As the COVID-19 pandemic continued to evolve, a call-to-action was issued by the US Department of Health and Human Services, Assistant Secretary for Health, Brett P. Giroir, M.D. His office issued an authorization under the Public Readiness and Emergency Preparedness Act (PREP) allowing licensed pharmacists to order and administer COVID-19 tests that the U.S. Food and Drug Administration (FDA) has authorized.  The statement issued by HHS Secretary Alex Azar read: “In an effort to expand testing capabilities, we are authorizing licensed pharmacists to order and administer COVID-19 tests to their patients. The accessibility and distribution of retail and independent community-based pharmacies make pharmacists the first point of contact with a healthcare professional for many Americans. This will further expand testing for Americans, particularly our healthcare workers and first responders who are working around the clock to provide care, compassion and safety to others.”

This PREP Act authorization has been followed by similar state-level executive orders from the governor of Florida, Governor Ron Desantis, and the governor of New York, Governor Andrew Cuomo, among others.   This allows pharmacists, especially at the community level, to provide greater accessibility for people to receive COVID-19 testing. It is universally agreed that significant expansion of testing is necessary to assist the identification of potentially infected individuals.  Contact tracing can then occur more efficiently, and isolation of infected persons can become more targeted and precise.  This also places an additional responsibility upon pharmacists to further engage in the fight against COVID-19 beyond what has already been accomplished.

Expanded COVID-19 testing by pharmacists must also achieve proper reporting mechanisms to regional departments of health, as well as other primary care providers if known.  This moment also offers an opportunity to establish necessary platforms to accomplish interprofessional interoperability between patients, pharmacists, and primary care providers.  Necessary exchanges of pertinent clinical information between health providers is long overdue.  A theoretical model of newly emerging roles for pharmacists is shown below (Figure 1):

Figure 1 – original from Kevin B. Sneed, PharmD, FNAP, FNPHA

In previous posts I have fervently advocated for the expanded utilization of mobile health technologies (mHealth) as a means of implementing a new type of data collection for medication therapies. Pharmacists can play a major role in the measurement and monitoring of medications, leading to more complete optimization of medication therapies.  In a recent conversation with a physician colleague, I stated that just because a medication was prescribed, and the patient took the medication, does not mean it worked, or achieved a metric-driven outcome.   During this COVID-19 pandemic event, numerous reports of patients suffering strokes or myocardial infarctions have been documented. (¹Zhang J, Wang X, Jia X, et al. Clin Microbiol Infect. 2020; ² McMichael TM, Clark S, Pogosjans S, et al.  MMWR Morb Mortal Wkly Rep. 2020;69(12):339-342; ³ Roncon L, Zuin M, et al. J Clin Virol. 2020;127:104354.). The increased internal vascular bio-inflammatory status of patients is likely a strong contributor to these events.  I would suggest that if mHealth technologies were already in widespread use, concomitant with enhanced implementation of telehealth platforms, the incidence of severe morbidity and mortality of patients with chronic diseases requiring multiple medications may have been fewer in number.  Further, facilitated implementation of mHealth and telehealth in underserved/ underrepresented communities may have attenuated the severe negative clinical impact in these populations. (Coronavirus And Health Equity- Again This (Too) Is Predictable – KBSneed)

Expanded COVID-19 testing is necessary to succeed in providing proper public health surveillance of viral spread containment strategies.  Community pharmacies are keenly positioned to contribute meaningfully to these community strategies.  Issues of PPE for pharmacists and staff, as well as costs of the tests remain key items to be figured out. The enhanced engagement of pharmacists during this COVID-19 pandemic will be essential in providing needed support to already strained health systems. There can be little disagreement that pharmacists should, and must, enhance our engagement in healthcare activities beyond purveyors of medicinal product and join the other health care clinicians in the war against COVID-19. The public health, societal, and economic implications are too great for anyone not to engage.

Effective medication therapy is at the core of managing patients with chronic disease states, such as diabetes or hypertension.  Unfortunately, medication therapy in this country has been far less than optimal, and in some cases creates harm (1).  Through multiple studies and reviews, it is well known that 50% of medications prescribed by health providers are not taken as prescribed within six-months, and 25% of prescribed medications are never filled or picked up (2).  Prescribers, most notably physicians, simply do not have the additional time or focus to follow behind patients about these medication challenges.  Pharmacist clinicians offer the best opportunity to not only improve adherence, but to measure and monitor the effectiveness and potential barriers to successful medication optimization (3).   Using mobile health technologies, these monitoring and measurement technologies create improved connectivity with patients in their daily ambulatory lives without requiring additional timely and costly visits to healthcare clinics.

I also foresee the possibility of bringing these technologies into underserved and underrepresented communities, which are often affected the most by lack of healthcare access. Putting these technologies into the hands of community health workers and other “health extenders”, with proper medical provider supports, could become an effective means of improving health disparities in many communities. Decreased emergency room visits and hospital readmission rates can be achieved, while creating an inclusive environment where people from all communities can benefit from emerging health technologies.  Ultimately, poor health in any community is a drag on all communities. The public health impact holds so much promise with the implementation of these technologies.

In my two most recent posts (Time for Pharmacists to Move from Behind the Counter  and Interprofessional Health Initiatives- Health Systems Cannot Succeed Without Them!) I expressed that Interprofessional Clinical Collaborations simply must evolve to achieve optimal health outcomes.   Interoperability of electronic platforms, Collaborative Practice Agreements, and capitated reimbursement models for clinical services will provide pathways for pharmacist clinicians to optimize medication outcomes as members of patient-centered healthcare teams.  Status quo healthcare delivery, siloed health providers, and avoidance of emerging health technologies will certainly stifle opportunities for our national and regional healthcare systems to provide the most outstanding healthcare at lower costs.  Mobile health technologies offer the best opportunity to initiate new communication paradigms between patients and their health provider teams. The Time is Now to embrace mobile health technologies.

1. Watanabe JH, McInnis T, Hirsch JD. Cost of prescription drug-related morbidity and mortality. Ann Pharmacotherapy. 2018;52(9):829-837.
2. Viswanathan M. Golin CE, Jones CD, et al. Intervention to improve adherence to self-administered medications for chronic diseases in the United States: as systematic review. Ann Intern Med. 2012;157(11):785-795
3. https://www.pharmacist.com/article/acos-can-do-more-medication-optimization-study-says (accessed 06/04/2019)

The following are excerpts from a previous post creating the argument that Interprofessional Teams must occur for Health Systems to succeed.  This reigns even more true today than when it was originally published.  

“During the past several months, I have been engaged in a number of meetings with health professionals from almost every sector of the health system. This includes CEOs, CMOs, researchers, community-outreach professionals, hospitals, community pharmacies, federally-qualified healthcare centers, and individual health providers. It has been rewarding to hear them all accept the basic premise associated with health reform measures, with the focus being on providing high quality health services, enhanced patient safety, and achieving improved,  measurable outcomes. All at lower costs than we realize today.  Regardless of the politics involved with healthcare reform, we are rapidly moving to a health-system that will hold health providers more accountable for the care that is provided to patients. If we remember the Institute of Medicine Report from 2001, Crossing the Quality Chasm: A New Health System for the 21st Century,  we find that a fair number of the recommendations made in that report are the foundation of many of today’s reforms.  And, these recommendations were made long before the initiation of the Affordable Care Act. However, we cannot take another 10-plus years to implement these necessary changes. Patients (especially Baby Boomers) are ready today…How can we create similar teams to treat entire communities?  Here are some of my thoughts:

1) Revise Health Education for health professions students. The Interprofessional Education Collaborative  was organized to create the “how-to roadmap” for teaching and training health professions students.  This offers the best hope for transforming future healthcare landscapes. This was also a foundation of the IOM report.

2) Advanced utilization of Informatics.  If interprofessional teams are to function effectively, there must be shared information among these professionals.  Also, there must be an opportunity for patients to have access to this information. After all, it is THEIR information.

3) Implementation of Emerging Disruptive Technologies. Emerging health technologies are outpacing clinicians’ abilities to learn and implement them into clinical practice.  Further, there are significant gaps in knowledge about the effectiveness of these technologies.  Concomitant study and assessment of these technologies must be undertaken.  Mobile Health technologies (prior blog) and Personalized Medicine (pharmacogenomics; DNA-based clinical decision-making tools) are two key futuristic technologies to watch.

4) Realistic Reimbursement Models. The databases of major health systems are driving informed decisions about the costs of health for patients. Morphing away from fee-for-service to realistic outcomes-driven payment models can allow for appropriate reimbursement of all health professionals that provide advanced care.  Pharmacists, for example, should automatically  be educating, monitoring, and assisting in the management and effectiveness of cardiovascular (chronic illness) medications, while being reimbursed for that service in addition to the product being dispensed. Information should be sharable between professionals associated with the care of a single patient, and the patient must remain at the center of all health-related decisions.  And, all health professionals must be held reasonably accountable for achieving positive outcomes associated with delivery of health provisions.

One thing is certain, we cannot achieve a healthier nation until operative interprofessional collaborations are achieved. This must happen! Patients are waiting for us to get it right! #LetsMakeItHappen”

This was a statement taken from the epilogue of an article published in 2004-05. Fifteen years later, we still have not developed a ubiquitous presence of pharmacist clinicians in alternative clinical environments. Many healthcare practitioners mainly associate pharmacists only as dispensers of medications. The general public is a bit more savvy, as they identify their pharmacists as medication experts that can make the time to explain how the medications are hopefully treating their medical condition, possible adverse effects, and methods to optimize the effectiveness of their medications.

However, many people in the public, including some health providers, still do not view the pharmacist clinician as a member of their total healthcare team. As outcome-driven healthcare continues to quickly evolve in our health systems across the country, profound shifts in the perceptions of the most effective roles of the various clinical professionals must begin to occur. Patients, providers, payers, and insurers must remove their traditional, decades-old view of siloed healthcare.  They must all begin to truly expect, even demand, patient-centered care. As in, the patient is truly the Center of attention, and all other health providers are encircled around the patient to provide their individual expertise to maximize opportunities for the patient to accomplish their best possible health outcomes. This is a significant paradigm shift in interprofessional team-based care that simply must occur in our country.

The ambitious goal of the “Triple Aim” – (1) enhanced patient experience, (2) improved population health, and (3) reduced healthcare costs, now has become the “Quadruple Aim” (Annals of Family Med November/December 2014 vol. 12 no. 6) which also includes (4) improved health provider wellness. Widespread reports of provider burnout, particularly among physicians, now necessitates a team-based approach to healthcare that heretofore had been confined to closed health systems such as Veteran’s Administration centers and Kaiser Permanente institutions, just to name a few. Technology now allows improved communication among health providers so that all members may together construct a patient healthcare plan, provide meaningful contributions, and document their activities according to the direction of the primary provider. Collaborative Practice Agreements allow for proper oversight of the patient, while inserting accountability for patient safety and outcomes. Finally, the patient is transparently made aware of their provider network, and the contributions of each. Sharing healthcare responsibilities allows for population health principles to be applied, while maintaining the individual focus that each patient deserves.

I have a fundamental plan to significantly transform the role of community pharmacists, and thus positively disrupt the healthcare system (see image). Patient-centered care can be achieved; it need not take another fifteen years for widespread implementation. Transformative utilization of pharmacist clinicians, with system-driven protocols, will significantly improve access to care for patients without increasing silos or breakdowns in provider communications. The Time is Now for Pharmacists to move from Behind the Counter and serve the public as valued medication specialists on team-based care units. Future postings will focus on a vision of the transformational role of pharmacist clinicians that will achieve the Quadruple Aim for people in all communities.

Through numerous conversations, health industry leaders have shared with me that it is almost cost prohibitive to retrain all of their current clinicians in these new integrated models.  Retail pharmacy leadership has shared the same about retraining all of their pharmacists in newer models of health delivery.  It has become abundantly clear to me that academic institutions must shoulder the task of training the next generation of health clinicians in these integrated healthcare models. The goal will be to create clinicians that are “team-based care ready” on day one, not after attending costly training sessions to acclimate them to interprofessional care models.  Efficiencies gained from well-trained healthcare team models will translate into financial savings for the entire health system.

Post-graduate residency programs in medicine and pharmacy have had a great deal of success in role-modeling integrated care models in acute-care inpatient environments.  I have a strong sense that this is lacking in broader community-based health arenas.  A recent IOM report supports this belief, and promotes reforming Graduate Medical Education funding to include expanded training in community settings.  In virtually every conversation I have with high-level health administrators, the gaps in community healthcare become more apparent; what lacks is a clear answer on how to improve healthcare in all communities.  The disparate nature of communities presents unique challenges, but also unveils enormous opportunities.  Inclusion of various healthcare professionals, especially in primary care, should become a goal of all health systems. A recent article by Kaiser Health News echoed this sentiment.  While this will mark a sharp shift by today’s healthcare standards, improved patient-centered care cannot be achieved in siloed territorial care.

This will be an enormous task for the various academies to achieve, especially since our various curricular structures generally have not been developed in ways that produce health clinicians capable of immediately achieving integrated health teams by the time they graduate. This is almost remarkable, given the length of time we spend training them!  There are national strategic initiatives promoting this very notion, with the Interprofessional Education Collaborative (IPEC ®) leading efforts for the various health academic associations to develop interprofessional curricular collaborations for student learners.  It is my strong belief that if we are to achieve improved healthcare outcomes, increased patient safety, all at lower costs, then it must begin with the academies achieving this interprofessional curricular goal.  Here at the USF College of Pharmacy, we understand this, and are working tirelessly toward this end.  Large amounts of health students emerging from the various disciplines will lead the way, but leadership is needed today if this is to become a reality in the near future.  Contemplative delays are not an option, this time to act is now!

Mentioned in that IOM report was the strong recommendation that interprofessional collaborations would likely provide the optimal care model.  There was also the strong mention that utilization of information technology would be an especially helpful tool in providing healthcare.  A review of the Centers for Medicare and Medicaid Services ACO Accountability Metrics for 2012 provides key insights into the achievable outcomes that are expected to be accomplished as quality targets for patient care.  There will be increased emphasis to achieve these targets in an outpatient manner, directly in the communities in which patients reside. And, while there will certainly be different models and metrics for various health systems, one can clearly foresee that interprofessional teams will be the best method for better health outcomes for patients.  No single practitioner will achieve significantly  improved health for all of their patients, and entire communities cannot attain improved health relying upon single and isolated practitioners.  It is time for all of the various components of the health terrain to become aligned to provide coordinated, patient-centered care.

And there begins the challenge.  How can multiple health professionals succeed in working together on population-health driven intiatives, in a relatively short amount of time, when we have all been conditioned to practice in silos during our entire professional careers? Overall, hospital environments possibly have the best collaborative practices; but one aim of health reform is to keep people out of hospitals, except for the very sickest individuals. How can we create similar teams to treat entire communities?  Here are some of my thoughts:

1) Revise Health Education for health professions students. The Interprofessional Education Collaborative  was organized to create the “how-to roadmap” for teaching and training health professions students.  This offers the best hope for transforming future healthcare landscapes. This was also a foundation of the IOM report.

2) Advanced utilization of Informatics.  If interprofessional teams are to function effectively, there must be shared information among these professionals.  Also, there must be an opportunity for patients to have access to this information. After all, it is THEIR information.

3) Implementation of Emerging Disruptive Technologies. Emerging health technologies are outpacing clinicians’ abilities to learn and implement them into clinical practice.  Further, there are significant gaps in knowledge about the effectiveness of these technologies.  Concomitant study and assessment of these technologies must be undertaken.  Mobile Health technologies (prior blog) and Personalized Medicine (pharmacogenomics; DNA-based clinical decision-making tools) are two key futuristic technologies to watch.

4) Realistic Reimbursement Models. The databases of major health systems are driving informed decisions about the costs of health for patients. Morphing away from fee-for-service to realistic outcomes-driven payment models can allow for appropriate reimbursement of all health professionals that provide advanced care.  Pharmacists, for example, should automatically  be educating, monitoring, and assisting in the management and effectiveness of cardiovascular (chronic illness) medications, while being reimbursed for that service in addition to the product being dispensed. Information should be sharable between professionals associated with the care of a single patient, and the patient must remain at the center of all health-related decisions.  And, all health professionals must be held reasonably accountable for achieving positive outcomes associated with delivery of health provisions.

Other components to achieve interprofessional collaborations include understanding population (public) health; implementation of the behavioral change necessary to achieve effective teams;  acceptance of futuristic technologies (stem cells, robotics, etc); surveillance of bioethics; and the list goes on.  One thing is certain, we cannot achieve a healthier nation until operative interprofessional collaborations are achieved. This must happen! Patients are waiting for us to get it right! #LetsMakeItHappen

In recent meetings with the executive leadership team of USF Health and external healthcare executives, the interim dean for the USF Morsani College of Medicine, Dr. Harry Van Loveren, has made bold public proclamations. They have been among the most assertive I have witnessed in such settings.  He stated on several occasions that the current healthcare system must begin to allow the most appropriate clinicians to engage patients in order to provide the care they need, “regardless of that clinician’s ability to bill for the service.” I have rarely heard this publicly from a physician, especially a physician specialist; privately I hear it all of the time.  I echoed his comments, with the understanding that our health systems must move towards value-driven care models with shared risks between the health system(s) and the payers.  In this fee-for-value system, improved patient outcomes trump an individual clinician’s ability to simply bill for services rendered. In this model, multiple clinical professionals come together to surround and provide each patient with the ideal care they need to achieve the best possible health outcome for that patient.  In these value-based systems, we strive for optimum population-health, one patient at a time.

USF Health is a very unique clinical environment, even by today’s standards for health science centers.  We have attempted to create a clinical and educational environment that unifies the talents and ambitions of all health professionals for the purpose of improving healthcare and safety for patients. The cultural change that has been required for this transformation has been enormous, but necessary and worthwhile.  We now find ourselves yearning for a truly integrated USF Health community, coalescing the educational, research, clinical, cultural, and administrative missions to create a high functioning, very efficient environment.

The healthcare arena is also yearning for this integrated model.  In a blog posted by the American Society of Health-Systems Pharmacists Executive Vice-President Paul Abramowitz, authors in an article published by Health Affairs stated that “pharmacists belong in Accountable Care Organizations and integrated care teams.” The authors very elegantly articulate the value of pharmacists on integrated healthcare teams; I can make the same assertion that this holds true for numerous health professionals, including public health clinicians, health coaches, and social workers. This was recently supported by Tom Frieden,  Director of the U.S. Centers for Disease Control and Prevention, in a recent Q & A stating the role of public health in clinical care.    In an at-risk financial health model, we believe that having these integrated teams will significantly reduce the amount of financial waste in the system, while producing improved health outcomes.

We must change how we train health clinicians.  The obstacles that exist in our curricular-driven academic models must be overcome. Ingenuity and innovation must overtake tradition and convenience.  In a blog posted by Dr. Stephen Klasko, president of Thomas Jefferson University,  he challenges the lack of educational transformation in our health academic institutions. Many will disagree with him; I happen to disagree with those that disagree!  And, the health industries are agreeing with me, one exec at a time.  With health reform now here, regardless of the politics, it is time to create integrated models of care. Here in the USF College of Pharmacy and USF Health, we are attempting to aggressively push those boundaries, while maintaining academic and clinical integrity.  Our destination? Successful interprofessional collaborations. Patients are waiting!

There is no more time to ponder whether interprofessional care teams should occur; patients deserve our best. As I would post on twitter: #ThinkInterprofessional #ThinkTeam #LetsMakeItHappen

Twitter – @KevinBSneed ; @futuristpharmd