Improving patient care and demonstrating value during a global pandemic: Recommendations from leaders of the Pharmacy Accountability Measures Work Group

The ASHP Pharmacy Accountability Measures (PAM) Work Group is charged with identification of pharmacy-related quality measures that health-system pharmacists can use to establish accountability for and demonstrate value in outcomes.^1,2 Our fundamental objective is to increase hospital and health-system pharmacists’ awareness, adoption, and implementation of existing measures in order to improve patient care, demonstrate pharmacist value, and identify gaps in measurement. Given the nature of the ongoing coronavirus disease 2019 (COVID-19) pandemic, we are applying our vision to encourage our colleagues on the front lines to think beyond the COVID-19 crisis and look towards future service expansion to meet the needs of patients, communities, and the healthcare system as a whole.

The global healthcare community has responded with undeniable courage and commitment to meet the needs of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while maintaining standard-of-care services for all patients. The COVID-19 pandemic has stretched the capacity of our healthcare workforce, increased demand for life-saving medications, and tested public health infrastructures globally. In response, legislative bodies, regulatory agencies, and standard-setting organizations have implemented emergency policy changes to reduce strain on the healthcare system and allow increased flexibility to facilitate rapid response. To support the practice of pharmacy, state governors and boards of pharmacy have relaxed regulations on medication preparation and administration, remote order verification, and prescription refill authorizations, to name a few recent actions. At the federal level, authorizations have enabled pharmacists to order and administer tests for SARS-CoV-2, improved patient access to telehealth pharmacy services, and provided flexibility in compounding requirements.

Federal and state lawmakers have taken unprecedented measures to allow pharmacists to protect the welfare of patients through practice authorizations previously expanded during natural disasters, such as fires and hurricanes, infectious disease outbreaks, and public health emergencies. The last time the world witnessed a novel viral strain, influenza A subtype H1N1, which caused the “swine flu” pandemic of 2009, pharmacists in all 50 states were granted emergency authorization to administer vaccines. In doing so, we met a public health need while simultaneously demonstrating our ability to safely and effectively administer vaccines. Over the last few years, states acted to allow pharmacists to provide naloxone to patients at risk for opioid overdose in an effort to curb the national opioid crisis. Emergency expansion of practice privileges during such critical times positions pharmacists to address significant public health shortfalls, expand patient access to medications, and triage patient care needs in the community. As a result, many of these emergency authorizations have the potential to become formalized into broader, permanent scope of practice changes that will advance the pharmacy profession.

The response to the COVID-19 crisis highlights pharmacists’ role as essential healthcare providers on the front lines of healthcare. This is particularly true in areas experiencing healthcare shortages, where pharmacists may be the only healthcare providers immediately accessible to patients.³ Pharmacists are leveraging their clinical skills and accessibility in the community to provide valuable public health services through provision of care as well as being a trusted information source to the public. Early in the COVID-19 pandemic response, state and national pharmacy organizations advocated on behalf of pharmacists and pharmacy technicians to advance emergency authorization of solutions to combat the pandemic, improve patient health outcomes, and ease the strain on the healthcare workforce and system. This advocacy resulted in numerous actions and authorities impacting our profession, which have been curated by the National Association of Boards of Pharmacy and the National Alliance of State Pharmacy Associations.^4,5

As pharmacists adopt roles that relieve stress on an already taxed healthcare system, including emerging advanced practice roles, it is important that the profession capture and communicate the impact of outcomes on patient health and healthcare efficiencies in order to improve acceptance and awareness of our professional capability and capacity. Moreover, identifying activities born of crisis whereby pharmacists can demonstrate their ability to contribute in nontraditional roles, such as through case studies/series or other primary literature, will assist continued advocacy efforts to advance pharmacy practice and the profession. In addition, emergency authorization actions are largely conducted at the state level. Therefore, we encourage pharmacy practice leaders to carefully study new authorities and flexibilities granted at local, state, and national levels; to identify which allowances lend themselves to improving patient care beyond the pandemic; and to evaluate and demonstrate the impact of expanded roles for pharmacists.

It is important to note that some provisions passed in emergency legislation will sunset when the emergency ends. As the nation continues to reopen, any previous law or regulation must be heavily scrutinized to assess if it is still needed or if a more permanent form of the law or regulation should be put in place to improve patient care and public health while reducing workflow burdens. Therefore, any temporary successes at the state and national levels would benefit from results garnered at the practice level to solidify patient care improvements and minimize practice inefficiencies permanently. For example, our profession is actively advocating for state and federal recognition of pharmacists as patient care providers. This policy initiative seeks to increase patient access to pharmacist services by reimbursing pharmacists under state Medicaid and insurance codes and laws and federally under Medicare Part B provisions of the Social Security Act. As we collectively work towards that goal, gathering evidence on the public health impact of our profession during the COVID-19 pandemic would inform and influence advocacy efforts to secure provider status.

During the current COVID-19 pandemic, the pharmacy workforce must focus on the immediate needs of patients, communities, and the healthcare workforce. However, when time and energy allow, the PAM Work Group encourages colleagues nationwide who are adopting expanded roles due to emergency authorizations to be proactive in documenting improvements to patient care and public health resulting from expanded pharmacy services. Such documentation necessarily includes identification and use of measures that demonstrate value of services. This effort could support advocacy for permanent expansion of scope of practice and drive improvements in access to care as well as quality and safety. This commentary seeks to provide a suggested framework for pharmacists to document improvements and demonstrate value during COVID-19 crisis management efforts.

The following are suggestions from the PAM Work Group regarding potential areas to identify metrics to evaluate the impact of expanded practice allowances. We recommend considerations on efficiency, safety, and quality, including access to care. This is not an exhaustive list but rather a conversation starter to encourage further dialogue about how the profession can demonstrate the impact of expanded pharmacist and pharmacy services during the COVID crisis and beyond.

Capacity/access to care. Potential COVID-19 responses to measure and evaluate in this area include:

• Expedited licensure

• Ability for pharmacist licensure programs to operate across state lines

• Remote verification of medication orders to reduce the risk of exposure/infection

• Expanded use of “tech-check-tech”

• Autoverification of orders in areas where providers are present (eg, emergency department [ED], operating rooms [pre-,intra- and post-operative areas])

• Use of home or mail delivery services to reduce exposure risk

• Telepharmacy services to reduce exposure risk

• Changes to automated dispensing cabinet requirements

• Relaxed access to rapid sequence intubation kits and critical care medications and intravenous preparations

• Pharmacist ordering and administration of COVID-19 or antibody tests and review of treatment results for appropriate triage

• Pharmacist-provided primary care services (eg, immunization)

• When possible, shifting patients to pharmacist-provided ambulatory care clinics to avoid an ED visit, such as for congestive heart failure, hypertension, diabetes, or minor infectious diseases

• Pharmacist-provided home-based care, with point-of-care testing and use of medications that require less routine monitoring (eg, direct oral anticoagulants vs warfarin)

• Pharmacist-provided services to assess and improve well-being and reduce burnout among providers, including nurses, physicians, and other healthcare staff

Medication adherence. Potential COVID-19 responses to measure and evaluate in this area include:

• Removal of specific days’ supply requirements

• Increasing refill supplies (eg, 3-month vs 1-month supply)

• Allowance of early refills

• Emergency fills for noncontrolled medications without refills or copayments for essential, life-sustaining medication

Emergency preparedness. Potential COVID-19 responses to measure and evaluate in this area include:

• Coordination of supply of medications with health authorities, such as for remdesivir

• Implementation of back-up plans when premade intravenous bags or preparations run out or are in short supply

• Investigational use of potential treatments and vaccines

• Provision of infection prevention education, including the use of masks, handwashing, and social distancing

• Optimization of use and reuse of personal protective equipment (PPE) within and outside pharmacy to preserve PPE in times of mass patient influx or PPE shortage

Medication shortages. Potential COVID-19 responses to measure and evaluate in this area include:

• Pharmacist authorization to make therapeutic interchanges and substitutions for medications in short supply

• Increased transparency and communication regarding shortages

• Extension of expiration dates for medications affected by supply shortages

• Restriction of use of medications in short supply

• Off-label use and/or prioritization of medications subject to supply shortages

Summary. Frontline pharmacists play a critical role during public health emergencies such as the COVID-19 pandemic. These emergencies provide pharmacists the opportunity to demonstrate and document improvements in efficiency, quality, and safety of care. Pharmacists can also provide access to and assist with public education, ensuring accurate understanding of safe practices and minimizing the spread of the virus. Expanded roles in times of public emergencies should be viewed as opportunities to solidify long-term changes in laws and regulations after the emergency has subsided. Using collaboration and communication with various partners, such as physicians, national organizations, and policymakers, these expanded roles—and associated metrics of improved patient care—should also be leveraged to achieve state and national reimbursement for pharmacist services and continued expansion of our role in healthcare.

Disclosures

The authors have declared no potential conflicts of interest.