MPhA May June 2013 journal by MPhA Minnesota Pharmacists Association

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INSIDE

May-June 2013

Volume 67. Number 3, ISSN 0026-5616

Upfront Views and News Presidentâ&#x20AC;&#x2122;s Desk: Reflections on an Interesting Journey . . . . . . . . . 5 Viewpoint: When Process Is the Goal, Is it Any Wonder that Outcomes Are Far Behind?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Clinical Issues Pharmacy and the Law: Discovery 101 . . . . . . . . . . . . . . . . . . . . . . . . . 10 Clozapine-Induced Neutropenia: A Review of Lithium and Other Currently Available Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Report of Drug Insert Labeling Revisions . . . . . . . . . . . . . . . . . . . . . . 21 Pronunciation of Active Ingredient Names. . . . . . . . . . . . . . . . . . . . . . 22

Industry News Pharmacists Improving the Health Care System: Implementing Stage 2 Meaningful Use Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Smart Cards in Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

On the Cover

Pharmacists Improving the Health Care System: Implementing Stage 2 Meaningful Use Criteria page 12

Minnesota News Updates from the Colleges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

MPhA News Organization Member Profile: Thrifty White Pharmacy. . . . . . . . . . . . . . 8 Report from the State Capitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Foundation Wine Tasting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 In Memoriam: Addie Elizabeth Whittemore . . . . . . . . . . . . . . . . . . . . . 19 Is MPPS for You? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Find us on Facebook... Minnesota Pharmacists Association Youâ&#x20AC;&#x2122;ll find quick updates about what is happening at MPhA and more photos from our events! Minnesota Pharmacist May-June 2013 n

MPhA Board of Directors Executive/Finance Committee: President: Martin Erickson Past-President: Scott Setzepfandt President-Elect: Jill Strykowski Secretary-Treasurer: Bill Diers Speaker: Meghan Kelly Executive Vice President: Vacant Rural Board Members: Eric Slindee Jeff Lindoo Metro Board Members: Cheng Lo Brittany Symonds At-Large Board Members: Tiffany Elton Tim Cernohous Keri Hager Amy Sapola Jason Varin

Upcoming Events Visit www.mpha.org for more information and registration 2013 MPhA Annual Conference May 17-18, 2013 | Marriott Minneapolis Northwest, Twin Cities

Not Your Mother’s MPhA 2013 MPhA Annual Conference

Student Representation: Duluth MPSA Liaison: Brittany Novak Minneapolis MPSA Liaison: Amy Herbranson Ex-Officio: Bruce Benson, COP MPhA Executive Vice President (vacant) MSHP Representative

May 17-18, 2013

Marriott Minneapolis Northwest

Pharmacy Technician Representative: Barb Stodola

MINNESOTA PHARMACIST

Official publication of the Minnesota Pharmacists Association. MPhA is an affiliate of the American Pharmacists Association, the American Society of Consultant Pharmacists, the Academy of Managed Care Pharmacy, and the National Community Pharmacists Association.

Editor: Laurie Pumper, CAE Managing Editor, Design and Production: Anna Wrisky The Minnesota Pharmacist (ISSN # 00265616) journal is published six times per year by the Minnesota Pharmacists Association, 1000 Westgate Drive, Suite 252, St. Paul, MN 551141469. Phone: 651-697-1771 or 1-800-451-8349, 651-290-2266 fax, info@mpha.org. Periodicals postage paid at St. Paul, MN (USPS-352040). Postmaster: Send address changes to Minnesota Pharmacists Association, 1000 Westgate Drive, Suite 252, St. Paul, MN 55114-1469. Article Submission/advertising: For writer’s guidelines, article submission, or advertising opportunities, contact Laurie Pumper at the above address or email lauriep@ewald.com.

Copyright 2013. Bylined articles express the opinion of the contributors and do not necessarily reflect the position of the Minnesota Pharmacists Association. Articles printed in this publication may not be reproduced in any manner, either in whole or in part, without specific written permission of the publisher.

Acceptance of advertisement does not indicate endorsement. 4 Minnesota Pharmacist May-June 2013 n

MPhA Mission: Call for Articles The Minnesota Pharmacist accepts articles for publication from its members and from nonmembers. All content is subject to review by the MPhA Editorial Advisory Committee and MPhA Staff, who will determine whether material is of interest to our readers. To submit an article or an idea/abstract, please send an email to Communication Director Laurie Pumper at lauriep@ewald. com.

Serving Minnesota pharmacists to advance patient care. The Minnesota Pharmacists Association is a state professional association, whose membership is made up of pharmacists, pharmacy students, pharmacy technicians, and those with a business interest in pharmacy. MPhA will be the place where pharmacists go first for education, information and resources to become empowered to provide optimal patient care. MPhA will be the recognized and respected voice of pharmacy with legislators, regulators, payors, media and the public.

Moved, graduated, or have a name change? Update your profile through your online MPhA Member Portal page to continue receiving important association updates.

Upfront Views and News

President’s Desk

Reflections on an Interesting Journey By Martin A. Erickson, III, RPh, Director of Professional Services and Regulatory Affairs, Fagron Dear colleagues, It is often noted by one ending an elected term of office that time passed quickly. No less was my experience this year. The intense, intentional and exceptional work of volunteers and staff made the work light, however. We have been on an interesting journey this year. Your board of directors took a bold step last Spring by instituting lower membership fees and initiating a process to gain members and financial support through corporate memberships. I reflect on this move and others in this column. I must begin this reflection by thanking my friend, Rev. Howard Bell, for his inspiration. Rev. Mr. Bell, in a recent sermon, suggested several steps that must occur in a leave-taking. These I adapt and adopt for your consideration. The first step was taken many years ago when the president’s term was set as one year, from annual meeting to annual meeting. One difference this year is the earlier meeting date. The second step is announcing the leave-taking. Your board announced an earlier meeting date several months ago. I regard changing our meeting date as a hopeful sign for greater member involvement, and the kind of activity that strengthens and unites the profession and the association. I

hope you join me in celebrating this change, the third step. The fourth step is not so simple: It requires sharing feelings, both positive and negative, with open ears and minds. In our context, I see this as a requirement for clear, honest, direct dialogue between the leave-taker and the organization. For me, it is an opportunity for all of us to express our views and work together to envision a bright future for the Association and the profession. Your board of directors and House of Delegates each provides an excellent forum for exchanging ideas about how our many and varied practices and settings can interact in positive, fruitful ways. The opportunities for improved practice and new models are before us. Let us build on the foundations laid by our pharmacist-ancestors, finding the courage and conviction they taught us. Our theme this annual meeting is “Not Your Mother’s MPhA,” which is apt: MPhA is different than it was for our mothers, but simultaneously it is our mothers’ — and fathers’ — MPhA, because it has the heart and soul they and previous generations of pharmacists prepared for us. It is incumbent upon us to continue the tradition: boldly expressing ourselves to lawmakers; exploring new avenues of practice; modernizing our methods; discovering opportunities in the Affordable Care Act.

The opportunities for improved practice and new models are before us. Let us build on the foundations laid by our pharmacistancestors, finding the courage and conviction they taught us. To this end, let us engage deeply in dialogue, expressing our ideas, impressions and feelings freely in the sure knowledge that, as we were taught, the profession and MPhA will experience increased vitality. During the past year, MPhA saw Julie Johnson move from 12 years with us to the University of Minnesota College of Pharmacy, a move that will surely strengthen our profession. I thank her deeply for her guidance and support in the past, especially in this presidential year. I am confident that our next leader will live up to the standard Julie set to continue building the association. I thank Ewald Consulting, especially David Ewald, Bill Monn, Laurie Pumper, and Jacquie Jaskowiak for their work and advice along the way. My heartfelt gratitude for all of the volunteers who make this association live and breathe. Your executive comPresident’s Desk continues on page 13

Minnesota Pharmacist May-June 2013 n

Viewpoint

When Process Is the Goal, Is it Any Wonder that Outcomes Are Far Behind? By Lowell J. Anderson, D.Sc., FAPhA Recently, I attended a meeting where “counseling” was discussed. Frustration with the seeming lack of quality counseling by pharmacists, as required by law, was the focus. The requirement for counseling originated in the OBRA90 legislation at the federal level. The act provided that dispensing pharmacists must offer to counsel each Medicaid recipient when filling a prescription for them. This 1990 recognition by the Congress that beyond dispensing, the pharmacist adds value to the use of a medication by “counseling” a patient, was pretty important. Actually, it started a new-product growth spurt for the pharmacy community. Medicaid programs required counseling by their networks as required in OBRA90, soon boards of pharmacy incorporated universal counseling into statute or rule, and continuing education providers developed a whole new set of courses on “How to Counsel.” The message appeared to be: If a pharmacist “counseled” each patient, the pharmacist’s professional responsibilities had been met. In the ‘90s, counseling was on the way to becoming an outcome! As usual, the new counseling requirements were unfunded mandates. I remember at the time OBRA90 went into effect there was lots of discussion

Minnesota Pharmacist May-June 2013 n

about what constituted an “offer to counsel.” Should it be written or oral? When was the offer to be made? Who needed to make the offer? For the most part, community pharmacists understood the importance of communicating with clients and continued doing what they had always done — discussing the new prescription and its use with our patients. Although we were a bit more attentive to the content of the discussions than we previously may have been. For the most part — but not all! Some saw in OBRA90 the important requirement to be to “offer” rather than provide. Again, a focus on a different aspect of the process. Those pharmacies who were focused on order fulfillment found that it met the letter of the law to incorporate an offer and waiver of the offer into the signature log. This was done with the expectation that most people couldn’t or wouldn’t bother to read the 10-point header on the log. Unfortunately, 23 years later, this is still the policy of some pharmacies. It may save pharmacists time, but does little to grow the profession’s brand! Getting back to 1990: As important as the congressional recognition of the value of the pharmacist in promoting appropriate medication use was, it was still a process requirement. A requirement not dissimilar to the old require-

ment that a pharmacy have one rubber spatula and one stainless steel spatula, or many of the other requirements found in the various rules that direct the practice. None are statements of expectations of a desired outcome. Much of the administrative burden on pharmacy practices that drive stress and overhead are process requirements. On the statute/rule side: In addition to the counseling requirements and required counseling areas, consider dispensing area size, HIPAA, and filling and filing of prescriptions. And on the PBM side: Signature logs, prior authorization, formularies, vacation over-rides, documentation of a wide array of numbers, and of course revenue-driven audits. In the PBM contracts and in law, the desired outcomes still focus on meeting the process requirements. Why? Partially because of the belief that if a professional follows these processes they will result in a desired outcome — many times there is no evidence of that being true. Also, because adherence to process is easier to measure — process requirements can be incorporated into a checklist. If pharmacists don’t get everything checked off in an inspection or an audit, they are in violation. Profitable penalties soon follow!

Process is the Goal continued online at MPhA.org/displaycommon.cfm?an= 1&subarticlenbr=152

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Organization Member Profile: Thrifty White Pharmacies Contact name: Jeff Lindoo, RPh Your job title: Vice President, Governmental & Regulatory Affairs Locations/number of pharmacies in your organization: Thrifty White has 86 pharmacy locations across Minnesota, North Dakota, South Dakota, Iowa, Montana and Wisconsin. We have 50 pharmacy locations in Minnesota. Our corporate office and warehouse are located in Plymouth, Minn. When was your organization established? White Drug was established in Jamestown, N. D., in 1884. Thrifty Drug Stores was established in Brainerd, Minn., in 1957. The two companies merged in 1985. Number of employees: We have 1,660 employees company-wide; 980 of those employees are located in Minnesota.

Why is it important to your organization to support MPhA? Nearly every business and professional group in the nation understands the need for an association to advance their business and professional interests. MPhA is the one organization in Minnesota whose mission is to advance the practice of pharmacy in our state. MPhA’s work on professional practice issues is vital to the continual development and dissemination of best practices in our profession. At the same time, their representation of pharmacy at our state Capitol is critical to assuring that our lawmakers advance legislation that enables us to continue to serve the best interests of our patients. They also work to maintain a valuable working relationship with the Minnesota Board of Pharmacy and other regulatory agencies in the state that impact our practice. None

Brief history of your organization; what makes it unique? Thrifty White was originally a privately held corporation. In 1993, an ESOP (Employee Stock Ownership Plan) was established as a means to transfer ownership to the employees of the company. In 2006, the transfer of ownership to the ESOP was completed and Thrifty White became 100% owned by the employees through the ESOP. Today, with more than 1,350 employee owners, we are one of the nation’s 100 largest employee-

owned businesses. We firmly believe that employee ownership gives our employees the incentive to provide the best service possible to our patients

Minnesota Pharmacist May-June 2013 n

of this can happen without financial and personal resource support from all of us in the profession. Maintaining a strong, vibrant association is critical to all of us who work in this great profession.

and customers and the opportunity to share in the rewards from their efforts.

Thrifty White’s unique service to patients: In the past one-and-one-half years, Thrifty White has made a major commitment to moving our pharmacists and pharmacy staff away from the dispensing role into focusing on patient care, particularly the issue of medication adherence. We have experienced dramatic success in many ways with our medication synchronization program. When a patient signs up for “Med Sync,” we synchronize all of the patient’s maintenance medications to refill on the same date each month. The patient then has to make only one trip to the pharmacy each month to Member Profile continues on page 19

Medication Synchronization Thrifty White/VCU Study with comparison to CMS Star Thresholds 90% 80% 70%

5 Star

60% 50%

4 Star

40% 30% 20% 10% 0% Control

ABM

Control

ABM

Control

ABM

Statins

ACE/ARB

Metformin

Cholesterol

Blood Pressure

Diabetes

Updates from the Colleges

It’s All About the Students By Julie Johnson, PharmD, Associate Dean for Professional and External Relations, University of Minnesota College of Pharmacy As challenging as my transition from MPhA to the College of Pharmacy has been, being back here (where quality student experience and education is king) feels good. My first 60 days in a new position have been filled with listening and learning. After the relative comfort of my 12 years at MPhA (where listening and learning were constant), it has been an adjustment. My appreciation of the college environment — and those among us who chose to devote their professional pharmacy career to educating young pharmacists — has always been high. The demanding teaching schedules the faculty here keep, the endless meetings to ensure processes for curriculum development and implementation go smoothly, the challenging budgets (yes, here too), are all part of my new role. Rho Chi Research Symposium recently featured Yusuf Abul-Hajj, distinguished medicinal chemist, professor, longtime department head, and author of From Digitalis to Ziagen. This chronicle of medicinal chemistry at the university provides the history of the creation of the College of Pharmacy plus information on the initial researchers like Frederick Wulling and a host of faculty and scientists who followed him. These people truly were the pioneers who

established pharmacy as a science and paved the way for pharmacy as a profession. Dr. Abul-Hajj delivered a delightful account of this rich history to a room packed with students who gained a great appreciation for this foundation and its continued contributions to drug research and development. Implementation of the College of Pharmacy’s new curriculum will begin this fall. This mammoth task, a culmination of years of planning, begins on August 19 with a class called, “Becoming a Pharmacist”. This firstyear course is a three-week module designed to provide the students a foundation upon which they will successfully maneuver through the next several years of learning as students and lifelong professional development as health care professionals. The content for this course will contain introductions to the educational domains, or content areas contained in the entire program. Patient-centered care, population health and vulnerable communities, health systems management, leadership and engagement, professional and interprofessional development and knowledge, scientific inquiry, and scholarly thinking will then continue throughout the program. The interconnection of the educational content

woven through each year provides continuous development of a pharmacist fully prepared to practice pharmacy in this new environment. Paul Ranelli, professor from the Duluth campus, and I are responsible for the delivery of this course. We have many faculty contributing their expertise to the various areas that will be introduced. I am excited to welcome these students to our college! Not one meeting ends without a person voicing concern for student needs. Much the same as association initiatives were held up to the “is it good for the patient?” questions, folks here from each department continually strive to create the best environment and opportunities possible for the students at the college. “How does this impact our students?” “Is this best for their experience?” “How can we continue to provide the best education possible?” Our College of Pharmacy will continue to produce great pharmacy professionals. The goal of this new program is to produce global citizens prepared to meet the challenges of health care. I am grateful to be a part of this team.

Minnesota Pharmacist May-June 2013 n

Discovery 101

Pharmacy and the Law

By Don R. McGuire, Jr., RPh, JD This series, Pharmacy and the Law, is presented by Pharmacists Mutual Insurance Company and your State Pharmacy Association through Pharmacy Marketing Group, Inc., a company dedicated to providing quality products and services to the pharmacy community.

Ask anyone who works in the claims department at an insurance company and they will tell you that the discovery phase of litigation is the most timeconsuming and expensive part of the process. But if you don’t work in the claims department or a law firm, could you readily explain what discovery is and why it is so costly? Discovery is defined by Rules 26 to 37 of the Federal Rules of Civil Procedure. Discovery is a process where opposing sides in the litigation share information about the case with each other. This process is mandatory, although compliance with the rules is generally self-enforced by the parties. This sharing of information takes many forms and helps each side to evaluate the strengths and weaknesses of its case prior to trial. These forms include; 1. Depositions by oral examination, 2. Depositions by written questions, 3. Interrogatories to parties, 4. Producing documents, electronically stored information, and tangible things, or entering onto land, for inspection and other purposes, 5. Physical and mental examinations,

and 6. Requests for admissions. Depositions, whether written or oral, are one of the largest cost drivers in the discovery process. Little use of depositions by written questions is seen in most cases, so I will concentrate on deposition by oral examination. The main reason that this exchange consumes so much time and money is that nearly anyone connected with the case can be deposed. The parties, employees of the parties, fact witnesses, and expert witnesses can all be deposed. Depending on the complexity of the case, the deposition can be a half-day, whole day or potentially even multiple days. Coordinating witnesses’, parties’, and attorneys’ schedules can be a nightmare. This is multiplied in multiple defendant cases or class action cases. Depositions are important because they give a preview of what a witness is going to say on the stand at trial. Witness testimony is crucial to evaluating a case. Preparation for a deposition, taking the deposition and analysis of the answers is time consuming for your attorney. If the number of depositions

is large, discovery is well on its way to being the most expensive part of litigation. Interrogatories are written questions that can only be submitted to the opposing party. They cannot be used to gain information from witnesses or other non-parties. There is a limit to the number of interrogatories that can be served on the opposition. Many times interrogatories are used to gather background facts such as date of birth, address, work history, and arrest records. As with deposition questions, it is permissible to object to questions, but the objecting party must have a good faith basis to object, beyond just not wanting to answer. Producing documents, electronically stored information, and tangible things, or entering onto land, for inspection and other purposes is comprised of two parts. The inspection of land and/or buildings occurs when relevant, but the bigger issue here is documents. In the not-too-distant past, this rule dealt almost exclusively with documents. Not so today.

Discovery 101 continued online at MPhA.org/displaycommon.cfm?an=1&subarticlenbr=153

The AWARxE campaign was founded by the Minnesota Pharmacists Foundation in 2009, in order to educate communities and individuals on the dangers of abuse or misuse of prescription medications. VISIT MPHA.ORG FOR MORE INFORMATION.

Minnesota Pharmacist May-June 2013 n

MPhA News

Report from the State Capitol By Patrick Lobejko, MPhA Lobbyist As this article was written, the 2013 legislative session was heading for the home stretch — bringing a new focus on the state budget for legislators. Shortly before the Easter/Passover break, both House and Senate leadership released their budget targets for the upcoming biennium. With the Legislature facing a $627 million budget shortfall, the Senate has proposed a $1.4 billion increase in spending. The House plan calls for a slightly lower spending increase of $1.1 billion. House leaders are also looking to repay schools the $854 million shifted from schools during the last biennium to balance the state’s deficit — which then stood at $5 billion. In order to repay the school payment shift, the House would place a temporary income-tax surcharge on those earning more than $500,000 a year. An item of concern for those working in health-related fields is that the budget targets proposed by both the House and Senate for Health and Human Services include reductions to

the HHS budget by $150 million over the next two years. Because of the $1 billion in reductions in Health and Human Services from the previous biennium, most health providers and non-profits were expecting a slight increase to the targets. House HHS Finance Chair Representative Tom Huntley and his Senate counterpart, Senator Tony Lourey, have released budget proposals based on these numbers. Given that Gov. Dayton’s HHS budget proposes a $128 million increase, we have yet to see how the governor and Legislature will resolve their budget target differences. House Budget Components: • Close Minnesota’s $627 million deficit. • Fully pay back the remaining balance of more than $800 million borrowed from Minnesota schools.

• Invest another $1 billion in priorities to strengthen Minnesota’s economic future, including $700 million for early childhood education through post-secondary, $250 million in property tax relief, and $46 million in job creation. Senate Budget Components: • Close Minnesota’s $627 million deficit. • $486 million in new spending for education, with the bulk of that going to fund all-day Kindergarten and buying down local school property tax levies. • Invest $262 million in higher education, $135 million for environment and economic development, $463 million for tax aids and credits to cities and counties.

For a full list of all Minnesota legislators

and their contact information, visit the MPhA website at www.mpha.org

Minnesota Pharmacist May-June 2013 n

Pharmacists Improving the Health Care System: Implementing Stage 2 Meaningful Use Criteria By Laurie Pumper, MPhA Communication Director

Meaningful Use (MU), part of the Affordable Care Act, is being phased in over several years, with Stage 2 implementation starting in 2013 for eligible hospitals and 2014 for eligible professionals. Jennifer Fritz, MPH, deputy director of the Office of Health Information Technology at the Minnesota Department of Health, says pharmacies are essential for implementing MU because e-prescribing is a required transaction for both hospitals and professionals (i.e., doctors in private clinics). Two Minnesota case studies show the important role the pharmacy plays.

to perform medication reconciliation upon discharge, reducing the error rate to 70%. Then, pharmacists were assigned to review the medication orders upon discharge. Nine months after adding pharmacists to the review, the hospital reported the medication error rate plummeted to “essentially zero” and the 30-day readmission rate was reduced by half. It cost the hospital an additional $112,000 to include pharmacists in medication reconciliation upon discharge, but the intervention saved Medicare an estimated $587,000 in medical expenses through reduced readmissions.1

A. Hennepin County Medical Center (HCMC) in Minneapolis ran a pilot program in which pharmacists checked discharge orders of 37 elderly patients, many with multiple chronic conditions, discharged from the hospital to nursing homes over three months in 2008 and 2009. HCMC discovered that 92% of these cases contained a medication error such as a wrong dose, duplication or an omitted medication. Nearly a third of the errors were identified as “likely harmful.” HCMC first implemented a system to use its EHRs

B. The Mayo Clinic in Rochester, Minn., implemented a similar pilot program in medication reconciliation in the academic family medicine hospital service. During the program, the Mayo Clinic found that potentially dangerous medication discrepancies occurred more commonly during discharge than during admission. The multi-disciplinary medication reconciliation program found pharmacists to be an “outstanding resource” for reducing the number and severity of medication errors over the course of the pilot. As a result,

Minnesota Pharmacist May-June 2013 n

Mayo empowered pharmacists to work with prescribers to edit patient medication lists in the electronic hospital summary. Mayo has since expanded the role of the pharmacist in coordinating with the discharge team and updated its electronic medical records to improve medication reconciliation upon discharge.1 Sen. Al Franken (D-MN) has been involved in the issue of meaningful use at the federal level. In May 2012, he sent a letter to CMS, encouraging the agency to adopt a policy that would require eligible hospitals to perform medication reconciliation for patients when they are discharged from the hospital. As proposed, the EHR incentive program would have only required that reconciliation be performed upon admission and for most referrals and transfers — and not upon discharge. “Patients leaving hospitals in Minnesota should be able to count on the fact that their prescriptions aren’t going to have bad interactions and send them back to the emergency room,” Sen. Franken said. “I’m proud of the pioneering efforts being made at the Hennepin County Medical Center to save lives by having

“Patients leaving hospitals in Minnesota should be able to count on the fact that their prescriptions aren’t going to have bad interactions and send them back to the emergency room,” Sen. Franken said. pharmacists review medications before a patient is discharged. On my end, I’ll keep working to create incentives so that hospitals nationwide can put this life-saving practice into place.” One reason why Minnesota is further along the path of electronic prescribing is that the Minnesota Legislature enacted an e-prescribing mandate in 2008. This legislation (Minnesota Statutes 62J.497) required prescribers, pharmacists and pharmacies, and pharmacy benefit managers to begin e-prescribing by Jan. 1, 2011. As of December 2012, 93% of Minnesota pharmacies (986 of 1058) were actively using e-prescribing and additional pharmacies have begun e-prescribing since that time.3 Of the seven different groups measured on this metric in Minnesota, the only group with a higher e-prescribing rate than pharmacies was clinics. For this measure, e-prescribing means secure, bidirectional electronic information exchange

between prescribing providers, pharmacists and pharmacies, and payers or pharmacy benefits managers. Computerized Provider Order Entry (CPOE) allows a provider’s order to be entered electronically which compares the order against standards, checks for allergies or interactions, and warns the provider about potential problems. There are some downsides to MU: Pharmacies are not included in MU as hospitals and eligible professionals are, and therefore are not eligible for monetary incentives. As MU progresses to future stages, it is expected that the e-prescribing requirements will become more difficult.2 For instance, in Stage 1, one of the objectives for eligible professionals is to generate and transmit permissible prescriptions electronically with the goal being that the eligible professional transmit at least 40% of all prescriptions electronically. During Stage 2, more than 50% of all permissible prescriptions written by those eligible professionals will need to be compared to at least one drug formulary and be transmitted electronically using Certified EHR Technology.4 The measures for stage 3 and beyond have not yet been established. Citations: 1 Letter from Senator Al Franken to CMS Acting Administrator Marilyn B. Tavenner, sent May 7, 2012. Material provided to MPhA by Sen. Franken’s office. 2 Email to MPhA dated March 27, 2013,

from Jennifer Fritz, MPH, deputy director of the Office of Health Information Technology at the Minnesota Department of Health. 3 Minnesota e-Health Brief, March 2013. Minnesota Department of Health, Office of Health Information Technology. http:// www.health.state.mn.us/e-health/briefehealth.pdf Accessed March 28, 2013. This document will be available at the MPhA website. 4 Centers for Medicare and Medicaid Services, Stage 1 vs. Stage 2 Comparison Table for Eligible Professionals, August 2012. This document will be available at the MPhA website.

Additional Resources: American Society of Health System Pharmacists (ASHP) Webinar: Meaningful Use Implementation Tools and Review of the Proposed Meaningful Use Phase II Initiatives, recorded Sept. 27, 2012, http:// www.ashp.org/DocLibrary/Education/ Webinars/Meaningful-Use-ImplementationTools.aspx Centers for Medicare and Medicaid Services (CMS). Introduction to the Medicare EHR Incentive Program for Eligible Professionals, August 2012. http:// www.cms.gov/regulations-and-guidance/ legislation/ehrincentiveprograms/stage_2. html Accessed April 1, 2013. Many additional documents are also available at this site. Minnesota Department of Health, Electronic Prescribing in Minnesota website, http://www.health.state.mn.us/ehealth/eprescribing/ Accessed March 28, 2013. Pharmacy Informatics blog, http://rxinformatics.blogspot.com/2012/08/meaningfuluse-stage-2-simplified-for.html, by Chad Hardy, also known as @pillguy.

President’s Desk continued from page 5 mittee was our search committee this year and with their tireless efforts, we identified excellent candidates for our executive vice president leadership position. The fifth step: a ritual of ending. In every ending there is indeed a new beginning. In MPhA, we have a ritual for ending my presidential term as we

all celebrate Jill Strykowski’s inauguration as president. Please consider this a personal invitation to you to attend the MPhA annual meeting: May 17-18, 2013. Please attend and participate, join long-time practitioners, new members, returning members, new graduates, technician trainees, technicians, spouses and

others in lively dialogue and meaningful learning. Here’s a challenge: I have it on good authority the holder of the oldest active pharmacist’s license in the state — Jeanne Erickson — plans to attend ... Will you join her?

Minnesota Pharmacist May-June 2013 n

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Minnesota Pharmacist May-June 2013 n

Industry News

Smart Cards in Health Care By Ann Brigl, PharmD candidate and Maria Agunsoye, PharmD candidate Smart cards are about the size of a credit card and transmit stored information by utilizing magnetic strips. The cards are capable of storing biometric information, photo identifications, and barcode information with the added capability of being able to sync to certain wireless radio transmitters. Smart cards can have several security features that encrypt confidential information that is very important based on the type of data they would more likely contain. The information contained on the cards can be regularly updated using universal medical computer systems. This makes it easy to carry them around and makes for ease of use facility to facility.8 Several countries have introduced electronic medical cards (smart cards) into their medical systems, Taiwan and many European countries included.5 It is an important time to learn about new health care-related technology with the Patient Protection and Affordable Care Act (PPACA) federal health care bill being phased in.6 Facilities that attempt to incorporate electronic medical records to reduce waste and improve patient safety into their system (as with smart cards) are eligible for incentive programs from Medicaid and Medicare.7 The United States is venturing into new territories; therefore, the government may be studying other countries to understand their methods of managing medical information. Electronic medical cards may even be up for consideration in the near future. The PPACA focuses on Electronic Medical Records (EMRs). Medicaid and Medicare have additional reimbursement for medical facilities that have made attempts to transition to EMRs. Electronic medical cards such

as smart cards would be a prime example. Countries such as Taiwan have attempted to use smart cards as part of health care reform initiatives. However, these attempts to use electronic medical cards have lead to increased wait times and various errors with the reader systems.1 Various challenges may be expected with the implementation of any new technology. Smart cards seem like a good idea, because they focus on privacy, accuracy and universal readability for patients who go to multiple facilities. However, physicians are currently charged with updating the information on the cards. Studies done in Taiwan show that if the system depends on only physicians to keep patient information up to date, information such as drug allergies may be omitted.2 However, some studies show that the use of smart cards reduced the use of harmful medications in pregnant women.3 The use of medical smart cards may not be a good choice for our current American health care system, mainly due to a lack of nationalized health care insurance. While we have used other countries’ examples as a way to reform our own health care, smart cards might not be the best step. Smart cards still represent a good idea due the potential for easy and simplified transfer of medical records from one facility to the next, especially since they are not tethered to an Internet connection.4 Logically and realistically, given the current health care climate in the United States, Internet-based electronic medical records that can be easily accessed by various practitioners could be the next step in the evolution of United States health care.

References 1 Liu, Chien-Tsai, et al. “The impacts of smart cards on hospital information systems — an investigation of the first phase of the national health insurance smart card project in Taiwan.” International journal of medical informatics 75.2 (2006):173-181. 2 Hsu, Min-Huei, et al. “Using health smart cards to check drug allergy history: the perspective from Taiwan’s experiences.” Journal of medical systems 35.4 (2011):555-558. 3 Long, An-Jim, and Polun, C. “The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan.” International journal of medical informatics (2012). 4 Lambrinoudakis, C, and Gritzalis, S. “Managing medical and insurance information through a smart-card-based information system.” Journal of medical systems 24.4 (2000):213-234 5 Alliance Activities: Publications : Smart Card Technology in Health care : FAQ. N.p., n.d. Web. 24 Aug. 2012. <http://www.smartcardalliance.org/pages/publications-smartcard-technology-in-health care>. 6 “The Health Care Law & You.” Home. N.p., n.d. Web. 24 Aug. 2012. <http://www. health care.gov/law/index.html>. 7 EHR Incentive Programs.” Home. N.p., n.d. Web. 24 Aug. 2012. <http://www.cms. gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html> 8 Hunt, J., and Holcombe, B. “GOVERNMENT SMART CARD HANDBOOK.” N.p., Feb. 2004. Web. 23 Aug. 2012. <http://www.smartcardalliance. org/resources/pdf/smartcard

Ann Brigl and Maria Agunsoye are pharmacy students at the University of Minnesota. Both students attend classes on the Twin Cities campus. They are currently in their fourth-year rotations. Maria and Ann have a shared interest in healthcare information technology.

Minnesota Pharmacist May-June 2013 n

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Clinical Issues

Clozapine-Induced Neutropenia: A Review of Lithium and Other Currently Available Options

By O. Greg Deardorff, Pharm.D., BCPP, Adjunct Clinical Assistant Professor, UMKC School of Pharmacy, Adjunct Clinical Faculty, St. Louis College of Pharmacy, Adjunct Clinical Faculty, MU School of Medicine, Clinical Manager, Fulton State Hospital, Fulton, Missouri; Kristin D. Ripperger, Pharm.D. Candidate, University of Missouri-Kansas City School of Pharmacy at MU, Columbia, Missouri. Reprinted with permission of the author. Available options are limited for patients with neutropenia needing to be initiated or maintained on clozapine therapy. A common strategy that is often utilized in these patients is the use of lithium as augmentation to clozapine, which enables the health care provider a means of continuing or initiating clozapine therapy. Clozapine is the most effective antipsychotic based on data from the U.S. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)1 and the UK Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS)2, but comes with the associated risk of neutropenia. This article reviews unique aspects of using lithium as an augmentation to clozapine, as well as other strategies that can be considered for maintaining or initiating clozapine therapy in patients with neutropenia. Many times our biggest challenge in using clozapine is finding a way to keep patients from developing neutropenia and keeping the absolute neutrophil counts (ANC) ≥1500mm3 and white blood cell (WBC) counts ≥3000/mm3. This is not an uncommon problem that health care providers encounter with patients on clozapine therapy. The conveyed frequency of agranulocytosis (<100 cells/mm3) and granulocytopenia (< 1500 cells/µL) is 0.6% and 28%, respectively.3 The Clozaril Patient Monitoring Services revealed 0.4% of patients had pre-treatment white blood

cell counts too low to allow initiation of clozapine. Of these patients, 75% were of African or African-Caribbean descent,4 likely due to the increased leukocyte marginalization that has been shown to be more prominent in these populations. Of all neutrophils in the body, 90% reside in the bone marrow and the remainder circulates freely in the blood or deposits next to vessel walls (marginalization). The addition of lithium has been shown to increase neutrophil counts by 2000/mm3, which is in part through demarginalization of leukocytes.5 This increase is not dose related but may require a lithium level of 0.4-1.1 mEq/L depending upon each individual patient.6 Since leukocyte marginalization appears to be more consistent in patients of African or African-Caribbean descent, it stands to reason that demarginalization of leukocytes caused by lithium may have more prominent effects in these populations. A commonly asked question regarding lithium-induced leukocytosis is if this desired side effect increases the body’s ability to fight off infection. To answer this question, we need to understand how lithium is proposed to cause leukocytosis. Lithium not only works by demarginalization or redistribution of granulocytes in the marrow reserve, but also by upregulation of granulopoiesis-stimulating factors, in addition to hypercortisolaemia.6 Hematological parameters gradually

improve during the first week of lithium administration, consistent with the time frame of patients administered granulocyte–macrophage CSF (GMCSF) or granulocyte colony-stimulating factors (G-CSF)3, which are known to boost the immune system to aid in fighting off infections. Lithium opposes prostaglandin E2, which has been demonstrated to have effects on bacteria, parasites, and even pathogenic fungi.7 Prodigious production of prostaglandin E2 causes stimulation of microorganisms and suppression of humoral and cell-mediated immunity.7 Immunostimulation is nonspecific and may be relevant to different types of infections. Lithium has been shown to inhibit the replication of type 1 and 2 herpes virus in cell cultures, in addition to reportedly inducing remission of viral infections such as sinusitis, sinobronchitis, frequent colds, sore throats, cold sores and genital herpes.8-13 A 29-year-old woman with a long history of recurrent skin infections was shown to have diminished polymorphonuclear neutrophil cAMP levels and restored normal chemotactic responsiveness when administered lithium and relapsed when lithium was discontinued.7 In contrast, other articles have shown lithium-induced neutrophils in vitro showing less bactericidal properties than non-lithium induced neutrophils.14 Clozapine continued online at MPhA.org/displaycommon.cfm?an=1& subarticlenbr=154 Minnesota Pharmacist May-June 2013 n

MPhA News

Minnesota Pharmacists Foundation Wine Tasting, February 8, 2013

FURTHERING PHARMACY

ADVANCING

CAREERS Find the best jobs and highly qualified pharmacists Minnesota has to offer.

ONLINE CAREER CENTER

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Minnesota Pharmacist May-June 2013 n

12/13/12 5:00 PM

MPhA News

In Memoriam: Addie Elizabeth Whittemore Addie Elizabeth Whittemore passed away on April 1, 2013. Addie and MPhA Past President Herbert “Herbie” Whittemore have been instrumental in supporting the Minnesota Pharmacists Foundation through the Herb and Addie Whittemore Scholarship. Our annual “Herbie Cup” golf tournament raises funds for the scholarship, which

awards funds to pharmacy students at the University of Minnesota campuses in Duluth and Minneapolis.

Tim Whittemore, and other family and friends. A memorial service was held on April 6 in Edina, Minn.

Addie was 73. She is survived by Herb; sons Mark (Linda) and Greg (Celeste); grandchildren Sgt. Joseph (Esther), Julie (David) Marcum, Joshua (Cassandra), Kate (Chris) Knorr, and

In lieu of flowers, memorials are preferred to the Pequot Lakes Baptist Church, PO Box 117, Pequot Lakes, Minn., 56472.

Is MPPS for You? By Richard Schugel, President

You may be missing out on one of the best kept secrets in the Twin Cities. Have you heard about the Metropolitan Professional Pharmacists Society, better known by the acronym MPPS? Yes, we are a group of not-so-retired and retired pharmacists who meet every third Tuesday of the month, year round, at the Ft. Snelling Officers Club at 395 Hwy 5 and Post Road, just on the South side of the airport.

We are open to all pharmacists, big or small. We gather starting at 11:30 a.m. with lunch — of your choosing — at high noon. Then at 12:30 p.m. we hold a short meeting, followed by our guest speaker. For this you receive one CE credit. We usually finish around 1:30 p.m. We hold our annual banquet in the month of May with part of your dues going toward the payment of the food and program.

We sponsor a plaque and monetary gift given to the student president of the College Board at the University of Minnesota College of Pharmacy. We are a non-profit society that enjoys the camaraderie of fellow pharmacists. So come visit on a third Tuesday and check us out. You will be pleasantly surprised at how well you fit in. We suggest an email ahead to confirm the meeting.

Member Profile continued from page 8 visit, the pharmacist will visit with the patient about their medications and discuss any problems they may be experiencing, including problems remembering to take their medications. We are also schedule immunizations or MTM sessions the patient may be eligible for on that day. The response from our patients has been overwhelming. To date, we have more than 23,000 patients signed up on the Med Sync program and

the number is still growing. We also offer compliance packaging called HealthyPakRx, as a free option with the program, where all of a patient’s medications are packaged in individual pouches, labeled by date and time they are to be taken. We recently completed a one-year study with Virginia Commonwealth University of the effect of our Med Sync program on patient compliance with their medications. (Please see

graph and supporting information.) The study showed that patients with three different disease states on the Med Sync program had approximately twice the compliance rate of a control group. Obviously, we are thrilled with the results of the study and the impact this program can have on patient health and in reducing overall health care costs. Additional charts can be found on the MPhA website.

Minnesota Pharmacist May-June 2013 n

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Minnesota Pharmacist May-June 2013 n

Clinical Issues

Report of Drug Insert Labeling Revisions Based Upon New Efficacy Information By Kent T. Johnson, MSPharm DRUG NAME

NEW INDICATIONS OR DOSAGE INFORMATION IN LABELING

DATE

Fentora (fentanyl citrate)

Revisions to D&A section to include sublingual route of administration.

Feb. 21

Intuniv (guanfacine hcl)

Provides changes to D&A section to inform practitioners that Intuniv can be taken once daily, either in the morning or evening, at approximately the same time each day.

Feb. 20

Zortress (everolimus)

Proposes a new indication: prophylaxis of allograft rejection in adult patients receiving a liver transplant.

Feb. 15

Victrelis (boceprevir)

Expands the indication to include prior null responders.

Feb.13

Lucentis (ranibizumab)

Provides for a new dosing regimen for treatment of Age-Related Macular Degeneration (AMD).

Feb. 6

Epiduo (adapalene and benzoyl peroxide)

Provides for treatment of acne vulgaris in patients 9-11 years of age.

Feb. 1

Prezista (darunavir ethanolate)

Feb. 1 Updates labeling with once-daily dosing of HIV-1 infected, treatment na誰ve pediatric patients 12 to less than 18 years of age (AND) patients 3 to less than 12 years of age; (AND) treatment-experienced pediatric patients 3 to less than 18 years of age with no darunavir resistance associated substitutions.

Gleevec (imatinib)

Provides for the treatment of pediatric patients with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) in combination with chemotherapy.

Jan. 25

Avastin (bevacizumab)

Revises Indication to include second line treatment, in combination with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin based chemotherapy of patients with metastatic colorectal carcinoma who have progressed on a first-line Avastin-containing regimen.

Jan. 23

Botox (onabotulinumtoxinA)

Provides for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have had an inadequate response or are intolerant of an anticholinergic medication.

Jan. 18

Minnesota Pharmacist May-June 2013 n

Clinical Issues

Pronunciation of Active Ingredient Names Of Recently Approved Drug Products By Kent T. Johnson, MSPharm This column provides a guide to pronunciation of the nonproprietary name of active ingredients (or active moiety) in drug products recently approved by FDA under a new drug application (NDA) or a biologics license application (BLA). The list is not exhaustive for every recent approval. For example, some newly approved drug products have active ingredients found in previously approved products. The pronunciation guide comes from: 2012 USP Dictionary of USAN and International Drug Names.

PROPRIETARY NAME

NONPROPRIETARY NAME OF ACTIVE INGREDIENT(S)

PRONUNCIATION

DATE APPROVED

Nesiga

alogliptin benzoate

al” oh glip’ tin

Jan. 25

Kynamro

mipomeresen sodium

mi” poe mer’ sen

Jan. 31

Ravicti

glycerol phenylbutyrate

glis’ er ol fen” il bue’ ti rate

Feb. 1

Pomalyst

pomalidomide

poe” ma lid’ oh mide

Feb. 8

Kadcyla

ado-trastuzumab emtansine

a” doe tras tooz’ ue mab em tan’ seen

Feb. 22

Stivarga

regorafenib

re” goe raf’ e nib

Feb. 25

Osphena

ospemifene

os pem’ i feen

Feb. 26

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MPhA Member Benefits Not a member? Visit mpha.org and join today! The Minnesota Pharmacists Association’s number one priority is its members. MPhA strives to provide services and benefits to our members that not only promote the profession of pharmacy in Minnesota, but the professional lives of our members as well. Ranging from advocacy and communication to discounted professional and business programs, we are always on the search for benefits that are valuable to you as pharmacy professionals. Many of our benefits can be accessed easily through our website. From online dues renewal, conference registration and member searches, we strive to not only make membership valuable, but easy to use and navigate. Not able to find what you are looking for? Contact our office and we can help point you in the right direction. MEMBERSHIP DUES: Check with your employer to see if they cover a portion of MPhA membership. Membership dues can be renewed online and a portion of your dues are tax deductible (consult your tax adviser with questions). We offer a variety of options to make payment more convenient, including a monthly debit program that will debit your credit card, checking or savings account each month (call the MPhA office to set up this feature). ADVOCACY MPhA works to provide members with a “voice” in pharmacy at the state and national levels. The association puts a “face on pharmacy” through media and outreach to health care entities that rely on MPhA for information and resources related to pharmacy services. Through legislative representation, policy planning, and lobbying, the association ensures that issues pertaining to pharmacy are not overlooked or undercut. We fight for the rights of pharmacists and pharmacy professionals to provide the highest level of care to the patients they serve. MPhA encourages members to become involved

in this process by being active in grassroots actions and events. As a member, you will have access to important updates and resources made possible by your support. PROFESSIONAL DEVELOPMENT AND EDUCATION MPhA provides a variety of events throughout the year to keep members involved in pharmacy issues while offering continuing education, networking opportunities and fun! Events are listed on the MPhA website and are open to all. Members receive a discount on selected event programming, such as Annual Meeting, Fall Clinical Symposium, and Midwinter Conference. PRODUCTS AND SERVICES Members benefit from discounted rates and prices on both professional and business related services. Professional Services • Pharmacists Letter • Pharmacists Mutual Insurance • Technician Manuals Business Services • Coupon Redemption Program • PAAS 3rd-Party Audit Services • Credit Card Processing Services • Pharmacists Financial Service • Discounted AAA Automotive Membership COMMUNICATION Communication is our cornerstone of keeping you informed of association, state and national news and action. Minnesota Pharmacist The Minnesota Pharmacist is the association’s journal that contains articles and features on today’s pharmacy topics. It mails to all pharmacists in Minnesota, reaching approximately 9,000 pharmacists, technicians, and students. The journal is published six times per year.

CAPS CAPS is our monthly faxed/emailed newsletter that keeps pharmacy professionals abreast of timely pharmacy issues and happenings. The newsletter is faxed to all pharmacies in the state, and is emailed to all MPhA members. Small Doses Our Small Doses email newsletter goes out to all subscribed members. Weekly e-news shares upcoming events, business topics, important legislative or regulatory issues, and other news. Pharmacy News Flash Once a week, Pharmacy News Flash is delivered by email to members. These updates include news about national issues affecting pharmacists, along with local headlines and job openings. CAREER CENTER Tailored to both our job seekers and employers, our Career Center allows you to browse openings or post opportunities at your convenience. Search for Minnesota locations, or broaden your search to outside states. The center holds a variety of options to tailor results to your needs. RESOURCES Members receive special online access to pharmacy resources. From MTM templates and brochures to information on immunizations, we save you valuable time by having these resources readily available to you for use in your practice.

Call today or visit the MPhA website to join this leading pharmacy association! 651-697-1771 or 800-451-8349 www.mpha.org

Minnesota Pharmacist May-June 2013 n

Not Your Motherâ&#x20AC;&#x2122;s MPhA

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