ARRX - The Arkansas Pharmacist Fall 2015

FALL 2015 Award-Winning Quarterly Publication of the Arkansas Pharmacists Association

MEDICATION THERAPY MANAGEMENT: The Missing Piece of Healthcare that Could Save Americans $300 Billion

A Decade of Growth: Harding Dean Looks Back on 10 Years

APA Staff

8

21

22

28

Mark S. Riley, Pharm.D. Executive Vice President and CEO Mark@arrx.org Scott Pace, Pharm.D., J.D. Chief Operating Officer Scott@arrx.org Eric Crumbaugh, Pharm.D. Director of Clinical Programs Eric@arrx.org Jordan Foster Director of Communications Jordan@arrx.org

Celeste Reid Director of Administrative Services Celeste@arrx.org Debra Wolfe Director of Government Affairs Debra@arrx.org Office E-mail Address Support@arrx.org Publisher: Mark Riley Editor: Jordan Foster Design: Gwen Canfield - Creative Instinct Arkansas Pharmacists Association 417 South Victory Street Little Rock, AR 72201-2923 Phone 501-372-5250 Fax 501-372-0546 AR•Rx The Arkansas Pharmacist © (ISSN 0199-3763) is published quarterly by the Arkansas Pharmacists Association, Inc. It is distributed to members as a regular service paid for through allocation of membership dues ($5.00). Non-members subscription rate is $30.00 annually. Periodical rate postage paid at Little Rock, AR 72201.

Current edition issue number 73. © 2015 Arkansas Pharmacists Association.

POSTMASTER: Send address changes to AR•Rx The Arkansas Pharmacist 417 South Victory Little Rock, AR 72201 Opinions and statements made by contributors, cartoonists or columnists do not necessarily reflect the attitude of the Association, nor is it responsible for them. All advertisements placed in this publication are subject to the approval of the APA Executive Committee. Visit us on the web at www.arrx.org.

WWW.ARRX.ORG

CONTENTS

Susannah Fuquay Director of Membership & Meetings Susannah@arrx.org

4 Inside APA: Pharmacists Are Trusted

Members of Every Community

19 Harding University: Harding COP

5 From the President: Strong

Sees Success and Growth Thanks to Arkansas Pharmacy Community

Relationships Lead To Positive Change

20 UAMS: Interprofessional Education

7 Member Spotlight: Cheryl Bryant,

at UAMS

Walgreens, Little Rock, AR

21 UAMS Announcement

8 FEATURE: The Missing Piece

of Healthcare: Innovating the Profession of Pharmacy through Medication Therapy Management

22 FEATURE: A Decade of Growth:

Harding Dean Looks Back on 10 Years of Challenges and Accomplishments

11 Legislator Profile: Senator David

Sanders

24 2015 AAHP Fall Seminar

13 New Drugs: First 3D-Printed Drug

26 AAHP: AAHP Councils Provide

Approved by the FDA

Opportunity to Move Health-System Pharmacy Forward

14 Rx and The Law: Delivering the

Prescription

27 APA Consultants Academy: Threat

15 Safety Nets: Electronic Prescriptions

& Assumptions Can Be A Deadly Combination

of Antibiotic Resistance Spurs New Treatment Method

28 2015 Arkansas Pharmacists

Association District Meetings

16 Compliance Corner: Hiring and

Training to Prevent and Detect Diversion

17 Medicaid Pharmacy Update:

18 2015-2016 Calendar of Events

33 Member Classifieds 34 USPS Statement of Ownership

Medicaid Inspector General Commits to Reducing Fraud, Waste & Abuse

Cover photo: Missy Vail counsels a patient on his medication during an MTM session.

DIRECTORY OF ADVERTISERS 2 6 6 12 12

Pace Alliance Law Offices of Darren O'Quinn Retail Designs, Incorporated APA Congratulates UAMS Pharmacists Mutual

18 Pharmacy Quality Commitment 21 UAMS 35 Arkansas Pharmacy Support Group 35 EPIC Pharmacies Back Cover: APA Honors Smith Drug Company

3

2

APA Board of Directors

INSIDE APA

2015 - 2016 Officers

INSIDE APA

President - John Vinson, Pharm. D., Bryant President-Elect - Eddie Glover, P.D., Conway Vice President - Lynn Crouse, Pharm.D., Eudora Past President - Brandon Cooper, Pharm.D., Jonesboro

Area Representatives Area I (Northwest) Michael Butler, Pharm.D., Hot Springs Area II (Northeast) Brent Panneck, Pharm.D., Lake City Area III (Central) Clint Boone, Pharm.D., Little Rock Area IV (Southwest/Southeast) Dean Watts, P.D., DeWitt

District Presidents District 1 - Denise Clayton, P.D., Mayflower District 2 - Max Caldwell, P.D., Wynne District 3 - Chris Allbritton, Pharm. D., Springdale District 4 - Betsy Tuberville, Pharm. D., Camden District 5 - James Bethea, Pharm. D., Stuttgart District 6 - Stephen Carroll, Pharm. D., Arkadelphia District 7 - C.A. Kuykendall, P.D., Ozark District 8 - Darla York, P.D., Salem Academy of Consultant Pharmacists Anthony Hughes, P.D., Little Rock Academy of Compounding Pharmacists Lee Shinabery, Pharm.D., Jonesboro Arkansas Association of Health-System Pharmacists Rob Christian, Pharm.D., Little Rock

Ex-Officio APA Executive Vice President & CEO Mark Riley, Pharm.D., Little Rock Board of Health Member Gary Bass, Pharm.D., Little Rock AR State Board of Pharmacy Representative John Kirtley, Pharm.D., Little Rock UAMS College of Pharmacy Representative (Dean) Keith Olsen, Pharm.D., Little Rock

Harding College of Pharmacy Representative (Dean) Julie Hixson-Wallace, Pharm.D., Searcy Legal Counsel Harold Simpson, J.D., Little Rock Treasurer Richard Hanry, P.D., El Dorado UAMS COP Student Elisabeth Mathews, Little Rock Harding COP Student Meredith Mitchell, Searcy

4

Find the APA on Facebook, or visit our website at www.arrx.org

Mark Riley, Pharm.D. Executive Vice President & CEO

Pharmacists Are Trusted Members of Every Community

A

s we traveled around for District Meetings this fall, President John Vinson and I had the opportunity to have multiple personal conversations with pharmacists across the state.

While the conversations were not totally focused on the negative, there certainly is good reason for frustration and a lack of clarity about many issues that we face. It has occurred to me that one of the main problems with troubling situations is that it robs us of the excitement and joy of what is good and rewarding about what we do every day; maybe even making us forget why we do what we do and how important it is to not only us but those around us that are affected by our actions.

One of the advantages of “getting old” is that a myriad of life experiences helps to keep a perspective about the whole of our lives, both opportunities and challenges, successes and failures.

We should never forget the positive effect we have on patients' lives and the trusted role we play every day in our practices, both in community and institutional settings. Remembering your purpose in what you do helps to avoid dwelling on the negative and can ultimately prevent “giving up and throwing in the towel.” A personal story that I draw on occurred when I was the local baseball commissioner in East End. One night at the park, I was taking a pretty good verbal lashing from an uninformed mom about how the ballpark was being run. I stayed calm and answered all of her questions and concerns and was able to explain the thought processes and reasons for our decisions and actions and the

conversation ended pleasantly with an apology from her and an offer to help. A friend nearby had heard the exchange and walked over and said, “Why in the world do you do this?” My answer was that around three hundred kids in the East End area were being provided something positive to do and were not getting into trouble that night.

I am sure that most of you are involved in activities for the same reason.

We should never forget the positive effect we have on patients' lives and the trusted role we play every day in our practices, both in community and institutional settings. Remembering your purpose in what you do helps to avoid dwelling on the negative and can ultimately prevent “giving up and throwing in the towel.”

Pharmacists are one of the most highly trusted healthcare professionals for a reason – they listen to and take care of their patients. When I was working in my store, I was initially amazed at and ultimately came to accept the confidence my patrons put in me.

My advice was sought for about any subject you can think of - from what kind of car should I buy to where can I find out how to repair something (of course, this was before the ubiquity of the internet). The point is that a lot of

AR•Rx

|

THE ARKANSAS PHARMACIST

FROM THE PRESIDENT

people depend on you both professionally and personally. It is important to not lose sight of that because it can motivate us to stay the course.

the pharmacists of Arkansas for your immense professional knowledge and sense of community. Hang in there; Arkansas needs you. §

For the “umpteenth” time – change is inevitable and creates both challenges AND opportunities. I have confidence in

FROM THE PRESIDENT

Strong Relationships Lead to Positive Change

F

or Arkansas pharmacists to succeed in the Triple AIM, we must invest in building and maintaining healthy relationships. Research has demonstrated that strong personal relationships can make people happier, improve health outcomes, and improve brain connectivity. Strong relationships are not just something we want but are also something we need both individually and as a profession.

As I reflect on traveling and conducting the 11 Arkansas Pharmacists Association District Meetings, I realize that we accomplish 3 main objectives: 1. Continuing Pharmacy Education (CPE) and dissemination of professional information 2. Sharing ideas for our profession 3. Strengthening relationships between pharmacists, student pharmacists, legislators, the Arkansas Pharmacists Association leadership and staff, the Arkansas State Board of Pharmacy leadership, UAMS College of Pharmacy leadership, Harding College of Pharmacy leadership, pharmacy wholesalers, and other friends and supporters of pharmacy in Arkansas.

These accomplishments at District Meetings are powerful not just for the short term but also for long term success in Arkansas pharmacy practice. I mentioned the 3rd accomplishment above in my Presidential address during district meetings. We are unique in Arkansas to have a history of working well with all of these key organizations and individual pharmacists present at the district meetings.

In addition, APA staff, APA pharmacists and APA student pharmacists have been extraordinary with strengthening relationships with political decision makers at the state and national level.

Most Arkansas pharmacists are familiar with CEO and Executive Director Mark Riley’s exceptional relationship skills. Mark has spent the last 13 years leading the APA with a key emphasis on strengthening relationships. Mark and

I also announced during District Meetings that Mark is going to John Vinson, Pharm.D. retire within the next year and that President succession planning is underway for the Association. The next CEO will need to build on the foundation that Mark has built in relationships in order to have a profound impact on the Triple AIM healthcare outcomes in Arkansas. In addition, we must not forget that relationship building is not automatic and it involves a significant investment of time and energy by much more than the CEO and staff at APA. We also need to think outside of the box and extend our grassroots efforts far beyond the political arena. It requires each of us doing our part to tell our story to those who will listen.

Research has demonstrated that strong personal relationships can make people happier, improve health outcomes, and improve brain connectivity. Strong relationships are not just something we want but are also something we need both individually and as a profession.

Dr. Jeremy Thomas, friend and pharmacy colleague, sent me an interesting story to tell published in the October 1st, 2015 American Journal of Health Systems Pharmacy.1 The article talks about successful integration of pharmacists into 6 patient centered medical homes in Rhode Island. Only 6 months into 2015, they have already tracked $2.1 million in savings from pharmacist interventions. These primary care practices with use of the pharmacists have also been able to improve their Medicare Star Ratings performance and increase the likelihood for bonus payments. Two of the most important keys to success stated by Beth Herbert-Silvia, assistant vice president of pharmacy for Blue Cross & Blue Shield of Rhode Island, were: (Continued)

WWW.ARRX.ORG

5

FROM THE PRESIDENT

1. High percentages of patient engagement with the pharmacists - strong patient-pharmacist relationships 2. Forming collaborative relationships and establishing trust with primary care providers – strong pharmacist-provider-primary care team relationships Arkansas pharmacists are well positioned to accomplish great things in the future because of strong relationships. We are united and have meaningful and collaborative discussions as the norm in Arkansas regardless of pharmacy practice.

These norms are not the norm in most states. These strong Arkansas pharmacy bonds are both unique and special. § 1 Thompson CA. Onsite pharmacist program in medical homes

declared a success. American Journal of Health Systems Pharmacy. Vol. 72 pp. 1596-1597

6

AR•Rx

|

THE ARKANSAS PHARMACIST

MEMBER SPOTLIGHT

Cheryl Bryant, Pharm.D. Healthcare Supervisor Walgreens - Little Rock

Pharmacy/Academic Practice: Chain Retail, Walgreens Co.

Oddest request from a patient/customer: My most unique

preceptor for 9 years

request from a patient was in Honduras while on mission trip.

In a small village, I was there early with a team to prepare for the clinics coming in the next week. One of the local patients, who was seen each year in the clinic, wanted to thank us in advance by preparing dinner for the team. It was my first meal ever eaten from a clay oven‌ priceless.

Favorite part of the job: What I love most about my job is

Recent Reads: Steve Jobs: A Biography by Walter Isaacson

Pharmacy School & Year: University of Arkansas for Medical Sciences College of Pharmacy, Class of 2004

Years in business/teaching: Pharmacist for 11 years, and

impacting and improving the lives of patients living in the communities we serve. As a Walgreens Healthcare Supervisor I am surrounded by great leaders from all walks of life. Having this exposure and the relationships it fosters allows me to make a difference in the lives of patients in a manner I would not be able to do alone.

Least favorite part of the job: The most challenging part of my job is finding innovative ways to expand healthcare access into rural areas of Arkansas.

What do you think will be the biggest challenges for pharmacists in the next 5 years? Currently the industry

of pharmacy is changing at a rapid pace. Reimbursements for traditional services are becoming more challenging with each day. Knowing this, I believe the biggest opportunity in the next 5 years is changing the way we traditionally practice pharmacy and being open to new concepts and ideas.

WWW.ARRX.ORG

and Dylan Baker, Executive Presence by Harrison Monarth

Fun Activities: Volleyball, kickball, surfing, and spending time with family and friends

Ideal Dinner Guests: Isaac Newton, Langston Hughes, and

Beethoven

Tell me a little about your new role on the Board of Pharmacy: I am honored to have been appointed to the

Arkansas State Board of Pharmacy. My goal while serving the state is to protect the health, safety, and welfare of the public. I will work together with other board members to ensure the regulations we initiate protect both patients and the profession of pharmacy. §

7

THE MISSING PIECE OF HEALTHCARE:

Innovating the Profession of Pharmacy through Medication Therapy Management

By Jordan Foster

“

If a plane carrying 342 people crashed every day in the United States, what would we do? We would probably change all kinds of rules, and surely we would not fly until the problems were fixed.

In the United States, 342 people die every day because of nonadherence to their medications.

As pharmacists, what we are currently doing to help prevent this consequence of nonadherence is not enough.

- Denise Clayton

88

”

AR•Rx

|

THE ARKANSAS PHARMACIST

MEDICATION THERAPY MANAGEMENT

A

rmed with sobering statistics and a passion to revolutionize the pharmacist/patient relationship, pharmacist Denise Clayton has a clear message for her colleagues: Medication Therapy Management (MTM) can no longer be seen as an option. In order to save thousands of lives each year, it is a necessity. According to a study done by The New England Healthcare Institute, there is a $290 billion healthcare burden in the United States of avoidable healthcare cost due to medication-related problems. This is equivalent to almost $2 spent on adverse effects for every $1 spent on obtaining the medications.

“Medication Therapy Management is different from what we are currently doing. MTM is beyond counseling, it’s really about going further for the patient and performing a comprehensive medication review with them to make sure they understand how to take all of their medications and what conditions their medications are being used to treat. We should also find out if they are having any medication-related problems that we can help solve. A targeted medication review that focuses on a specific problem that could be due to a medication is another example of an MTM intervention.”

According to a study done by The New England Healthcare Institute, there is a $290 billion burden in the United States of avoidable healthcare cost due to medicationrelated problems.

Breaking Through the Barriers

Before establishing an MTM program, Denise says that pharmacists need to know that the barriers that come with MTM are not insurmountable and, for many pharmacists, will sound familiar. “Years ago, we dealt with the barriers of giving immunizations. Many pharmacists said, ‘I don’t know how to give shots; I don’t have a room to do immunizations in my pharmacy; who is going to pay me to do it; I don’t have time; my employer is not going to let me do it.’ Then you look at MTM, there are some of the same hurdles. Today, most pharmacies provide immunizations. It’s a patient care service that they want to offer their patients. I like to make that comparison because when I frame it up in that way, a lot of pharmacists can relate to the barriers that they have been able to overcome.”

Finding time to provide MTM services by figuring out how to change the work flow is the first big barrier that pharmacists will face in establishing an MTM program in their pharmacies.

That’s when pharmacists should utilize the team around them.

“When I talk to pharmacists I try to set the stage for how they can make it work - how they can use clerks, technicians and students to do some of the non-clinical tasks that go along with MTM. They can do things like reconcile the patient’s medications over the phone and set up MTM appointments for patients. This all saves time for the pharmacist.” Denise also points out that, looking beyond your pharmacy, there are pharmacists that you can hire specifically to manage your MTM program. Some pharmacies have even experimented with closing an hour during the day to take MTM appointments.

Creating a Business Model

Moving forward with a viable MTM business model means

WWW.ARRX.ORG

determining how to present it to your patients. “If you want patients to view MTM as a different service and an enhancement for them, you have to provide the service in a different place from basic counseling. You shouldn’t provide MTM services while standing at the pharmacy counter. It is also important to tell the patient what you’re doing for them so that they see the value in what they’re getting. This is especially true for someone whose insurance doesn’t pay for MTM services, and they are paying out of their pocket. Let your patients know that at the MTM appointment you will be sitting down with them for 30-45 minutes to go over all their medications and answer any questions that they may have about them. Let them know that before they come to their appointment, you may need to call their doctor to obtain their most recent lab work, to ensure they are meeting their goals. You can also tell them that you will be reviewing their drug regimen for safety issues, drug interactions, duplications of therapy, and gaps in care. Inform the patient that after they leave the MTM visit, you will follow up with their doctor to provide the information you have discussed and any recommendations that have come from your discussion."

Marketing and vernacular are also incredibly important when expressing the value of MTM. “We get a much higher patient participation rate when we talk to them about a 'medication check-up' with their pharmacist. Patients go to a doctor for a check-up yearly, and should go to their pharmacist for a yearly medication check-up to make sure they are not having any medication problems. Setting up MTM this way will help pharmacists to be more successful at getting patients to participate than saying, ‘your insurance company wants you

9

MEDICATION THERAPY MANAGEMENT

to come in and talk to me about your medication.’ For best results, simply frame it as a benefit to the patient.”

Face-to-Face with Your Patient

Once you have the patient in front of you, it’s crucial to find out what his/her goals are through the use of motivational interviewing. Asking open-ended questions to get a dialogue started, such as “What are some issues you’ve been having day to day that you want to better manage?” or “Tell me what you learned about your inhaler today that you didn’t know before you came in.” According to Denise, “it’s not about what you think the patient should do, it’s about where the patient is in their world, what’s important to them and how can we assist them in achieving better results from their healthcare.

“If it’s already been established that there’s a problem, you can ask, ‘I see that you’re not being adherent with this medication.

Is there a problem going on with that medication? Is there something we could do to help you become more adherent?’

Focusing on the patient’s needs and personal goals should lead to better healthcare results for the patient. It will also develop a patient who is more loyal to the pharmacy and the pharmacist who listened.”

and consider the big picture; it isn’t about the fee you receive for working an MTM case, rather the improved patient care and loyalty you generated by providing this patient care service.”

MTM Certificate Training Program

The Arkansas Pharmacists Association has purchased the license for the APhA MTM certificate training program to assist pharmacists in starting an MTM program of their own. Denise says this training program can be invaluable to a pharmacist that is interested in MTM but doesn’t know where to start. “The APhA MTM certificate training program is great for pharmacists who are unsure about what MTM is, how to provide it, and where to start. Going through the modules of the self-study and then the 8-hour live training, will give the pharmacists a lot of information about how to provide MTM services for patients.”

Unforeseen Consequences and Benefits

First and foremost, MTM is about taking care of patients and putting their needs first, but it’s important to realize that when these cases sit in the queue and they expire, that is lost revenue for pharmacists. “Someone is going to work those cases; they’re going to be reassigned to a call center. You lose the opportunity to take care of your patient and to make sure that your patient is getting the best care possible. You also lose the revenue from the MTM case, as well as possible future business from that patient.

“At RxResults, for our commercial clients we pay pharmacists $70 for the initial comprehensive medication review and then we pay $40 each for up to three follow up reviews in a year. In addition, for most patients there are opportunities to provide needed immunizations when you’re doing MTM (especially those with Medicare Part D). There are also opportunities for some over–the-counter or non-medical products that the patient may need. If you’re improving adherence, you’re filling an average of three additional prescriptions a year. If you’re filling a gap in care, that will result in additional prescriptions as well. What else happens when people are in your pharmacy?

They will look at and buy your front end inventory.”

MTM is an important step in providing good care for your patients. Those patients become more loyal; they tell their friends what a good pharmacist you are, generating positive feedback in your market. Soon that $70 you’re getting for a comprehensive medication review turns into $400-$500 a year when you’re taking care of that patient and providing MTM services (plus possibly growing your customer base by adding some of their friends and neighbors). Take a moment

10

“I was so pleased about our first live APhA MTM certificate training program in July. Pharmacists were able to talk, network and share knowledge about what’s going on with MTM in their pharmacy setting. I think it gave the pharmacists more confidence in themselves to know that they’re not the only ones struggling to try and figure out how to set up an MTM program.

When you sit in a room full of like-minded people, you have someone who you can go back to and ask questions or follow up with on certain things as they arise.”

“I think pharmacists sometimes are disconnected from the big picture and the big picture is that we have this huge problem nationwide. If we can teach someone how to use their inhaler; help them understand how to treat their asthma or their diabetes or their hypertension; if we can sit down and talk with them and have an action plan to help them stay out of the hospital we are helping to chip away at that $290 billion healthcare burden. It’s not for nurses to do, it’s not for doctors to do. We are the pharmacists, it’s our profession, and we are the medication experts who should be providing Medication Therapy Management to our patients.” §

AR•Rx

|

THE ARKANSAS PHARMACIST

LEGISLATOR PROFILE

Senator David Sanders DISTRICT 15 - Conway, Faulkner, Perry & Van Buren Counties

Years in Office: Five (two years in the House and three in the Senate)

Occupation: Director of Institutional Advancement with the Baptist Preparatory School

Your hometown pharmacist: Ray Turnage, Market Place

Pharmacy

What do you like most about being a legislator? I enjoy

the work — hammering out solutions to flummoxing policy questions and working toward consensus on a difficult issue all of which can be mentally and physically taxing at times, but it’s absolutely worth it. We’ve been given an enormous privilege to serve and we have an obligation to pour our time and a focus into the job.

Advice for pharmacists about the political process and working with the AR Legislature: Always come to the

table with real innovation. Yes, your world is changing and is impacted by outside forces that are challenging your traditional business model. Move forward boldly. There is such value in the patient/pharmacist relationship.

Your fantasy political gathering would include: Dinner with all 15 Republican presidential candidates at the same time — four hours and I would set the ground rules for the table discussion.

Toughest issue of the past session: We worked hard and were

not to focus on the negative.

successful at passing the Arkansas Healthcare Transparency Initiative Act 1233. There were many traditional players in the health care space that initially had a visceral response to the bill and fought it. The fact is if we do not transform 21st century health care into informed, consumer-driven enterprise focused on value and quality, then we all lose.

Most admired politician: Edmund Burke, 18th Century

What do you do for fun? I spend time with my five

What do you like least about being a legislator? I try to

Member of Parliament in the British House of Commons.

Burke was a gifted politician, masterful author and brilliant political theorist who was blessed with a keen intellect and vast repositories of courage that enabled him to challenge his opponents with certitude, moral clarity and strength.

WWW.ARRX.ORG

exceptional children: one daughter and four sons. §

11

12

AR•Rx

|

THE ARKANSAS PHARMACIST

First 3D-Printed Drug Approved by the FDA

T

he FDA has approved several new molecular entities/ biologics and dosage forms since our last column, with notable firsts including the 3D-printed tablet.

or ribavirin. Quadracel® is a new combination vaccine for immunization against diphtheria, tetanus, pertussis, and poliomyelitis.

3D Drug Printing Technology: Medical device manufacturers

Oncology: Odomzo® (sonidegib) is a hedgehog pathway

have used 3D printing to develop items ranging from bone prosthetics to artificial organs, and now it has made its way into drug development. Spritam® (levetiracetam) is the first approved drug to be manufactured using this technology.

The product looks like a regular tablet but the ZipDose® delivery system can achieve high doses up to 1,000 mg while maintaining rapid disintegration. Children, elderly, and other patients with swallowing difficulties will appreciate these easy to administer tablets that quickly dissolve in as little as 4 seconds with a single sip of water.

Cardiovascular: Praluent® (alirocumab) and Repatha™

(evolocumab) are first in a new class of cholesterol-lowering antibodies called proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors. These agents serve as adjunct to maximally tolerated statin therapy in adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease who require additional lowering of LDL-cholesterol.

Neither drug is approved for use in statin intolerant patients.

Entresto™ (sacubitril/valsartan), a combination neprilysin inhibitor and angiotensin receptor blocker, received fast track designation and priority review as a treatment shown to reduce cardiovascular death and hospitalization related to heart failure. Kengreal™ (cangrelor) is an IV antiplatelet used to reduce the risks of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis in patients undergoing percutaneous coronary intervention.

Central Nervous System: Addyi™ (flibanserin), originally

developed as an antidepressant, is the first approved treatment for acquired hypoactive sexual desire disorder in premenopausal women. The FDA previously denied approval based on safety concerns, but this time was approved with a black box warning for hypotension and syncope in patients using alcohol, with hepatic impairment, or taking CYP3A4 inhibitors. Because of these potentially serious adverse events, Addyi™ is only available through a REMS program. Rexulti® (brexpiprazole), an atypical antipsychotic, was approved for schizophrenia or as add-on to antidepressant therapy for adults with major depressive disorder.

inhibitor approved to treat adults with locally advanced basal cell carcinoma that has recurred following surgery or radiation therapy, or who are not candidates for surgery or radiation therapy. Odomzo® carries a boxed warning of death or severe birth defects in a developing fetus when administered to a pregnant woman. Varubi™ (rolapitant) was approved to prevent delayed phase chemotherapy-induced nausea and vomiting and can be used in combination with other antiemetics.

Specialty Products: Orkambi™ (lumacaftor/ivacaftor) is a

first-in-class combination product approved to treat cystic fibrosis (CF). Orkambi™ received priority review and orphan drug status as the first drug directed at treating the cause of CF in people who have two copies of the F508del mutation (one inherited from each parent), the leading cause of CF. Xuriden™ (uridine triacetate) is the first approved treatment for hereditary orotic aciduria, a rare metabolic disorder reported in approximately 20 patients worldwide. Xuriden™ was approved on the basis of a single-arm, open-label trial in 4 patients.

New Dosage Forms: Significant new dosage forms that have

been approved include: Invega Trinza™ (paliperidone, injection) a 3-month, long-acting atypical antipsychotic; Keveyis™ (dichlorphenamide, tablet) for primary hyperkalemic periodic paralysis; Envarsus® XR (tacrolimus, extended-release tablet) to prevent organ rejection in kidney transplant; and Synjardy® (empagliflozin/metformin, tablet) for type 2 diabetes. § Contributing Authors: Shunika Bryant and Floyd Moon, Pharm.D. Candidates

Harding University College of Pharmacy

Infectious Diseases: Daklinza™ (daclatasvir) received priority review for use in combination with sofosbuvir to treat hepatitis C virus (HCV) genotype 3 infections. Daklinza™ is the first drug to demonstrate safety and efficacy for this type of HCV infection without the need for concomitant interferon

WWW.ARRX.ORG

13

DeliveringConduct The Prescription Wrongful Rule This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and the Arkansas Pharmacists Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

A

lot has been written about quality processes in the dispensing function and many good ideas are out there; the Two Dosage Unit rule, shelf talkers, NDC checks, etc.

But one thing that isn’t often talked about is getting the right prescription to the right patient. All of the safety and quality processes go for naught if the prescription is given to the incorrect patient. Consider these two examples.

Tom Smith comes into Anytown Pharmacy to pick up his wife’s prescription. In the will-call bin with her prescription was also one for Ron Smith. The technician thought Tom had said Ron and assumed that the second prescription was his.

She gave Tom both prescriptions. The error was discovered when Tom returned home. Paul was making a delivery for City Pharmacy one afternoon and pulled into a driveway shared by 101 and 103 Main Street. Mary was standing in the driveway. “You got here just in time; I’m headed out for my doctor’s appointment.”

Paul ignored his normal protocol at the insistence of the patient. He gave the prescriptions to Mary who left for her appointment. Paul discovered later that the prescriptions were for a patient who lived at 103, but Mary lived at 101.

Many times pharmacists don’t think about the actual hand-off to patients. They would be surprised to learn what happens at the delivery point. For example; patients step forward when someone else’s name is called, patients or staff hear names incorrectly, patients with the same or similar names appear at the pharmacy at the same time, or patients in the same extended family with the same name utilize the same pharmacy. Unfortunately, claims history tells us that these patients are very likely to take the medications that they go home with or get delivered to them. This occurs even when their name isn’t on the label, they have never heard of the drug, or their own doctor’s name is not on the prescription.

Also unfortunately, juries are less inclined to place blame on the patient for these sorts of mishaps. Fair or not, the responsibility falls on the pharmacy to get the right medication to the right patient. A number of solutions are available.

patient counseling is not always needed or required, so we need other tools. Asking the patient to produce identification and requiring the staff to review prior to handing over the medications is one method. Others have asked the patient for a second identifier to differentiate patients with similar names; address, phone number or social security number.

This has to be done as discreetly as possible to protect the patient’s privacy. It is also helpful to ask additional questions of persons picking up others’ prescriptions; what is their relationship to the patient or ask some of the secondary identifiers above. Delivery drivers should never deviate from their protocols and should verify the address and identity of the patient when delivering medications. Date, time and to whom the medications were delivered should all be documented.

Most of the time, delivery to the patient is not a problem, so little attention is paid to it. But, ignoring this step of the dispensing process creates a weak point in the pharmacy’s overall quality initiative. History shows us that patients will take whatever medication is given to them, even when it makes no rational sense to do so. It is essential that this final step in the dispensing process gets the same attention as other steps in the process. Once the medication is in the wrong hands, it is impossible to predict the outcome. § ________________________________________________________________ © Don R. McGuire Jr., R.Ph., J.D., is General Counsel, Senior Vice President, Risk Management & Compliance at Pharmacists Mutual Insurance Company.

This article discusses general principles of law and risk management.

It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with policies and procedures of their employers and insurance companies, and act accordingly.

Previous articles have extolled the value, to both the patient and the pharmacist, of patient counseling. This article won’t repeat all of those benefits, but patient counseling is an effective tool to discover errors at the time of delivery. But

14

AR•Rx

|

THE ARKANSAS PHARMACIST

UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES COLLEGE OF PHARMACY

Electronic Prescriptions & Assumptions Can Be A Deadly Combination Welcome to another issue of Safety Nets. This issue of Safety Nets highlights the potential hazards associated with E-prescriptions. Thank you for your continued support of this column.

T

he electronic prescription illustrated in Figure One was transmitted from a physician assistant's office to an independent community pharmacy in Central Arkansas.

The pharmacist who examined the prescription noticed the valacyclovir order contained two patient sigs. One sig. instructed the patient to "take one tablet every 12 hours for 30 days," while the other instructed the patient to "take one tablet daily for 10 days then take one tablet daily thereafter." The Figure One pharmacist immediately called the prescriber's office for clarification.

The pharmacist was surprised when the prescribing physician assistant answered the telephone.

After explaining the problem, the physician assistant responded by saying: (NOTE TO READERS: the following is not paraphrased or exaggerated in any way - it Figure Two is exactly what the physician assistant said to the pharmacist.)

"I never really learned how to use the e-scribe thing. I just put in a bunch of stuff and hope it comes out right. I really just rely on the pharmacist to call me to make sure the drug and directions are right." The physician assistant then told the pharmacist that the patient was to take one tablet twice daily for ten days, then one tablet daily for 20 days (30 days total therapy). After this, the valacyclovir prescription was correctly filled and placed in the will-call bin for patient pickup.

Electronic prescriptions are now commonplace in healthcare.

While not guaranteed to be error-free, they may have certain advantages over handwritten prescriptions particularly by promoting legibility and by reducing mix-ups between medications with names that look and/or sound alike (i.e.

Lamisil and Lamictal). These advantages, however, are of little importance when any individual fails to exercise diligence in using E-prescription software. The shocking attitude expressed by the prescriber in this case is completely unacceptable. That attitude is a first step onto the slippery slope in increased risk for liability.

Even though the prescriber alone is responsible for the cavalier attitude, the prescriber wrongly increases the pharmacist's chance of involvement in an error. Most importantly, this sort of attitude places patients at extreme risk. "Putting in a bunch of stuff and relying on the pharmacist" is lazy, unprofessional,

WWW.ARRX.ORG

and dangerous. If this prescriber is unwilling to take the time necessary to learn how to correctly use software, they should immediately stop using the system and handwrite, or telephone, every prescription to the pharmacy.

A patient presented the prescription illustrated in Figure Two to a pharmacy technician employed by a chain pharmacy in South Arkansas. The technician entered the prescription information into the computer as "ketorolac 10 mg tablets, quantity 100", with directions to the patient of "take one tablet, by mouth, every six hours as needed for pain". The pharmacist verifying the technician's input accuracy immediately noticed the large ketorolac quantity. The pharmacist immediately telephoned the prescriber's office and explained to a nurse the prescribed quantity was not in accordance with ketorolac labeling guidelines. The nurse consulted with the prescriber and instructed the pharmacist to change the ketorolac quantity to 20 tablets. After this, the prescription was correctly filled and the patient appropriately counseled.

This prescription serves as a reminder to all Arkansas pharmacists. Ketorolac labeling states: • ketorolac is indicated for short-term treatment of moderately severe acute pain requiring analgesia at the opioid level; • oral ketorolac is only indicated as continuation treatment following parenteral ketorolac administration; • the combined use of oral and parenteral ketorolac should not exceed five days.

The pharmacist in this case is to be commended. Our colleague took the time necessary to treat this prescription as a unique entity for a unique patient. The pharmacist also displayed the initiative sufficient to ensure the patient received proper - not excessive - treatment for severe acute pain. If the pharmacist had been working in a robotic fashion and filled the order as written, the patient could have been seriously harmed. We may also reflect that had the patients stopped taking ketotolac after five days, 80 tablets of a potentially harmful analgesic would have remained in a medicine cabinet somewhere. We would need less "Take-Back" programs if every medication handler displayed this pharmacist's concern. §

15

Hiring andWrongful Training to Conduct Prevent andRule Detect Diversion

I

n the previous two installments of this series on preventing and detecting the diversion of controlled drugs from your pharmacy, we focused on physical site security measures (Spring issue) and policies for ordering, receiving and tracking controlled drugs (Summer issue). Now we turn to tips on how to hire and train the people you must rely on to implement your security and policies—your employees.

First, your hiring practices are crucial to the success of your anti-diversion efforts. Many pharmacists don’t realize that an applicant can have an unrestricted license or registration from the Board of Pharmacy but still have issues or problems in their past that you—the prospective employer—may want to know about before hiring them. Under Arkansas law, no type of criminal history totally disqualifies a person from licensure—even a convicted drug felon may hold a license under some circumstances.

Many pharmacists don’t realize that an applicant can have an unrestricted license or registration from the Board of Pharmacy but still have issues or problems in their past that you—the prospective employer—may want to know about before hiring them.

Prospective employees may also have a history of substance abuse that could impact their ability to perform their job duties.

Many professionals in recovery are excellent employees but you should be aware of significant issues such as this before you bring them into your pharmacy. I also suggest that you require applicants to take a drug test before they can be offered a position.

Recommended Hiring Policies:

• Criminal background checks for every applicant before an interview. I recommend including a form giving you written consent with your application.

• Pre-employment drug testing. Many locations across the state can conduct urine screening in less than 24 hours. Do not give the prospective employee more than a few hours notice of the testing.

• License history check. A quick phone call to the Board of Pharmacy for a license or registration history on an applicant is time well spent.

16

Second, you must provide the appropriate training for the great employees you’ve hired. Although many pharmacists and other staff have learned through experience, you can’t depend on them coming to you with the right kind of knowledge to protect you from diversion. Providing— and documenting—training for your employees will also demonstrate to the Board and the DEA that you have taken all possible steps to prevent and detect diversion, whether through employee theft, robbery or fraud.

Recommended Training for All Employees:

• Training to recognize signs of impairment in customers and other employees • Training to recognize signs of diversion by employees • Training on how to recognize fraudulent prescriptions, including a fraud checklist at each register • Training on how to handle a robbery/burglary • Training on how to anonymously report suspected impairment, diversion or fraud to the permit holder/PIC • Training and clear policies on all controlled drug procedures • Clear training/policies on when to contact prescribers and who is authorized to do so • Clear training/policies on when to refuse to dispense a prescription and when to contact law enforcement • Policies requiring photo ID, verification of address or other methods to ensure identity of person picking up a controlled drug prescription

In the next installment of this series, we will examine case studies from real-life diversions to illustrate how putting these tips into practice would have prevented a lot of heartache for permit holders and PICs. § _____________________________________________________ About the author: Erika Gee represents clients in government relations, regulatory and compliance matters at Wright, Lindsey & Jennings LLP. She previously served as general counsel to the Arkansas State Board of Pharmacy for 6-1/2 years and as Chief of Staff and Chief Deputy Attorney General for Attorney General Dustin McDaniel. She uses her experience as general counsel for state agencies and licensing boards to assist clients to resolve regulatory and disciplinary disputes with state government.

AR•Rx

|

THE ARKANSAS PHARMACIST

Medicaid InspectorWrongful General Commits to Reducing Conduct RuleFraud, Waste & Abuse

G

overnor Asa Hutchinson appointed Elizabeth Smith as the state’s next Medicaid Inspector General. Smith has practiced law for more than 20 years, including more than 15 years combined as a prosecutor and then as associate general counsel for the University of Arkansas Medical Sciences.

Self-Reporting

Fraud, waste, and abuse reduction within the Arkansas Medicaid system is a major priority of the Office of Medicaid Inspector General (OMIG). One way to enhance this process is by partnering with providers through self-disclosure.

Periodically providers will notice improper payments. In these situations, self-reporting of such errors is beneficial to both OMIG and the provider. If improper payments are discovered by a provider and reported, OMIG may extend the following benefits to providers who initiate a good-faith self-disclosure1: • Extended repayment terms • Waiver of penalties or sanctions • Allowance for probe sample sizes that are less rigorous than the standards employed by the OIG • Timely resolution of the overpayment • Recognition of the effectiveness of the provider's compliance program and a decrease in the likelihood of imposition of an OMIG Corrective Action Plan with additional required reviews In addition to the benefits listed, this partnership may also lead to a more thorough understanding of the OMIG’s audit process, which could benefit the provider in the future.

Should you discover an improper payment, please submit a written disclosure to: Office of the Medicaid Inspector General 123 Center Street, Ste 1200 Little Rock, AR 72201

Reporting Fraud of Others

In addition to self-reporting, reporting the fraud of others is an important step in minimizing fraud, waste, and abuse in the Arkansas Medicaid System. Unreported Medicaid fraud, waste, and abuse can cost the taxpayers of Arkansas millions of dollars each year. Every Medicaid dollar that is used inappropriately is one less dollar that can be used to help Medicaid recipients in need. If you suspect or have

WWW.ARRX.ORG

knowledge of pharmacy fraud, waste or abuse, please contact OMIG via phone (855) 527-6644 or online: http:// omig.arkansas.gov/fraud-form/. §

PHARMACY BILLING IMPROVEMENTS -

Common Billing Errors At this time, our office has reviewed thousands of pharmacy claims. Below are some of the most commonly identified billing errors as well as helpful tips on how to prevent such billing errors from occurring in the future.

1. Incorrect Day Supply – Pay special attention to how the

day(s) supply is calculated and submitted for billing.

Utilize calculators at prescription entry station(s). Explain to all staff the importance of correct billing. Check your work – make sure that the pharmacist who is checking the prescription prior to dispensing is checking and correcting day(s) supply errors.

2. Incorrect Quantity – Make sure that all drug kits are converted correctly (especially after a software update). Ensure that all prescriptions contain a complete quantity. Instruct staff to contact the prescriber if there is more than one package size available. Check your work – make sure that the pharmacist who is checking the prescription prior to dispensing is verifying that the quantity being dispensed matches the directions on the prescription.

3. Incomplete Directions – Pay special attention to prescriptions that lack specific, calculable directions and require additional clarification prior to dispensing. Contact the prescriber to clarify “take as directed” directions. Ensure that sliding scale insulin directions contain a maximum number of units to be used per day.

4. Incorrect Written Date – This date must be correct when billing Arkansas Medicaid because prescriptions are only payable by Arkansas Medicaid for 6 months from the written date on the prescription. Check your work–make sure that the pharmacist who is checking the prescription prior to dispensing is checking and correcting written date errors.

1 OMIG, Self-Disclosure Protocol 2013 About the author: Summer Moody, PharmD, JD, represents the Office of the Medicaid Inspector General (OMIG) as the Director of Pharmacy Audits on behalf of Optum Program Integrity and SCIO Health Analytics. Dr. Moody uses her experience as both an attorney (10 years) and pharmacist (13 years) to conduct Arkansas Medicaid Pharmacy Audits on behalf of the OMIG.

17

2015-2016 Calendar of Events 2015

2016

DECEMBER

FEBRUARY

APRIL

December 6-10 American Society of HealthSystem Pharmacists Midyear Clinical Meeting and Exhibition New Orleans, LA

February 24-27 International Academy of Compounding Pharmacists Educational Conference San Diego, CA

April 7* Arkansas Pharmacy Foundation Golf Tournament Location TBD

February 26 CPE at the Races Oaklawn Park Hot Springs, AR

MAY

December 5-6 APA Committee Forum and Board Meeting Little Rock Marriott (Formally Peabody Hotel) Little Rock, AR

Dates TBD National Community Pharmacists Association Legislative Conference Washington, D.C.

MARCH March 4-7 American Pharmacists Association Annual Meeting & Exposition Baltimore, MD

JUNE June 23-25 APA 133nd Annual Convention Hot Springs Convention Center/ Embassy Suites Hot Springs, AR

March 13 APA Board Meeting Hosto Center Little Rock, AR

18

*Dates have not been finalized.

AR•Rx

|

THE ARKANSAS PHARMACIST

HARDING UNIVERSITY REPORT

APA HOSTS LEGISLATIVE DAY JANUARY 28

Harding COP Sees Success and Growth Thanks to Arkansas Pharmacy Community Julie Hixon-Wallace Pharm.D., BCPS Dean

I

t is hard to believe, but Harding University College of Pharmacy has just seated its eighth class and in May 2015 graduated its fourth class. I’m just beginning my tenth year as dean of the college having arrived in August of 2006 as the first member of the college’s founding leadership team.

Time has gone by so fast! I was reflecting on this the other day and realized how far we have come in being assimilated into the Arkansas pharmacy community. On that note, I wish to express my gratitude to you all. I believe that while the college has made a positive impact on the pharmacy community in Arkansas, that has been due in large part to the wonderful way we have been welcomed into your pharmacies, hospitals, clinics, and other settings.

I believe that while the college has made a positive impact on the pharmacy community in Arkansas, that has been due in large part to the wonderful way we have been welcomed into your pharmacies, hospitals, clinics, and other settings.

In the course of the last four years we have graduated an additional 213 pharmacists in the state of Arkansas, of whom approximately 50% have stayed in Arkansas even though only about 30-40% were originally from Arkansas.

We have participated in political advocacy efforts that have resulted in changes to the pharmacy practice act and been able to assist the APA with nurturing relationships with state legislators. Much of this has been made possible because over 200 of you serve as preceptors for the program at Harding allowing us to expose our students to the many innovative practices of pharmacy in Arkansas. Those of you who choose to mentor our students by being a preceptor hold a very special place in my heart, so thanks again for serving our profession in this way.

• Health screenings – a total of nearly 3,000 people were screened last year, 2,000 for diabetes, 2,700 for hypertension, over 500 for BMI, and about 350 for hyperlipidemia • Health literacy – participants at multiple health fairs and other venues were educated about everything from proper nutrition to tobacco cessation • Participation in international experiences – a total of 28 students and four faculty have visited Haiti, Ghana, Nicaragua, and Zambia this year to complete both introductory and elective advanced pharmacy practice experiences providing oral rehydration and birthing kits, education on HPV awareness, oral health, and communicable diseases, and provision of traditional pharmacy services as well as physical assessment during medical clinics Diversity is important to us at Harding University. The University as a whole has students from all 50 states and 52 foreign countries. In our incoming fall 2015 pharmacy class alone we have students who have origins from Ghana, the Ivory Coast, Cuba, South Korea, Vietnam, Ethiopia, the Bahamas, and several Latin American countries. Two students in the P1 class previously attended our annual summer Pharmacy Camp. This past summer’s camp enrolled 28 students from eight states and this continues to be a good recruiting tool for us. We believe we are following our mission and values and appreciate you joining us in making it possible to achieve our goals at Harding University College of Pharmacy. I look forward to seeing what the next ten years will bring! §

When the college was established its mission was set — to graduate pharmacists who accept the responsibility of improving the spiritual and physical wellness of the world by providing patient-centered care that ensures optimal medication therapy outcomes delivered through the highest standards of Christian service. We try to keep this mission at the center of all we do. The following are some of the ways we believe this mission is being accomplished:

WWW.ARRX.ORG

19

UAMS REPORT

Interprofessional Education at UAMS

I

f you have been at a venue to hear a college of pharmacy Kathryn Neill report over the past several Pharm.D. months, you have likely heard Interim Dean about our preparation for the implementation of a new set of accreditation standards which go into effect July 1, 2016. A variety of committees and teams made up of faculty, students, preceptors, and community and health system partners have been working to insure the College is meeting these new requirements.

One area of significant focus has been the growth and development of interprofessional education (IPE) which occurs when students from two or more professions come together to learn with, from, and about each other.

Over a two-year period, a curriculum was designed for students from all five UAMS Colleges (Pharmacy, Medicine, Nursing, Public Health, and Health Professions) and the Graduate School to enhance IPE of students from more than 70 distinct degree programs. The curriculum framework consists of three phases based on students’ stage within their degree program – exposure (novice), immersion (intermediate), and competence (advanced). Learning activities are designed to address the goals of the Triple Aim – improved patient experience, improved population health, and reduced cost of the healthcare system. These are the same Triple Aim goals Dr. John Vinson has addressed in his remarks and focus for his year as APA President.

The Triple Aim IPE curriculum was approved as a graduation requirement for all students entering UAMS programs in the fall of 2015. These activities were launched in August with four workshops in which almost 800 students came together to learn about common themes affecting health care professionals including social determinants of health, health literacy, cultural sensitivity, patient centered care, the role of the payer, and research. Other IPE activities include a simulation where teams come together to work through the difficult conversation of disclosing a medical error and discussions built around movies and documentaries that teach concepts of patient centered care and interprofessional practice as well as deliver knowledge about a variety of health topics.

In the fashion that we continually see from our active student organizations, one of the most successful activities delivered to date was suggested, designed, and facilitated by a group of third year pharmacy students. Students proposed an activity to raise human papilloma virus (HPV) awareness among all UAMS learners. This topic was chosen because - according to the CDC - only 19% of adolescent females in Arkansas have completed the three-dose HPV series and less than 13% of adolescent males have even started the

20

series. This translates into Arkansas ranking 49th out of 50 states in HPV vaccination rates. An educational event built around the documentary film Someone You Love: The HPV Epidemic was delivered to 160 students from five colleges.

The activity targeted awareness of the risks of HPV and provided information to help educate health care providers about the benefits of vaccination and how to convey this information to the parents of children in the target vaccine population. A community-based immunization fair to educate and provide HPV vaccination is now being planned based on students’ response to the learning event. This activity serves as a key example of how IPE can highlight opportunities where teams of health care providers can work together to target improved health of individual patients and populations. Participation in the interprofessional 12th Street Health and Wellness Center in Little Rock and North Street Clinic in Fayetteville are other key IPE activities, and additional events where students work together to provide patient care in health fairs/screenings and serve as student educators to inform others about their profession are planned.

Interprofessional learning activities are also being incorporated in continuing education (CE) for practicing pharmacists. The new central CE office at UAMS is working toward certification as an IPE credentialed provider, and many programs are incorporating multiple professions in the development and delivery of CE sessions. One recent example is a session on error disclosure that was delivered to physicians, pharmacists, nurses, and public health providers during the UAMS Alumni Reunion weekend in August. It is an exciting time to explore the expanding role and recognition of pharmacists in a changing healthcare landscape. We welcome the opportunity to partner with you and hear your ideas for building these learning activities for our students and your continuing education needs.

In closing, I would also like to share my thanks for your support and well wishes over these past few months as I have had the privilege to serve as interim dean for the College. It has been my sincere pleasure to represent UAMS faculty, staff, and students, and continue the relationships we have with so many of you in the pharmacy community.

We are excited to welcome our new dean, Dr. Keith M. Olsen, and I look forward to the opportunity to introduce him to you in the coming months and celebrate the strength of the pharmacy community across our state. §

AR•Rx

|

THE ARKANSAS PHARMACIST

UAMS REPORT

UAMS Announcement On November 1, Keith Olsen, Pharm.D., returned to UAMS to take the reins as the new dean of the UAMS College of Pharmacy.

Olsen was a member of the UAMS College of Pharmacy faculty from 1989 to 1993, serving as associate professor and director of the Clinical Pharmacokinetic Laboratory and Monitoring Service. He has been chair of the Department of Pharmacy Practice at the University of Nebraska Medical Center (UNMC) College

of Pharmacy in Omaha since 2007. He also served as manager of education and research in the Department of Pharmaceutical and Nutrition Care at UNMC. Olsen earned his bachelor’s degree in chemistry from Wayne State College in Wayne, Nebraska, his doctor of pharmacy from UNMC in 1980, and later completed a residency in clinical pharmacy at UNMC. Olsen succeeds Dr. Stephanie Gardner, Pharm.D., Ed.D., who became the UAMS provost and chief academic officer on July 1. Kathryn Neill, Pharm.D., served as interim dean of the College until Olsen took his new post.

“My wife Theresa and I are extremely excited to return to Arkansas to serve the UAMS College of Pharmacy,” Dr. Olsen said. “The College of Pharmacy is an established national leader in education and research, and I am proud to lead from here to the next chapter.”

— Dr. Keith Olsen, Pharm.D.

WWW.ARRX.ORG

21

A Decade of Growth: Harding Dean Looks Back on 10 Years of Challenges and Accomplishments

By Jordan Foster

“

BEING THE 50TH OR 100TH YEAR OF SOMETHING IS EXCITING, BUT WHEN YOU’RE THERE FROM THE BEGINNING, WHEN YOU’RE THE FIRST YEAR OF SOMETHING, YOU’RE BUILDING A LEGACY.

W

”

ith that, Dean Julie Hixson-Wallace illustrates the excitement, trepidation, vision, and perspective that 10 years as Dean of the Harding University College of Pharmacy has brought her. An educator to the core, the girl who drew diagrams of the heart for a bedroom full of stuffed animals became the leader charged a decade ago with building a culture, a future, and a legacy for hundreds of future students and faculty where once sat an empty plot of land, literally building a college of pharmacy from the ground up.

An alumnus of Mercer University and Mercer Southern School of Pharmacy, Julie was exposed to the healthcare field from a young age. “I always wanted to be a physician, it ran in my

22

family. My mother and grandmother were nurses, my greatgrandfather was a physician, my grandfather was a pharmacy tech in the Army Air Corps, and all three of my brothers worked in a pharmacy growing up, so pharmacy was always on my radar.” After completing her pre-pharmacy courses at Mercer University and applying to the school of pharmacy there, Julie expected to work for a year at a pharmacy and start her P1 year the following August, but her plans were accelerated during the interview process, bringing a significant sacrifice.

“I was interviewing in December and discovered that, due to the way the courses were structured, there was a class starting in January, into which I was accepted. I thought I was on track to graduate four years later in December, until May came around and I heard my classmates talking about summer classes.” In order to sync up with the class that started the previous August, summer courses were part of the class schedule, meaning Julie had to sacrifice competing in a national figure skating competition that summer that she had been anticipating, compressing her pharmacy college experience into 3.5 years, and ultimately leading to a hospital residency and a 20+ year career in academia.

AR•Rx

|

THE ARKANSAS PHARMACIST

A DECADE OF GROWTH: HARDING DEAN LOOKS BACK ON 10 YEARS

“I’ve always liked the balance of being able to practice but also being able to teach, having influence over the next generation of pharmacists. As a practitioner, I could take good care of my patients in my limited location, but with teaching, I could communicate my passion for excellent care to a large group of students each year who would go out and promulgate that through a greater sphere of influence on the profession.”

In 2006, Julie’s dedication to teaching led her to an opportunity to impact the profession of pharmacy on a broader scale as dean of a new college of pharmacy in Searcy, Arkansas, halfway across the country from her home in Atlanta. Not only would she be training a new generation of pharmacists, but she would have an opportunity to set the culture of a new institution to reflect her personal passion in pharmacy. “I think my predilection to being a hands-on healthcare provider has enabled me to practice in a way that I wish all pharmacists would embrace. Even when I was in school we were talking about pharmacists providing hands-on patient assessment and care. Seeing pharmacists as healthcare providers who accept full responsibility for the care of the patient while utilizing all the skills that we have been teaching in pharmacy schools for decades now, that’s my real passion – getting everyone in our profession to embrace that and move practice forward is something I’ve tried to bring into the culture here.”

Coming from a large, longstanding school, Julie knew that there would be hurdles in such a huge undertaking as establishing a new college. Some, such as finding faculty and planning curriculum, were expected; other hurdles were nearly fatal to the success of the school. A lawsuit against the university and a late decision to construct a new building for the college were noted difficulties, but the accreditation process ultimately threatened to derail plans more than any other challenge.

initial successful pre-candidate visit. Because we ended up having to wait a year to get pre-candidate status, the start date for our first class was pushed back. It was a very challenging experience because the rules were changing in the middle of the game.”

Fast forward 10 years and the Harding University College of Pharmacy has grown into a school renowned for its graduates’ dedication to service, a lesson that Julie notes is part of Harding’s overall mission and one she plans on deeply instilling in her students in the future. “Harding has a rich history of missions, meaning going out into the world and serving. Ten years from now, we would like to see the college of pharmacy rise up even more to the mission levels of other Harding programs that routinely send large numbers of students to international locations. We want people to know that Harding pharmacists will reach out and help and are dedicated to service to others and giving back, being more outward looking.”

With its challenges and setbacks, Dean Hixson-Wallace says the experience has ultimately been rewarding and energizing.

“You’re building a culture at a new college. You have to think about what you want that culture to be and what you want that culture to look like. You have to think 50-100 years into the future. Everything you do is setting a precedent, setting traditions, that will shape the culture of the college for decades to come. You are at the creation point of a legacy. You’re not the 50th or 100th year of something, you’re the first year and that brings with it so much excitement.” §

“We happened to be starting the college at a time when some really bad things had happened with a couple of other new schools of pharmacy, so the Accreditation Council on Pharmacy Education (ACPE) was changing the whole process and we were right in the middle of it. The year before we applied for accreditation, you could start a school and enroll students without undergoing a pre-candidate visit. However, we were part of the first group of schools required to achieve pre-candidate status before enrolling students, and that did end up affecting our first class.

We had accepted students for the inaugural class all the while telling them things would depend on an

WWW.ARRX.ORG

23

2015 AAHP Fall Seminar

AAHP Residency Showcase Manager of the Year: Jason Eakin, Pharm.D., with AAHP President Rob Christian, Pharm.D.

Clinician of the Year: Brandy Hopkins, Pharm.D., with AAHP President Rob Christian, Pharm.D.

Residency Preceptor of the Year: Ashley Wilson, Pharm.D., with AAHP President Rob Christian, Pharm.D.

24

Fall Seminar Keynote Speaker Chris Jolowsky, MS, RPh, FASH

AR•Rx

|

THE ARKANSAS PHARMACIST

AAHP Executive Director Susan Newton, Pharm.D.

Staff Pharmacist of the Year: Nuria Fecher, Pharm.D., with AAHP President Rob Christian, Pharm.D. Technician of the Year: Felicia Paxton, CPhT, with AAHP President Rob Christian, Pharm.D.

New Practitioner of the Year: Erin Beth Hays, Pharm.D., with AAHP President Rob Christian, Pharm.D.

WWW.ARRX.ORG

UAMS Faculty member Drayton Hammond, Pharm.D., leads discussion during the Poster Session.

25

ARKANSAS ACADEMY OF HEALTH-SYSTEM PHARMACISTS

AAHP Councils Provide Opportunity to Move Health-System Pharmacy Forward Rob Christian, Pharm.D. President

I

f you were able to attend our 49th annual Fall Seminar, I think you will agree that this year’s meeting offered a wide variety of quality continuing education. The event also provided a great opportunity for pharmacists, residents, students, and technicians to network and learn from other practice sites, not only in Arkansas, but from across the country. For those of you that may have helped plan for an event of this size, you know how much work and planning goes on throughout the year to make the event a success. For this year’s meeting, Dr Erin Beth Hays served as the Fall Seminar Chair, and at this time I would like to publicly thank her, and her entire Committee for all their hard work.

As you may or may not know, AAHP has remained an allvolunteer organization since its inception in 1957, and it is because of this fact that we continue to seek individuals that can help strengthen our organization overall. With this said, I wanted to share some of the councils and program opportunities we have available for those of you that want to help move the practice of Health-System Pharmacy forward in Arkansas. The table below shows the current chair of each council, and I would ask that you reach out directly to them or one of our board members to inquire about getting involved.

Below the table is a short synopsis of activities that some of the councils work on throughout the year, as well as some of their recent accomplishments.

Hospital Advisory Council

This is a group of pharmacists from around the state that look at Health-System pharmacy practice opportunities, and then work to develop new solutions for our membership.

Sometimes these solutions come from other states that have already overcome the same challenge, while other instances only pertain to Arkansas due to state laws and regulations.

Many times this group works with the Arkansas State Board of Pharmacy to amend or pass new regulations, based on the issue at hand. Some of the topics this group has worked on in the past have involved nursing logs for automated dispensing cabinets, tech-check-tech programs, and offsite order verification. The group is currently working on

26

compiling data from a state-wide hospital pharmacy director survey, but more to come on this in the next article.

Programs and Education Council

This Council strives to improve the healthcare of the patients through high-quality healthcare educational activities that are knowledge-, application-, practice- and evidence-based by utilizing a variety of educational delivery methods (virtual, online, live, and enduring). The programming is constantly evaluated for timeliness and relevancy. Additionally, educational programs are shaped by conducting needs assessments, influences from professional pharmacy organizations, regulatory bodies, health care groups and consulting with pharmacy professionals. Finally, the Advisory Council on Programs and Education is committed to providing continuing education programming in a cost-effective manner while providing life-long learning opportunities for pharmacists and technicians. This council is ceaselessly thinking of subject matter for continuing education opportunities for our members at various sites throughout the state, and includes the Fall Seminar Committee. One of the most recent accomplishments of this council was to start offering live CE webinars, and to date this program continues to grow in popularity and attendance. In the past few years, the Council has also partnered with the Arkansas Hospital Association on a state wide adverse events project, and is currently working with them on an antibiotic stewardship initiative.

Membership and Communication Council

This Council focuses on growing our membership numbers, as well as retention of our existing members. Since we know that “membership” carries a different meaning based on what generation you belong to, this group works to ensure we offer something to everyone that joins, regardless of where they are in their professional career. Some of their efforts include managing our Facebook page, speaking to student organizations, and appearing on local television and radio programs to promote the practice of pharmacy. One of the more recent programs this council has instituted is a mentor

AR•Rx

|

THE ARKANSAS PHARMACIST

ARKANSAS ACADEMY OF HEALTH-SYSTEM PHARMACISTS

program where a tenured member will reach out to the new member soon after they have joined.

New Practitioner, Resident and Student Council

This council, originally the Residency Council, focuses on supporting Pharmacy Residency Programs, Directors, and Preceptors through preceptor development seminars, as well as conference calls to help sites starting residency programs or seeking accreditation. The council has recently added the focus on new practitioners and students and worked to develop the new Junior Board Member positions. These new positions provide students with opportunities to strengthen leadership and communication skills working closely with board members within our organization

Technician Council

This group focuses on topics directly effecting technicians, and is responsible for coordinating the technician programing during Fall Seminar. This council was also responsible for administering a state-wide technician survey, so we could develop strategies to better serve that population of members. They also work to ensure that programming is offered each year to help more technicians achieve national pharmacy certification.

As you can see, our organization has a wide variety of ways for you to plug in and make a difference, not to mention we have the best group of people from across the state to collaborate with. Now comes the hard part, deciding which council you want to join. §

APA CONSULTANTS ACADEMY REPORT

Threat of Antibiotic Resistance Spurs New Treatment Method

E

ach year we attend numerous continuing education programs. Some are good and some not so good. In June of this year, I attended a program presented by the Arkansas Association of Health-System Pharmacists on antimicrobial stewardship. It just knocked me out. I would like to share the major points that I took away from the really great program.

Plus, I wish to acknowledge both Dr. Buddy Newton, M.D. of Fayetteville and Dr. Mike Broyles, Pharm.D. of Pocahontas as major sources of information in the next few paragraphs.

We are faced with a growing problem in antibiotic resistance around the world and we must attempt to manage this issue. It has been suggested that as much as 90% of antibiotic usage is inappropriate. Did you know that small doses of antibiotics administered daily would make most animals gain as much as 3 percent more weight? Then would it surprise you that in the United States that 80% of all antibiotics used are in the food and animal industry at a rate of 20 million pounds in the food supply annually? “Would you like your burger with or without a little fluoroquinolone?”

What if I said a simple blood test can determine the need for an antibiotic and even predict when to stop that antibiotic therapy?

Have you ever heard of Procalcitonin (PCT)? PCT is a precursor of the hormone calcitonin and is produced by C cells of the thyroid and by the neuroendocrine cells of the lung and the intestine. In the bacterial infection PCT is produced and released from the entire body.

Levels of (PCT) in the blood increase rapidly when a person has sepsis. They are typically only mildly to moderately elevated when a person has a viral infection, so in simplest terms, if this WWW.ARRX.ORG

test were performed early and often in the infection process it could identify if the infection is bacterial or viral in many cases and could direct us when to stop therapy.

Anthony Hughes, P.D. President

A healthy person should have a PCT concentration of <0.05ng/ml. This quickly shoots up with a bacterial infection.

So concentrations of >0.5ng/ml indicates a bacterial infection.

These values can show up as quickly as 6 hours and peak in 12 hours. Plus, they will drop very quickly when the bacterial infection is abated so we can impact duration of therapy. Tests are drawn on days 3, 5, and 7 and the antibiotic is stopped when there is an 80-90% decrease in the peak PCT level. In the outpatient setting the last PCT can predict duration of therapy at >0.25-0.5ng.ml of 3 days, >0.5-1.0ng/ml of 5 days and >1.0ng/ml of 7 days*. With everything we have exceptions.

The exception comes with newborns <48 hours, extensive trauma, burns, major surgery, certain thyroid carcinoma, circulatory failure, Malaria and certain fungal infections when PCT does not apply.

The advantage comes quickly with reduced length of therapy and antibiotic utilization. These results are being shown across the state in places like Washington Regional Medical Center in Fayetteville with Buddy Newton, M.D., FACP and Five Rivers Medical Center with Mike Broyles, Pharm.D. of Pocahontas.

This could be our best first step for Antibiotic Stewardship and the pharmacist. § *Philip Schuetz, M.D., MPH; Victor Chiappa, MD; Matthias Briel, M.D., MSc; Jeffery Greenwald, M.D., March internal MED/vol171 (NO 15) Aug 8/22, 2011. www.ARCHINTERNMED.COM

27

2015

Arkansas Pharmacists Association District Meetings

T

he Arkansas Pharmacists Association held its 2015 District Meetings in 11 cities across the state during the month of September. Members were able to engage with state pharmacy board and APA leaders, get updates from the colleges of pharmacy, and enjoy camaraderie and fellowship with fellow pharmacists in the area. APA member participation is integral to the success of the association. Thank you to all who attended!

Bentonville

Tiffany Dickey, Chris Allbritton, Victoria Seaton, Michelle Pie

UAMS College of Pharmacy Dean Keith Olsen

CAMDEN, Lenora Newsome, Mark Riley

Casey Deyampert, Jennifer Davis

Donna Green, Ken Miller

Bobby Glaze, Lenora Newsome

28

ARâ&#x20AC;˘Rx

|

THE ARKANSAS PHARMACIST

Nicole Joe, Kelly Barlow

FORT SMITH, Rep. Justin Boyd

Charles Wimberly, Mark Kincannon

HOT SPRINGS, Stephen Carroll

Jim Yarbrough, Percy Malone

WWW.ARRX.ORG

Cody Miller, Brian McGalliard, Fran Stotts, Theresa Thoma

Phil and Gayle Tygart

29

Jonesboro

Blair Thielemier, Emily Late, Cheyenne Smith

Doug Baltz, Kristy Reed

Little Rock Kristen Glover, Elisabeth Mathews, Bethany Boyle, Courtney Bookout, Talon Burnside, Kat Neill

Jared Brown, Mariana Matute 30

Rachel Stafford, Terry Perkin ARâ&#x20AC;˘Rx

|

THE ARKANSAS PHARMACIST

Monticello

Mountain Home, Darla York

Julie Hixson-Wallace, Harding College of Pharmacy Dean

James Bethea

Jason Bentley, Carla Willi

Gary Denton, Gayle Fowlkes

Russellville WWW.ARRX.ORG

Sarah McCoy, Kaci Rood 31

Searcy

Kadyn Pace, Mallory Sanson

Adam Slayton, Rob Welch, Travis Ezel

Stuttgart

Alton Chambless, Brandyn England

32

Kristi Whitmore, Gail Northcutt

ARâ&#x20AC;˘Rx

|

THE ARKANSAS PHARMACIST

Member Classifieds

Member Classifieds are free to APA members and $65 per issue for non-members. Contact communications@arrx.org for more information.

Southwest Arkansas pharmacy for sale. Owner ready to retire.

Pharmacy has been in operation over 50 years with good solid business and room to grow. Best place in Arkansas to live. E-mail swardrugstore@gmail.com Pharmacy Hardware For Sale! Lexmark MS811 printer, 2 pharmacy work stations with Canon DR-C125 Scanners with 22" flat panel screens. Two point of sale cash drawers including signature pads. All equipment is like new, used less than one year. $10,500. Call 501-412-7786.

Experienced hospital pharmacist now learning retail looking to pick up 16-32 hr/wk hospital or retail. Immunization certified. Will travel reasonable distance. Contact 501-847-6620 orsmc1994@ yahoo.com.

Full time technician needed in Fayetteville - Harps #355 seeking full time pharmacy technician. Technician required to work well with fellow pharmacy team members, pharmacy customers, and other health care professionals. Seeking self-motivated, reliable, confidential, professional worker available to work hours between 9am-7pm Monday-Friday, 9am-5pm Saturday. Prior pharmacy experience and valid tech license preferred. Contact Heather at 479-442-7917 or HarpsRx355@yahoo.com.

Regional Pharmacy Manager - Provide leadership for all aspects of Pharmacy Services of the Southeast Health regional facilities.

Medication management, patient safety, and effective and efficient utilization of drugs are a focus. Qualifications: BS in Pharmacy or Pharm D and active MO license. PGY1 residency and hospital pharmacy experience preferred. Interested? Contact Kristen atKdaniel@sehealth.org.

Full Time Pharmacist Needed in Retail Setting: AllCare Pharmacy in Texarkana, AR is looking for a highly motivated, outgoing individual. We are a growing company with a competitive salary. Please contact Michele at: michele@allcarepharmacy.com or 870-246-5553.

Pharmacist Needed at Little Rock AFB. Qualifications: A Bachelors, Masters, or Doctoral degree in Pharmacy from a college of pharmacy accredited by the American Council on Pharmaceutical Education (ACPE). A current, valid, unrestricted license to practice Pharmacy in any one of the fifty States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or

the U.S. Virgin Islands. Hours: Mon-Fri 7:30 to 4:30. Contact Kelly Hardin at 1-800-852-5678 ext 116.

Pharmacist - Clinical Pharmacy Coordinator - NARMC, Harrison, AR. Develops, implements, and maintains systems that promote desirable patient outcomes through appropriate medication therapy. Required: graduate of an ACPE-accredited College of Pharmacy with a Doctor of Pharmacy degree and licensed in the state of Arkansas or eligible for licensure. Preferred, but not required: BCPS, PGY1; hospital pharmacy or clinical pharmacy experience.Submit resume and application to: donna. copeland@narmc.com, Phone: (870) 414-4689 EOE www.narmc.com Pharmacy technician needed full or part time for Jonesboro retail/LTC pharmacy. Experience in LTC preferred but not required.

Must have active technician license. Call Amanda@ 870-935-6364 for details.

For Sale: Parata Max $40,000. Purchased in October 2008 and was in use until October 2014. The machine was functioning properly and under maintenance agreement when we stopped using it. We will consider selling the Parata cells individually. Call 479-452-0278 or email Jamie@medisav.com. Speak with Jamie Schmalz or Keith Larkin at MediSav Pharmacy.

Immediate opening for Pharmacist at Ouachita County Medical Center, Camden, AR. Full-time or part-time available. Arkansas license required and clinical experience preferred. Must be able to perform well individually and within group settings. Ability to handle situations professionally and accurately is required. Must have strong interpersonal skills. Must be able to provide care with courtesy, friendliness and respect. Please email mbridges@ ouachitamedcenter.com or visitwww.ouachitamedcenter.com for an application. Applicants can also call Mary Bridges at 870-836-1395.

Pharmacy located in the heart of north central Arkansas seeking full-time or part-time pharmacist. Retail pharmacy offering wonderful hours, no weekends, and a very competitive compensation package. Benefits include company IRA with match, paid vacation and bonus opportunities. If interested please contact Eddie Mitchell at (870)214-0415 or email resume tomainstpharmacy@mvtel.net.

AAHP Board Executive Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Susan Newton, Pharm.D., Russellville President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rob Christian, Pharm.D., Little Rock President-Elect. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kendrea Jones, Pharm.D., Little Rock Past President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Marsha Crader, Pharm.D., Jonesboro Treasurer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Rayanne Story, Pharm.D., Searcy Secretary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Wendy Jordan, Pharm.D., Jonesboro Member-at-Large . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Brandy Owen, Pharm.D., Conway Member-at-Large. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Niki Carver, Pharm.D., Jonesboro Member-at-Large . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Erin Beth Hays, Pharm.D., Pleasant Plains Technician Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Holly Katayama, CPhT, Little Rock

Arkansas State Board of Pharmacy President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Lenora Newsome, P.D., Smackover Secretary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stephanie Oâ&#x20AC;&#x2122;Neal, P.D., Wynne Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Steve Bryant, P.D., Batesville Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tom Warmack, P.D., Sheridan Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Kevin Robertson, Pharm.D., BCPS, Little Rock Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cheryl Bryant, Pharm.D., Little Rock Public Member. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carol Rader, Fort Smith WWW.ARRX.ORG

33

34

AR•Rx

|

THE ARKANSAS PHARMACIST

WWW.ARRX.ORG

35

WWW.ARRX.ORG

36