?

In a pandemic, do you think your pharmacy

would be willing to [continue to] offer home
delivery?

Drive-thru window

Home Delivery
Yes, continue to offer

Yes

38%

26%

34%
Yes, newly offer

Yes, would be
willing to offer
home delivery

No

61%

8%
64

Harvard Opinion Research Program, February 24 - April 23, 2012

Key Take-Aways

Relatively high acceptability among pharmacists

Supportive of the effort overall
Willing to participate personally
Believe participation would strengthen public health role
Pharmacy participation seems logical

Important possible barriers to participation

Problems with antiviral supply
Insufficient protection for family/self
Insufficient legal protection

Logistical challenges
Increasing number of staff
Increasing Internet access

Opportunities
Building relationships with public health and physicians
Sharing more perspectives: other pharmacists; executives; the public

65

Harvard Opinion Research Program, February 24 - April 23, 2012

Appendix:
Fictional Scenario
Please imagine for a minute that there is an outbreak of pandemic flu, where the strain
is much more severe than the 2009-2010 H1N1 outbreak, and a nationwide public
health emergency has been declared. Antivirals are most effective against this strain if
taken within 48 hours of symptoms. Commercial supplies are nearly exhausted and so
the governments stockpiles are the primary source of the medication.
Unlike past outbreaks, when the government distributed antivirals mostly to public
health departments, imagine that there is a new system where the government is also
providing antivirals directly to pharmaceutical distributors for distribution to pharmacies.
Imagine further that your pharmacy agrees to receive shipments of antivirals and to
dispense these antivirals for patients who have a prescription. Because the new flu
virus is causing a lot of serious illness in many people, you would expect more patients
to come to your pharmacy than usual. The antivirals will be in unit-of-use (unit-dose)
packaging and will be provided to pharmacies for free from the government, but your
pharmacy can charge patients a dispensing fee. The government has established a
special claims submission process in order to ensure reimbursement for patients
without insurance. Finally, depending on the severity of the pandemic, measures will
be recommended to protect you and pharmacy staff from the virus that will reduce the
chance you will get ill and thereby reduce the chance you will infect others.
66
Harvard Opinion Research Program, February 24 - April 23, 2012

Terminology
CollaborativeDrugTherapy
Management(CDTM)1
Collaborativepracticeundera
protocol
Goal:providepatientcareservices
thatachieveoptimalmedication
useandpatientoutcomes.

Collaborativepharmacy
practiceagreement(ID)
Agreementbetween1ormore
pharmacistsand1ormore
practitionersforthepurposeof
conductingdrugtherapy
managementservices
1

Protocols/Standing
Orders
Guidesactivities
outlinedwithinCDTMor
separatefromCDTM
(likeimmunizations)
Describesnature,scope,
communicationand
proceduresofdrug
therapymanagementor
patientcareservices

Source: NABP Model Act

CollaborativeDrugTherapy
Management(CDTM)
Teamapproach
Mayinclude,butarenotlimitedto:
Initiating,modifying,andmonitoringapatientsdrug
therapy;
Orderingandperforminglaboratoryandrelatedtests;and
Assessingpatientresponsetotherapy.
Authorityrangesfromsetting/patientrestrictionstobroad
authority
Nonemergency
Declaredemergency

States/TerritorieswithnoCDTMauthority:AL,DC,
DE,OK,PR,SC

PublicHealthEmergencyLaws
InanemergencyastateGovernorcanbe
providedauthoritytoissueanemergency
ordertoallowpharmaciststoevaluateand
dispenseantiviralmedications
Somestateshaveexistinglaworareproposing
specificlaw
SomestatesgobyGovernoremergency
declarationability

ApproachestoGainAuthority
ideallyinnonemergencysituationthatcouldapplytoemergencysituation

HealthDepartmentAdvocacy
StateBoardofPharmacy
WashingtonState
CollaborativeDrugTherapyAgreementforAntiviral
MedicationsforTreatmentorProphylaxisduringan
InfluenzaOutbreak.
specificallyauthorizespharmaciststoprescribeantiviral
medicationsandwillonlybeeffectivewhenauthorizedby
publichealthofficials.
Availableat
http://www.doh.wa.gov/Portals/1/Documents/Pubs/69021
3.pdf

CDTM
Forpharmaciststoengagetothefullextentin
dispensingantiviralmedications,CDTMlaws
needtobestructuredtoallowpharmaciststo
evaluateapatientperaprotocolandorderan
antiviralmedicationforthatpatient.
Nottobeconfusedwithprescribing

Thesemedicationshaveatimefactorfor
receivingmaximumbenefit

BroadorOpenEndedLanguage
Usepermissivelanguage
Typesofcollaborativeauthoritydecisions,including:
typesofdiseases,drugs,ordrugcategoriesinvolvedandthetypeof
collaborativeauthorityauthorizedineachcase;and
procedures,decisioncriteria,orplansthepharmacistsaretofollowwhen
makingtherapeuticdecisions,particularlywhenmodificationorinitiationof
drugtherapyisinvolved;

Offersanopportunityforpharmaciststoevaluateapatientpera
protocolandorderanantiviralmedicationforpatientseenunder
theCDTM.

CDTMlawsthatmayhinderabilityof
pharmaciststoorderantiviraltherapy
RequirementforaPrescribersInitialDiagnosis
ofthePatient
RequirementforaPhysicianOrderforTherapy
foraSpecificPatient
RequirementthatCDTMTakePlaceina
HospitalorSimilarFacility
RequirementthatthePharmacyHavea
PrivateSettingforCDTM

Recap
Bepreparedbeforeaneventoccurs
Servethepublichealthneedsofcommunities
Havetheservicebeapartoftheservices
providedbythepharmacy
Timeisessentialforeffectivenessofthetherapy

SelfAssessmentQuestion#1
1.Thepurposeofexploringanewmethodof
pandemicantiviraldistributionanddispensingis
to:
A. Improveaccesstoantiviralsduringaninfluenza
pandemic
B. Increasetheburdenonpublichealthduringa
publichealthemergency
C. Provideantiviralsforfreetothepublic
D. EnsureeveryAmericanhasadoseofantivirals

SelfAssessmentQuestion#2
2.CDCspharmacysimulationexercisesprovided
informationthat:
A. Pharmaciescanprovidemedicinesduringan
emergency
B. Pharmaciescanincreasethenumberofpatients
servedduringafuturepandemic
C. Usualstandardsofaccuracyandqualitycontrol
canbemaintainedwhendispensingantivirals
duringapandemic
D. Alloftheabove

SelfAssessmentQuestion#3
3.CollaborativeDrugTherapyManagement
(CDTM)encompassesthefollowing:
A.Itisateamapproach
B.Mayinclude,butisnotlimitedtoinitiating,
modifying,andmonitoringapatientsdrugtherapy
C.Canbeutilizedinnonemergencyanddeclared
influenzasituations
D.Alloftheabove

Iftheproposedstrategyisfeasibleandacceptable
May,2011

May,2013

Project Plan for CDC Alternative Antiviral Distribution and

Dispensing Project

Fall2012
CDCdevelops,issues,receivesRFPsandevaluatesthemfor
feasibility,suitability,practicalityandacceptability
CDCwillfinalizenewapproachesandawardcontracttoentities
CDCwilldevelopSOPs,amendstateplanningguidance,and
workingwithASTHOandNACCHO,disseminatefinalplansto
SLTTpartners

9/19/2012

Questions??

HowtoObtainyourCPECredit
RecordAttendanceCodeprovidedduringthewebinar
Pleasevisit:http://www.pharmacist.com/liveactivities
andselecttheClaimCreditlinkforthisactivity
Youwillneedapharmacist.comusernameand
password
SelectEnrollNoworAddtoCartfromtheleft
navigationandsuccessfullycompletetheAssessment
(selectcorrectattendancecode),LearningEvaluation
andActivityEvaluationforaccesstoyourstatementof
credit.YouwillneedtoprovideyourNABPeprofileID
numbertoaccessyourstatementofcredit.