Extending COVID-19 Pharmacy Technician Duties: Impact on Safety and Pharmacist Jobs

Abstract

Background: The 2019 coronavirus pandemic (COVID-19) led to an expanded scope of practice for pharmacy technicians. As the pandemic wanes, state governments are faced with the decision of whether or not to make permanent the authority of pharmacy technicians to perform extended duties. Objective: Determine the impacts on patient safety and job market demands preadoption and postadoption of Idaho’s expanded technician duties in 2017 as a natural experiment for expanded technician duties. Methods: Data from the National Practitioner Data Bank (NPDB) is used to explore patient safety outcomes in Idaho preadoption and postadoption and as compared with its border states. Data from Pharmacy Demand Reports is used to compare job postings in Idaho and its border state, and National Association of Boards of Pharmacy census data are used to compare growth in the number of pharmacists and technicians in Idaho and its border states over time. Results: For Idaho pharmacists, the average number of disciplinary actions reported against both pharmacists and technicians dropped after implementation of expanded technician duties. Idaho also had a lower rate of discipline for pharmacists and technicians than its border states. Idaho had the third highest job postings for pharmacists and the second highest for technicians among its border states. Idaho also had the largest growth in the number of licensed pharmacists and technicians of the observed states in the study period. Conclusion: Available statewide data from Idaho as compared with its border states suggests that expanded technician duties did not adversely impact patient safety outcomes or the pharmacist job market. Additional states may wish to expand pharmacy technician duties in the years ahead.

The 2019 coronavirus pandemic (COVID-19) prompted an “all hands-on deck” response to the surging demand for pandemic-related testing, vaccinations, and treatment. The federal and state governments used executive authority to expand scope of practice of many health care professionals, including pharmacists and pharmacy technicians. ¹ One federal official highlighted the relatively untapped potential of 425 000 pharmacy technicians nationwide to augment immunizer supply, and technicians became an integral part of the 300.9 million doses of COVID-19 vaccine administered through the Federal Retail Pharmacy Program.^2-5

Beyond vaccine administration, technician roles changed in many ways during COVID-19. Some states relaxed supervision requirements such as pharmacist-to-technician ratios. ⁶ Other states allowed technicians to perform remote work, such as offsite data entry and prescription procession. Still others allowed pharmacy technicians to accept verbal prescriptions from prescriber offices, transfer prescriptions to other pharmacies, and perform health testing. ⁶ In general, each of these duties were allowed through emergency authority at the state level, and therefore the allowances expire as the COVID-19 declarations of emergency expire.

As the pandemic wanes, state governments are faced with the decision of whether or not to make permanent the authority of pharmacy technicians to perform extended duties. It stands to reason that any duty that was performed by a health professional during a public health emergency should similarly be allowed outside of an emergency absent information that demonstrated it was unsafe. While simple in concept, scope of practice issues—such as making permanent pharmacy technician authority to administer vaccines—are often among the most contentious issues that manifest in state legislatures, with concerns about safety often masking concerns about job security from the incumbent practitioners.^7,8

Idaho provides a natural experiment to see if either of these concerns—patient safety and job security—have materialized at the state level.^9,10 In 2017, the Idaho Board of Pharmacy adopted one of the most extensive pharmacy technician role expansions in the United States that predated many of the same allowances that states focused on during COVID-19. Idaho pharmacy technicians can administer vaccines, conduct health testing, prescribe naloxone, perform final product verification, accept verbal prescriptions, transfer prescriptions, and perform any other duty assigned by a pharmacist as long as it is consistent with the technician’s education, training, and experience.^11-16 Idaho also eliminated its pharmacist-to-technician ratio and allowed technicians to work from remote locations, and operate at a telepharmacy.

Idaho had standard requirements for entry into practice as a pharmacist or technician when the expanded technician duties were enabled. Idaho pharmacists have to satisfactorily graduate from a school of pharmacy accredited by the Accreditation Council for Pharmacy Education (ACPE) and pass the North American Pharmacist Licensure Examination® (NAPLEX®). At the time, an Idaho certified technician had to be at least 18 years old, graduate from high school or its equivalent, and obtain certified pharmacy technician (CPhT) status through the Pharmacy Technician Certification Board (PTCB) or the National Healthcareer Association (NHA). Given that these requirements are relatively standard across states, Idaho provides a useful comparison to draw upon.

This manuscript will explore the impacts on patient safety and job market demand preadoption and postadoption of Idaho’s expanded technician duties in 2017. Exploration of these outcomes may inform other state legislatures and regulatory boards considering the expansion of pharmacy technician duties.

Methods

Impact on Patient Safety

Statewide data on patient safety outcomes associated with pharmacy regulation is limited. ¹⁷ One postulated method of measuring patient safety outcomes at the state level is the National Practitioner Data Bank (NPDB) web-based repository of reports on adverse actions against health professionals and medical malpractice payouts. ¹⁸ Federal law requires certain entities to report to NPDB, including state licensing boards, federal agencies, medical malpractice payers, and private accreditation organizations.

The NPDB data analysis tool includes specific reports on pharmacists and separately “technicians and assistants.” The latter includes pharmacy technicians and pharmacy assistants, among other support personnel (eg, physical therapy assistants and occupational therapy assistants). ¹⁹ For this analysis, we looked at pharmacist discipline, since technicians fall under a pharmacist’s supervision in all states, and separately at technicians, using the broader NPDB category as if all technician reports referred to just pharmacy technicians.

Two analyses were performed. First, the average annual NPDB-reported disciplinary cases (number of adverse action reports and medical malpractice payments) against Idaho pharmacists and technicians were compared for the 5 full years prior to expansion of technician duties (2012 through 2016) and the 5 years following (2018 through 2022).

Second, the total number of NPDB-reported disciplinary cases for Idaho pharmacists and technicians were compared to the same rate in each of Idaho’s border states for 2021. The number of disciplinary cases were divided by the total number of pharmacists or technicians licensed or reported in each state as of July 30, 2021, as reported in the National Association of Boards of Pharmacy (NABP) Survey of Pharmacy Law to calculate a rate of discipline per 1000 pharmacists and separately for technicians. ²⁰

Impact on Pharmacy Job Market

The Pharmacy Workforce Center has published quarterly Pharmacy Demand Reports (PDR) since 2020, with data from the first-quarter of 2019 onward. ²¹ The PDR includes a “postings quotient” which looks at the number of pharmacist job postings per state divided by the number of licensed pharmacists in the state. A separate metric looks at the number of technician job postings per state divided by the number of employed pharmacy technicians in the state based on Bureau of Labor Statistics data. For both pharmacists and technicians, the average postings quotient per state from 2019 through 2022 was calculated for Idaho and each of its border states.^22,23

The NABP Survey of Pharmacy Law has census data reported by boards of pharmacy on the number of pharmacists licensed by each state and the number of pharmacy technicians reported in each state. We used the reported counts reported as of July 30, 2015 and July 30, 2022 to look at each state’s growth rate for pharmacists and technicians prior to and after Idaho’s adoption of the expanded technician duties.^24,25 We also examined the number of pharmacists with a reported in-state address in Idaho and its border states in 2015 and 2022 to determine the growth rate as a potentially better proxy for the in-state pharmacist job market.

Results

Impact on Patient Safety

For Idaho pharmacists, the average number of adverse action reports and medical malpractice payments in the 5 full years prior to the adoption of expanded technician duties was 45.8 reports per year. In the 5 years after adoption, total reports averaged just 11.6 reports per year. The average number of NPDB reports for Idaho technicians similarly dropped over the same time period (23.4 preimplementation vs. 6.4 postimplementation).

Idaho also had a lower rate of discipline for pharmacists (4.14 reports per 1000 licensed pharmacists) than its border states (6.15). Similarly, Idaho technicians had fewer disciplinary reports (1.77 reports per 1000 technicians) than its border states (8.70).

Impact on Pharmacy Job Market

Data on the pharmacy job market is presented in Table 1. Over the study period, Idaho had the third highest job postings for pharmacists (108.9 per 1000 licensed pharmacists) in the region, behind Washington (130.7) and Montana (128.5). Idaho was also second in technician job postings (347.5 per 1000 employed technicians), behind just Washington (406.3).

Table 1.

Comparison of Pharmacist and Technician Job Market Data in Idaho and its Border States.

State	Average pharmacist job postings per 1000 licensed pharmacists (2019-2022)	Percentage growth in pharmacist licenses (2015-2022)	Average technician job postings per 1000 employed technicians (2019-2022)	Percentage growth in technician registrations (2015-2021)
Idaho	108.9	63.0%	347.5	75.9%
Montana	128.5	17.6%	320.8	7.5%
Nevada	74.3	−6.1%	256.3	−2.2%
Oregon	96.3	34.4%	338.9	21.3%
Utah	73.2	30.2%	312.2	31.1%
Washington	130.7	15.1%	406.3	−4.0%
Wyoming	65.4	12.1%	255.4	2.8%

Idaho had the largest growth in the number of licensed pharmacists (63%) from 2015 through 2022, nearly doubling the second place Oregon (34.4%). When looking at just pharmacists with in-state addresses, Idaho still led the pack in pharmacist growth (27.4%), with Montana being second (18.3%). Idaho also saw the largest growth in the number of pharmacy technicians reported in the state (75.9%), more than double second place Utah (31.1%).

One state (Nevada) saw a decline in total licensed pharmacists from 2015 through 2022 (−6.1%), though the same state reported 1.7% growth among pharmacists with in-state addresses. Two states (Nevada and Washington) reported a decline in total technicians during the time period (−2.2% and −4%, respectively).

Discussion

In the years following the adoption of expanded pharmacy technician roles in Idaho, there are no data to suggest statewide patient safety outcomes worsened based on the measures used in this study. In fact, the average annual NPDB-reported disciplinary cases for both pharmacists and technicians dropped after implementation of the law changes, and Idaho also had a lower rate of discipline of pharmacists and technicians than its neighboring states.

There are limiting factors to using NPDB as a surrogate for statewide patient safety outcomes so caution must be exercised in drawing too firm of conclusions. NPDB reports are based on many factors, such as the regulatory philosophy of a state’s licensing board and the number of consumer complaints filed with a board. The Idaho Board of Pharmacy evolved its approach to discipline during the reporting period, with an enhanced emphasis on a “just culture” approach to resolving complaints which may have led to fewer NPDB reports.^26-28 Thus, we stop short of saying that the patient safety outcomes are improved in Idaho after implementation of the expanded technician duties, but we do note that using NPDB data does not suggest that statewide patient safety has worsened after expanding technician duties. Similarly, another limitation is using the broader category of “technicians” reported by NPDB as reflective of just pharmacy technicians. That said, the number of disciplinary cases against technicians was low, so it is unlikely there are significant differences across state lines even if data are narrowed to just pharmacy technicians.

This finding of state-level safety—or at least the absence of evidence that expanded technician duties was unsafe at the state level based on available data—is consistent with individual studies of expanded technician duties. In this space, the largest body of literature exists around pharmacy technician final product verification (eg, “tech-check-check), with studies dating to the late 1970s.^29-33 Snoswell reported on 12 studies, calculating the pharmacist accuracy rate to be 99.27% compared with pharmacy technicians (99.72%), which reached a level of statistical significance (P < 0.0001). ³⁴ With a higher accuracy rate, fewer medication errors are committed. Thus, allowing technicians to perform final product verification should lead to fewer NPDB disciplinary reports for both pharmacists and technicians.

To what extent do individual studies demonstrating safety scale to the state level? In Idaho’s case, it appears successful as no state-level data suggested harm after a major regulatory package allowing expanded technician duties. This may, alternatively, be due to low uptake of expanded technician duties in practice. When a law is changed allowing for expanded technician duties, for example, there is often a gap between what the law allows and what happens in practice. ³⁵ Indeed, uptake of pharmacy services in practice often is underwhelming and it takes years to decades for new models to become mainstream. ³⁶ Thus, an alternate explanation is that few Idaho pharmacists may be delegating expanded duties to technicians even though it is allowed legally, and this may account for the purported statewide safety outcomes. Even if this is the case, however, it would suggest that pharmacists and pharmacies are demonstrating caution and discretion in delegation decisions. This, too, is suggestive of why states should allow expanded technician duties in practice because pharmacist discretion provides a layer of safety in practice.

Debates on the proper role of pharmacy technicians have historically been pharmacist-centric. ³⁷ Thus, while safety alone should be the decision point that states use as the basis for expanding technician duties, concerns about pharmacist jobs often underpin such debates. Thus, the absence of statewide data that suggest Idaho pharmacist jobs have been diminished in the time period after adoption of expanded technician duties should provide additional mental comfort to state policymakers. In fact, Idaho nearly doubled the growth rate of the next closest state in pharmacist licensee growth from 2015 through 2022. This growth may be due, in part, to Idaho’s elimination of the state law exam, which lowered the barrier to entry for pharmacist licensure.^38,39 Still, Idaho had a high number of job postings for pharmacists, ranking third among its neighboring states, and exceeding Nevada, Oregon, Utah, and Wyoming, and also led the pack among pharmacists with just in-state addresses.

Of note, Idaho rated second in technician job postings, trailing just Washington. Idaho also saw the largest growth in technicians from 2015 through 2022, doubling the nearest state. As such, there is an argument that expanded technician duties may catalyze additional job opportunities for pharmacy technicians. Some national pharmacy entities moved central processing operations into Idaho, likely in part due to the expanded technician duties, and this partially catalyzed the increased demand for technicians relative to other states.^40,41

States considering the extension of expanded pharmacy technician duties post-COVID can learn from Idaho’s experience. Coupled with the studies on individual technician duties, state boards of pharmacy can reasonably deduce that expanded technician roles can be safe, effective, and may also catalyze additional job opportunities for technicians.

For these states, the natural question may be which combination of expanded technician duties should be allowed to still ensure that patient safety is maintained? While Idaho originally itemized in law which expanded duties technicians can perform, it abandoned this in favor of a “standard of care” regulatory approach.^28,42,43 In such a regulatory model, a technician can perform any duty that is delegated by a supervising pharmacist. Thus, the supervising pharmacist, not the law, is the rate-limiting step in determining what technicians can do in practice. Given the patient safety and job market data reported for Idaho, other states should emulate the standard of care approach to technician duties.

Conclusion

Expanded pharmacy technician duties can provide additional capacity to the health care system and increase accessibility of services to patients throughout the country. Individual studies demonstrate expanded technician duties are safe and effective. Statewide data from Idaho as compared to its surrounding states suggests that expanded technician duties did not adversely impact patient safety outcomes or the pharmacist job market. As such, additional states may wish to expand pharmacy technician duties in the years ahead.