Elements Magazine Vol. 10 Iss. 4 December 2021

RISKY BUSINESS Risk management strategies for small businesses

RELIEF RX Pharmacy relief agencies come through during temporary staff shortages

THE ROLE OF

VOL. 10 ISS. 4 | DECEMBER 2021

ARTIFICIAL INTELLIGENCE

IN PHARMACY

18

CONTENTS ON THE COVER

18 FEATURE

| The Role of Artificial Intelligence in Retail Pharmacy

DEPARTMENTS NEWS 06

| CancelRx

New study evaluates e-prescribing tool that improves the accuracy of medication lists

FEATURE | The Role of Artificial Intelligence in Pharmacy

08 TRENDS

16

Why every pharmacist should take mental health first aid

12 RETAIL

| Crisis Support

| Shelf Improvement

Best practices for front-end pharmacy shelving

16 SOLUTIONS

26

| Make It Your Own

he advantages of offering your own T brand of OTC products

SPOTLIGHT | Pharmacogenetic Testing

This independent pharmacy personalizes patient care down to DNA

30 MONEY

| Risky Business

Risk management strategies for small businesses

32

OUTLOOK | Relief Rx

Pharmacy relief agencies come through during temporary staff shortages

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

SOLUTIONS | Make It Your Own

3

E

ON THE WEB

ELEMENTS

The business magazine for independent pharmacy

VOLUME 10, ISSUE 4

Find more strategies, tips, and expert advice to improve your business.

DECEMBER 2021 PUBLISHER & EDITORIAL DIRECTOR Matthew Shamet EDITOR Greyson Honaker

The Real Reason Pharmacy Profit Margins Are Declining There’s one statistic in the industry data that doesn’t make headlines. A statistic that tips the profit pendulum.

SR. ART DIRECTOR

Most importantly, a statistic that

Brenda Reagan

pharmacies can actually control.

CONTRIBUTING WRITER Erin E. Rand

Biden’s Executive Order on Drug Pricing Reform INTERESTED IN ADVERTISING? elements@pbahealth.com

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How to Perform a Break-Even Analysis (and Why You Should) This essential equation determines the exact point you start turning a profit.

Learn how to use it to make your business viable for the longterm.

Follow Elements magazine on Facebook, Twitter and Elements magazine is published quarterly by PBA Health. © 2021 PBA Health. All rights reserved.

Neither this publication nor any part of it may be reproduced without written permission by PBA Health.

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NEWS

CANCEL RX New study: e-prescribing tool improves the accuracy of medication lists

T

he implementation of electronic health records (EHRs) has been

After CancelRx was implemented, workflow didn’t change much on

nothing short of a miracle for retail pharmacies. E-prescribing

the prescriber’s end. The e-prescribing software simply prompted

has effectively eliminated the second-guessing of medication

them to identify medications that were being discontinued and

names or dosages while trying to decipher a prescriber’s chicken-

select a reason for why. That information was then automatically

scratch handwriting.

sent to the pharmacy.

But while EHRs have been indispensable in reducing

transcription errors, there is still plenty of room for miscommunication to occur. A prescriber might decide to change a patient’s dosage and send over a new prescription, leaving the pharmacy with two prescriptions on file—but only one of them is correct. Or perhaps a prescriber decides to discontinue a therapy but doesn’t inform the pharmacist, who continues to fill it for

After the study was over, the percentage of medication discontinuations reported to pharmacies went from 34% to 93%

the patient.

Such oversights can cause adverse drug events, which harm

patients’ health and cause $8 billion in unnecessary healthcare expenditures every year. Before now, there was no consistent

CANCEL RX FOR PHARMACIES

way for prescribers and pharmacists to communicate about

For pharmacies, CancelRx made more waves. They received

discontinued therapies, but an innovative piece of technology

approximately 20 to 50 cancelation messages a week. For some

called CancelRx aims to change the landscape of electronic

participating pharmacies, that increased level of communication

communication between prescribers and pharmacists.

proved to be an irritant—especially when the messages were about acute therapies with no refills, like antibiotics. Despite this

WHAT IS CANCEL RX?

frustration, after a bumpy start, most pharmacists eventually

An e-prescribing tool, CancelRx allows prescribers to electronically

acknowledged that the technology was too important for patient

communicate updates about medication discontinuation orders,

safety to stop using it. Nine months after implementation, it only

which means pharmacies can always have accurate medication lists

took pharmacists between 5 and 10 seconds to acknowledge each

for their patients.

cancelation message from CancelRx.

In a recent study of CancelRx at the Wisconsin-based health

Errors sometimes did occur, like when an older prescription

system UW Health, 80 outpatient clinics and 15 community

had already been marked as inactive by the pharmacy

pharmacies implemented the technology in an attempt to reduce

management system or when the prescription had been

information discrepancies.

transferred by the pharmacy to another pharmacy. There were also

occasional technological hiccups if both the clinic and the pharmacy

Before the study, the medical system had no consistent

method for canceling medications and communicating that

did not have the CancelRx functionality activated.

information to pharmacies. Often, employees at the clinic relied

on patients to remember what they were currently taking, and

discontinuations reported to pharmacies went from 34 percent to

many did not feel it was their responsibility to discontinue a

93 percent, significantly reducing the risk that a pharmacy would

After the study was over, the percentage of medication

medication from a patient's electronic health record. Occasionally,

dispense a discontinued medication to a patient and cause an

clinic staff would call or fax pharmacies to let them know about a

adverse drug event.

medication discontinuation, but this level of intentional outreach

was uncommon.

SureScripts, has been around for about a decade but has never

been widely implemented because of the cost. However, SureScripts

Under this system, a mere 34 percent of medications that were

CancelRx, which is distributed by the e-prescribing vendor

canceled at the clinic were also canceled at the pharmacy. Worse, 5

has announced that it will remove financial barriers for community

percent of discontinued medications were later dispensed by the

pharmacies, and the Centers for Medicaid and Medicare Systems

pharmacy, and about a third of those medications were considered

have included CancelRx in its Stage 3 Meaningful Use criteria, which

high risk for adverse drug events.

means it is eligible for the EHR incentive program.

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TRENDS

CRISIS SUPPORT Why every pharmacist should take mental health first aid

I

n the United States, one in five people suffer from a mental illness.

Nearly half of Americans will experience a mental health crisis in

their lifetime. And if those numbers aren’t troubling enough, less than half of the people who had a mental disorder in the past year received professional help.

These were the statistics before a pandemic swept through

the country and upended all facets of life, including vital social connections and access to care. In August of 2020, the Centers for Disease Control and Prevention reported that the number of people with an adverse mental health condition doubled from 20 percent to 40 percent, mainly driven by rising rates of depression and trauma.

Pharmacists aren’t the first professionals that come to mind

when thinking of mental health issues. But they are uniquely positioned to benefit those in need, particularly the 55 percent who never seek care. "Pharmacists have more eyes on patients than any other healthcare provider," said Hannah Fish, PharmD, director of strategic initiatives at the National Community Pharmacist

providing support for someone who might be undergoing an acute

Association (NCPA). "They are going to notice changes in their

mental health crisis, in which case they need to be referred to

patients because they're seeing them more often and because

additional help," Fish explained.

of their highly trained medical background. They are that perfect

bridge to open the door for a patient to talk to someone and get

You see a person collapse with a heart attack, you try to resuscitate

the level of referral that's needed."

until the ambulance arrives and takes over. Much the same,

you see a patient hyperventilate from a panic attack during an

The way for pharmacists to be the bridge, Fish said, is to take

While CPR is triage for the body, MHFA is triage for the mind.

the national Mental Health First Aid (MHFA) training, an eight-

immunization, you support them during the crisis, and then direct

hour course on how to identify and respond to signs of mental

them to professional care.

illnesses and provide initial help and support to someone who may

be developing a mental health problem or experiencing a crisis.

say they have encountered the opportunity to provide mental

In Bishop’s experience as a certified MHFA trainer, pharmacists

"Look for a course, then get trained and train your staff," she said.

health first aid far more often than CPR. And Bishop has personally

"The skills are crucial right now, especially during this time when

found almost no limit to the applications of the training in his

everyone is at their wits' end and probably experiencing some sort

pharmacy. "There are examples every week I could go through. I

of mental health problem."

use parts of it every single day."

When Clark Bishop, pharmacist and owner of five independent

Bishop has trained his staff in MHFA at all five of his

pharmacies, attended the training for the first time, it turned his

pharmacies, teaching them how to have conversations with

worldview upside down. Like many others who have taken the

patients and recognize needs. "We’re arguably the most accessible

training, he discovered how much of his thinking had been driven

healthcare provider," he said. "Someone can walk into our

by social stigma and misunderstandings. "It dispels a lot of the

pharmacy and visit with a staff member when they’re struggling,

misconceptions of the common person," he said. "It’s a complete

and we can use our tool to help them."

change of how you treat mental health issues."

The tool Bishop refers to is ALGEE, an acronym for a series of

actions to perform when you encounter someone developing or PHARMACY’S ROLE IN MENTAL HEALTH

experiencing a mental health crisis. The gist is to approach them

Pharmacists aren’t expected to provide mental health services, or

and assess their health, listen nonjudgmentally, and encourage

to even diagnose mental health illnesses. "It’s really more about

them to get help. Fortified with the knowledge from the in-depth

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MHFA training, staff members can use ALGEE as a shorthand reference to confidently navigate the whole spectrum of mental health crises. "You can apply those five steps to any situation in the pharmacy," said Fish.

The final Es in the acronym refer to two different kinds of

encouragement, personal or professional, based on the level of care they need. "If it's something mild, can you encourage someone to get exercise or do some meditation or some of the general best practices?" Fish explained. "If we're dealing with a mental health disorder, then we encourage professional help: Do you need to see a counselor or a doctor?"

Bishop’s staff uses a couple of methods to recognize when a patient might need aid. First, a patient’s medication profile—looking out

THE ALGEE ACTION PLAN ASSESS for risk of suicide or harm.

Try to find a suitable time or place to start the conversation with the person, keeping their privacy and confidentiality in mind. If the person does not want to confide in you, encourage them to talk to someone they trust.

LISTEN nonjudgmentally.

Many people experiencing a challenge or distress want to be heard first, so let the person share without interrupting them. Try to have empathy for their situation. You can get the conversation started by saying something like, "I noticed that …" Try to be accepting, even if you don’t agree with what they are saying.

GIVE reassurance and information.

for antidepressants, in particular. Second, watching for dramatic changes in behavior or mood.

This is one area where independent community pharmacists

show their unique value in mental health first aid—they know their patients well enough to identify when something is amiss.

And because the staff has relationships with the patients, it

makes patients more open and receptive to the next step in the first aid response: asking them directly if they are thinking of hurting themselves or someone else.

"The first couple times are extremely difficult. You're terrified

when you do it," Bishop said. "But once you get into a rhythm of doing it, it becomes second nature. I probably subconsciously do the five steps of mental health first aid all throughout the day at different periods without even realizing it."

BEST PRACTICES For Bishop, the key to it all is using your ears more than your mouth. "Mostly what I do for mental health first aid is listen," he

After someone has shared their experiences and emotions with you, be ready to provide hope and useful facts.

said, "because a lot of these people haven't had an opportunity to

ENCOURAGE appropriate professional help.

The earlier someone gets help, the better their chances of recovery. So, it’s important to offer to help this person learn more about the options available to them.

said. "Now that the door is open, they become much more willing

ENCOURAGE self-help and other support strategies.

This includes helping them identify their support network, programs within the community, and creating a personalized emotional and physical self-care plan.

so it’s just as accessible to your clerks as it is to your pharmacists.

have someone listen to them in a long time. You'd be shocked at the response you get from the patients."

Even if they don’t want to talk, you’ve still opened a door. "They

now realize that somebody else is capable of seeing that they're going through something and cares enough to ask them," Bishop to talk to you."

To make mental health first aid effective, it takes more than the

pharmacist. The national curriculum is designed for the layperson, In addition to being more helpful to patients, having your staff trained helps with workflow by allowing the pharmacists to stay

Source: www.mentalhealthfirstaid.org

behind the counter when necessary.

Right now, pharmacies can only bill for mental health first

aid services through a collaborative practice agreement with a prescriber, but Bishop hopes that will change in the future. "We have to figure out documentation on e-care plans, get the data, and show the money these third parties are saving before it will become completely reimbursed."

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

9

CULTURAL TRANSFORMATION After he received the training, Bishop applied what he learned to his pharmacy. "I immediately saw a complete culture shift inside of my store because it started changing the way we actually dealt with our patients," he said.

At Bishop’s pharmacy, the staff used to play a game. Whenever

a certain difficult and talkative patient called, everyone put their finger to their nose. The last one to do it had to take the call. "What I didn't realize at the time is that it was having a huge impact on how we treated all patients," Bishop said. "I got the training, it completely changed my perspective on what this person is going through. I no longer think of it as somebody who's crazy or nuts or lost their marbles. I think there's somebody who's dealing with a mental health issue but is capable of being made well."

Then Bishop trained his entire staff in mental health first

aid, and now his employees race to be the first to answer when that difficult patient calls. "They know the kind of impact they can make because they have this new tool," he said. "They are no longer scared of this person or worried about not being able to help them."

In the lobby of the pharmacy, there’s a white board hanging

on the wall. They call it the Community Hope Board. "We invite members of the community to share their victories here and what they have hope for," Bishop said. "Once a few people start writing, it just takes off and I have to erase it and start all over again because so many people are sharing. It’s amazing."

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OUTLOOK RETAIL

SHELF IMPROVEMENT Best practices for front-end pharmacy shelving

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W

hen designing your pharmacy space, shelving might seem

like a utilitarian choice: shelves do the simple job of holding

patients will have another opportunity to browse on the way out.

By placing your retail checkout counter at the front of the store,

up your merchandise. But your shelving can affect everything

But they might take a different route, so be sure to consider the

from how patients move throughout the store and interact with

shelving at the perimeter of your store, as well. Wall units can be

merchandise to how they perceive your pharmacy.

used in conjunction with lighted canopies to draw patients in.

DiOrio noted that pharmacy owners should be aware of local

"The design of your retail shelving can have a significant impact

on revenue," said Steven DiOrio, marketing manager for Storflex

laws when creating a floor plan because every state has different

Holdings, a retail store fixture manufacturer. With proper shelving

requirements when it comes to the spacing between aisles.

and store design, you can create a friendlier shopping experience for your patients by improving the organization of your front end

FORM AND FUNCTION

and enhancing the visibility of your merchandise.

Pharmacy shelves should be attractive enough to create a welcoming

atmosphere, but you should never prioritize aesthetics over function.

Shelving isn't just a matter of picking out some gondolas and

end caps and putting your products on them. It is an extension

A few simple investments can add some flair to your shelving.

of merchandising, helping you arrange your products in a way

"If your pharmacy is in a high-end geographic location or you

that makes them more appealing to patients. "Pharmacists must

want to impress your customers, gondola shelving units featuring

develop a strategic design centered around merchandising," said

slatwall panels with a beautiful wood-tone finish won't hurt or

DiOrio. "A terrific way to look at it is by taking each three-foot or

sacrifice the merchandising functionality business owners require,"

four-foot section and developing a plan for each area."

DiOrio said. Another budget-friendly option is to add mica panels

How you display your products affects patients' perception.

Not every item in your pharmacy will look great on a shelf. In your

on your end cap displays. Adding a wooden top to your gondola shelves can both improve the appearance and create more space

oral care section, for example, toothbrushes won't be appealing

for merchandise that lands right at patients' eye level.

if they are scattered on a shelf. Instead, achieve a cleaner look by

Show off some of your pharmacy's unique flair by

displaying toothbrushes on peg hooks hanging from slatwall. On the

incorporating the colors of your pharmacy branding into the

other hand, toothpaste should be displayed on shelves only, so that

shelving or adding eye-catching signage or decor.

patients can clearly see all the diverse options your pharmacy carries.

you can keep it that way for a long time. DiOrio recommended

One of most important shelving units in your store is the end

The good news is that once you've settled on the right shelving,

cap, which needs strategic arrangement to maximize value. "Most

sprucing up your displays every five to seven years. In the interim,

retailers think that end caps should be for your most popular

focus on keeping your shelves clean and tidy. "Many customers

products," DiOrio said. But in reality, they are a chance to increase

view pharmacies as an extension of a medical facility. Therefore,

exposure to your most profitable products. "When designing a

pharmacists must keep their stores as clean as possible, including

store with the goal of boosting profits, you want to merchandise

the store fixture displays and retail sales counter," he said.

your highest-profit margin items on those end unit displays."

CREATING A FLOOR PLAN Your shelving unit choices influence your floor plan, which dictates how patients move around your pharmacy. Typically, the pharmacy department is at the back of the store because it’s most people's ultimate destination. Creating retail displays that encourage people to browse on the way to the pharmacy counter increases the chances they will add something to their cart. "When creating a floor plan, the goal is to increase sales of impulse items," DiOrio said.

The design of your retail shelving can have a significant impact on revenue.

Most of the shelving in the middle of the floor will be gondolas,

which are double-sided islands. Gondolas can display a wide variety of merchandise and can be strategically placed to encourage flow through the pharmacy in a specific direction. To encourage impulse buys, DiOrio recommends "prominently featuring end cap displays and other free-standing displays around the sales counter," in addition to standard gondolas.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

13

SHELVING FAUX PAS High-quality shelving can encourage people to shop more, but low-quality shelving will work against you. DiOrio emphasizes investing in good shelving as a customer relations strategy. With well-maintained shelving, you will create a positive impression as soon as patients walk into the pharmacy.

When planning a remodel, shelving should be one of your first

priorities. Set the budget for shelving at the very beginning of the

CHOOSING THE RIGHT GONDOLA SHELVING

process so that you don't get to the end and realize you can't afford the shelving that works best for your store.

Worn or cheap-looking shelving will negatively color patients'

impression of your pharmacy. If a shelf is falling apart or poorly maintained, patients might subconsciously worry about the quality of the merchandise displayed on those shelves. Look out for chipping paint, sagging shelves, or cracks in your shelving and take quick action to repair or replace them.

Shoddy shelving can also pose a physical danger to your

patients. If shelves aren't sturdy, they could fall over or cause patients to trip. Aisles that aren't wide enough can create accessibility problems for patients using mobility aids. Walk through your front end periodically to examine shelving and identify any potential hazards or age-related deterioration.

Gondola shelving is the most versatile option for showcasing your pharmacy’s front-end merchandise.

You can mix and match pieces to create the perfect setup based on the products you sell.

Here’s what to consider before investing in new gondola shelves.

SIZE Consider the size of your pharmacy and how patients move around the fixtures. If shelves are too big, your pharmacy will feel cluttered and crowded. If they are too small, you miss out on merchandising opportunities.

Also reference local laws regarding aisle width.

MATERIAL

Many customers view pharmacies as an extension of a medical facility. Therefore, pharmacists must keep their stores as clean as possible.

Metal shelving is more affordable and easier to keep clean. It can also be more versatile, allowing you to change shelf spacing and add features like hooks for hanging merchandise. Wood shelving is pricier, but can give your pharmacy a high-end feel. Wood shelves can also be custom fit to your space.

ACCESSORIES Think about what will be displayed on and around your gondola shelving unit. Will the products benefit from additional undershelf lighting? Should the products be hung on hooks rather than set on a shelf? Will you add an end-cap display for cross-merchandising?

STYLE Your shelving should complement the rest of the pharmacy’s look and feel. Customize the steel colors to coordinate with your pharmacy branding, or upgrade to a wood-toned pegboard or slatwall. Also consider how you will incorporate signage into your shelves.

Sources: Storflex Holdings, Shelving Design Systems

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SOLUTIONS OUTLOOK

MAKE IT YOUR OWN The advantages of offering your own brand of OTC products

C

ostco has Kirkland; Walmart, Great Value; Target, Good & Gather.

retailers to funnel purchases to their products. The retailer controls

Think of any major retailer and fill in the blank. They all have

the positioning, the in-store marketing, and the prices of those

their own private brands, which span categories: household goods,

products—meaning they have all the means to direct shoppers to

apparel, pharmaceuticals, health and beauty.

their brand over the competitors. Moreover, consumers who trust

If there’s a unanimous trend among the large chain retailers

the retailer are likely to trust their brand.

across industries, there are probably good reasons. Costco’s

Kirkland Signature brand is worth $40 billion, Walmart’s Great

independent retailers are getting in on the trend, including

Though this practice is seen at major corporations, some

Value $27 billion, and Kroger’s private brands $23 billion. Store

pharmacies. Whit Moose, owner of Moose Pharmacy in North

brands account for more than a quarter of many of these retailers’

Carolina, had noticed a lot of demand for probiotics, but he wasn’t

total sales.

satisfied with the quality of the available brands and generics.

At the same time, he had been thinking of ways to promote his

In a recent poll, 63 percent of American consumers said they

plan on buying more private label goods in the future. According

pharmacy. That’s when he had the idea to invest in his own line of

to CB Insights, a technology data platform, private label sales are

high-quality probiotics, branded with his pharmacy’s logo. "When

poised to account for a quarter of all sales for packaged goods in a

patients go home and take their vitamins or supplements, that's

few years.

our name and our logo they see when they open that bottle every

day," he said. "Just the name recognition part of it is huge."

Store brands are often a product of "white labeling," which

is the process of purchasing goods from a manufacturer and

branding them with your own label. These products are referred

Moose’s strategy was ahead of the curve. In the past, private labels

Looking at the current landscape of store-branded products,

to as private label, store brand, or owned brand. For example,

were seen as inferior but much more affordable than their brand

Walmart, Target, and Amazon all get their acetaminophen from

peers. But now, store-branded products have grown into legitimate

the same manufacturer (Perrigo) but put their own brand's logo on

competitors in quality and variety while still winning the pricing battle.

their bottles.

than he makes selling generic versions. But he earns about the

On average, private labels earn margins 20 to 35 percent

higher than brand names. Creating a store brand also allows

16

pbahealth.com/elements

In general, Moose makes more money selling his own brand

same as the pharmaceutical-grade and name brands because of

his commitment to quality. "It’s not like you’re buying it for pennies

products based on demand, he is cautious before making any

and selling it for a huge amount," he said. "We wanted it to be a

decisions because of the volatile nature of the supplement industry.

quality brand and a product we could expand on."

"Most of what we have are tried-and-true. They’re not fads," he said.

"You have to be nimble enough to strike when it’s hot, but at the

But quality not only elevates the pharmacy's brand, it also

makes the products more desirable. He’s found that over time

same time, supplements come and go. By next year something new

patients prefer his products over the cheaper alternatives because

will come along and everyone will have forgotten about it."

they provide the greatest benefit.

and apply your pharmacy’s labels for you. Moose decided to

"All in all, I’m pleased with how it’s gone," Moose said. "It is a

Most vendors that offer a white label option can also print

great opportunity to put your name out there, and as independent

produce his own labels through a marketing firm for more creative

pharmacies we want people to see our name on people’s shelves,

capabilities and more control over the final product. "What we were

not Walgreens and CVS."

looking for was more advanced than what a lot of these folks were

GETTING STARTED

professional product."

willing or capable of doing," he said. "We wanted ours to look like a The hardest part of getting Moose's private label off the ground was finding a supplier. Many manufacturers that he preferred couldn’t or

MAKE THE PRIVATE LABEL SUCCESSFUL

wouldn’t provide a private label. It would have been easier if he was

The most important decision for store-branded products is how

willing to settle for lower quality, but Moose prioritized products that

to price them. Pricing varies depending on the retailer's goals and

he knew would benefit his patients the most.

what else is on the shelf. Because Moose chose to focus on quality,

he must walk a fine line. "With our community, we try to be price-

He began by picking up the phone and contacting vendors he

already used and liked, asking if they could make him a private

conscious, but this is not the cheapest product you can get," he said.

label. Most were worried about increasing competition with their

branded products or lacked the production capacity to supply a

alongside theirs, giving patients a "good, better, best" option to suit

private label. Eventually, after much Google searching and cold

people of every financial situation. Moose’s version is the "best" in

calling, he found a quality brand to partner with.

each category, but its price point lands between the generic and

"It’s been a good choice and a good relationship," he said. Since

The pharmacy sells the generic and brand name versions

the brands.

then, he has broadened his partnerships to expand his assortment

and has changed some suppliers after they stopped servicing the

educates them on the alternatives, noting many of them aren’t going

When someone comes in for brand-name products, Moose

pharmacy. "One thing we learned was to make friends, find other

to give them nearly the benefit that Moose’s will. "This is not the

vendors that you can use," he said. "Because you never know what

cheapest product you can get, but quality-wise you can't beat it," he

might happen with your current vendor."

said. "You are more likely to get the results you’re looking for."

After seeing the success of his probiotics, he started adding

Much of Moose’s private label success has come through

more supplements based on popularity and trends. "As we would

prescriber referrals, which began unexpectedly. During a meeting

see a product that was about to take off, and we felt like it would be

about his compounding service, he offhandedly mentioned his

a good fit with what we were doing, we would add additional ones."

probiotics. To his surprise, the prescribers were much more

interested in those than in his compounding.

Now the pharmacy offers 15 products branded with Moose

Pharmacy’s logo, all in the supplement category. Although he adds

"The one we offered was so much better than what they were

recommending to patients," he said. "So we were able to get on their formulary and in their dispensing or prescribing software, and now we get referrals from the local GI doctor group. When that happened, it really took off."

When patients go home and take their vitamins or supplements, that's our name and our logo they see when they open that bottle every day.

Moose wishes he would have been more confident when he

started out. A part of making this work, he said, is "taking a leap of faith." As an independent, the risks aren’t as great because you can adapt quickly. You don’t even have to revamp your entire inventory.

Moose said many of these vendors will let you buy just a dozen of the items to test out. "If you get a deal like that, what’s the worst that can happen?"

In the end, Moose thinks most independent pharmacies can

create a private label that works. "Give patients a good reason to buy," Moose said. "And if you can do that, if you believe in it, if you understand the products, then I think you can be successful."

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

17

FEATURE

THE ROLE OF ARTIFICIAL INTELLIGENCE IN RETAIL PHARMACY

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W

hen you think of artificial intelligence, what comes to mind? A killer cyborg from the future? A Pixar robot saving humanity

from itself? A virtual assistant who can fall in love?

AI holds the potential to enable community pharmacies to be even more proactive and personalized in how they understand and serve their patients.

Although artificial intelligence (AI) is still in its early stages, it

is no longer just the projection of Hollywood and science fiction.

"Because of all the advances in computing, artificial intelligence is not pie in the sky," said Ken Perez, vice president at Omnicell, a multinational healthcare technology company. "It's something that is already occurring."

Artificial intelligence is nearly everywhere in life, though it

isn’t the kind of thing that will destroy or save all of humanity.

Its application is more mundane, powering many of the daily conveniences we now take for granted: search suggestions, autocorrect, face recognition, chatbots, ridesharing apps, social media recommendations, Spotify playlists. Machine learning powers Apple’s Siri, Amazon’s Echo, and Google’s Assistant.

Likewise, you might not recognize AI even though it powers familiar pharmacy technology. "For the most part, AI is under the hood of various solutions," Perez said.

AI solutions in retail pharmacy can offload laborious, menial,

and time-intensive tasks so pharmacists can center their time

To illustrate, Subramanian gave the example of a GPS. On a regular

around patient care. "The technology is going to aid in reducing the

computing model, the program will tell you when to turn to reach

pharmacist’s load so that they can actually practice at the top of

the chosen destination. With AI, the program will not only tell you

their training," said Ram Subramanian, PhD, chief technology officer

which path to take but will adjust the route in real-time based on

at InterLinkAI, an automated pharmacy management system that

changes in the environment, such as a pedestrian crossing the

uses machine learning.

street or a red light. "It's not just blindly taking a right or left. It's

actually sampling some information from the environment, and

Although it may sound counterintuitive, leveraging more

technology will enable independent pharmacies to become

then based on known examples that we've used in the past, it's

more human, and more personal, than they have been since the

going to make the best decision possible."

soda fountain days. "AI holds the potential to enable community

pharmacies to be even more proactive and personalized in how

and the computer choosing one of them depending on the

they understand and serve their patients," Perez said. "AI is the

circumstance. Instead, it’s the result of the machine mimicking

engine that empowers them to do even better personalization."

brain neurons by organically reconfiguring connections as it learns

AI DEFINED

explains it like this: "With life experience, depending on a particular

Most simply, artificial intelligence describes computer systems that

person’s trials and errors, the synaptic connections among pairs of

mimic the brains of humans. Perez puts it this way: "How can a

neurons get stronger or weaker. An artificial neural network could

This isn’t the result of humans inputting a bunch of formulas

new data. Gideon Lewis-Kraus, in New York Times Magazine,

computer simulate the intelligence of the human being?"

do something similar …. It wouldn’t need to be preprogrammed

with fixed rules. It would, instead, rewire itself to reflect patterns in

Humans can input new information (learning) and change

their output (behavior) based on what they learned. They can

the data it absorbed."

make judgments based on context and situation. They can identify

patterns and adapt. They can recognize things visually. The goal of

computer and it can come up with all kinds of insights on its own,

AI is for a machine to imitate those kinds of abilities.

even ones humans would not have expected. "With big data you

can extract information automatically," Perez said. "You can sort

Most of the time, the phrase artificial intelligence really refers

That means you can give massive amounts of data to a

to "machine learning," a subset of AI. As the name indicates,

it. You can analyze it. You can apply algorithms to it. And you can

machine learning systems process information and change their

actually learn and draw conclusions and derive insights."

output organically as they learn new things. The machine identifies

patterns over time, building an increasingly complex database that

unprecedented potential. Because there is no limit to the amount

enables it to respond more specifically to any given situation and to

of data an AI machine can absorb, it can not only copy advanced

This unique capacity for data analysis and application unlocks

more scenarios it hasn’t encountered.

human abilities but surpass them. "Computers can do some

amazing things that would take smart people with PhDs literally

"We're using a lot of data in order to develop a decision-making

system that then tells us what to do next. Given an input, what

decades," Perez said. "The algorithms draw conclusions that are

should we do?" Subramanian explained.

way beyond what a lot of humans can do."

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

19

AI IN THE PHARMACY With its unique ability to mine and track tons of data, machine

SEVEN WAYS AI CAN IMPROVE PHARMACY BUSINESS

learning can make calculations and predictions more quickly and accurately than humans. This predictive prowess can drive all sorts of optimizations in inventory management, workflow, patient treatments, patient interactions, and customer service.

"There’s a huge variety of things that pharmacists can use,"

said Scott Nelson, PharmD, assistant professor of Biomedical Informatics and director of the MS Applied Clinical Informatics (MS-

Personalized care

ACI) program at Vanderbilt University. "Some of those will help the business in terms of workflow and in terms of having better quality

Drug diversion prevention

control and better adherence for patients."

For workflow, AI can streamline operations by optimizing

staff levels to match expected traffic, reducing the time to fill with automatic pill counters, and minimizing wait times with more

Reduced medication errors

accurate timing for prescription pick up.

Computers can do some amazing things that would take smart people with PhDs literally decades.

"Think of a pharmacy getting 50 orders within the hour. AI can

Improved medication adherence

Inventory optimization

More efficient operations

Delivery optimization

Better patient monitoring

SKUs in real time; minimizes holding costs through precise

determine which order has a higher priority because the patient is

forecasting; syncs inventory purchases more closely to the time of

more likely to pick it up within the hour versus picking it up after an

pickup; and more.

hour," Subramanian explained. "So now you can prioritize which prescriptions you're going to package first. There are nuances that

PERSONALIZATION

will ease any sort of bottlenecks in the workflow for the pharmacy."

AI enables more precise and personalized care by learning a lot

about your patients: who is unlikely to adhere, who might need a

Technology exists to translate e-prescriptions, saving at

least 10 seconds per prescription while improving accuracy from

consultation, who needs medication reviews, who needs delivery,

40 percent to 90 percent compared with manually transcribing,

who will respond to what type of intervention.

according to one company. AI populates all the necessary fields,

flags missing information, and substitutes NDCs based on current

who would benefit from patient communications or medication

inventory stock—all automatically.

therapy management, or who would be more likely than not to

respond well to these actions," Perez said. "Understanding who will

AI can help pharmacies master inventory control with greater

precision, helping them order the right items in right quantity at the

"Predictive and prescriptive models can identify individuals

respond to which interventions is as important as understanding

right time. It does this in several ways: predicts demand by mining

who needs those treatments."

historical and real-time purchasing data and other factors; reduces

costs by finding the best prices and tracking contract incentives

its patients into very specific categories with common behaviors,

to maximize rebates; minimizes spoilage by monitoring individual

allowing the company to tailor its service to better meet needs.

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Perez described a company that is already using AI to segment

"At first they say we're talking about women who live in rural areas

to identify the pills, so there's no chance of a wrong medication

in the Northeast who are between the ages of 30 and 40 who have

getting to the patient," Subramanian explained.

two children," Perez explained. "They discover these women don’t

pick up medications from retail pharmacies. Why is that? Because

virtually, which means a single pharmacist can work at multiple

With this technology, pharmacists can verify prescriptions

it’s hard to get daycare. They've got two kids, not one. It's a hassle

locations without leaving a computer. A remote pharmacist can,

to put them in the car and it's treacherous driving. There's ice and

among other benefits, provide extra support during peak hours

snow. And during these months from, let's say November through

but simply be on call during regular hours. This not only enhances

February, the retail pharmacy should ask if they would like their

operational efficiency but also provides a safer environment by

medications mailed or delivered."

allowing pharmacists more breaks and preventing long shifts that lead to errors.

SAFETY

Artificial intelligence is especially suited to improving safety in the

different data sources, it is effective at preventing controlled

pharmacy. It can reduce adverse events and errors by noticing

substance diversion, Nelson said. AI can continuously analyze

immediate problems, like the wrong number or kind of pill, and by

prescription information with a patient’s entire history in view and

foreseeing potential problems, like who may experience serious

spot predictors of opioid abuse the instant a prescription comes in.

Because of AI’s ability to quickly identify patterns among

side effects.

"It could identify weird outlier medications, like wrong dosage

FUTURE OF PHARMACY

or wrong patient, and it would flag those errors," Nelson said.

Although artificial intelligence offers much promise, its practical

With fully adopted AI applications, perennial issues related to

application will be limited until there are more robust and universal

polypharmacy and drug-drug interactions could almost disappear.

data-sharing solutions among all the stakeholders in healthcare.

But AI can go beyond noticing outliers through information

"One of the key challenges is the gap between pharmacists

alone—it can recognize objects visually as we do. In a sense, it has

who understand the problems and workflows, the developers

eyes. Just as a pharmacist would notice a pill is blue instead of red,

and data scientists who create the model, and the administrators

artificial intelligence can spot errors by "looking" at it through a

who make decisions about which AI solutions to client," Nelson

photo lens.

said. "There's a gap that needs to be crossed to bring together the

leading science and the clinical practice."

Subramanian referenced technology by InterLinkAI that

not only counts pills but also scans them visually. If a clonidine

accidentally mixes in with clonazepam, for example, the machine

technology, they are at the whim of companies to provide the

And no matter how enthusiastic pharmacies are about AI

will recognize the difference in the lettering and send an alert even

solutions. "They need vendors to aggregate the data and apply

though the pill count is accurate.

algorithms to build the models and to produce the analytics and

"From a safety standpoint, not only are we recording an image

of every code being dispensed, but every code is also using AI

generate recommendations, and those need to be integrated into work," Perez said.

AI will continue to grow and transform retail pharmacy in

ways even unforeseeable right now. There was a time when it was inconceivable that a computer could translate language on its own or that cars could drive themselves. What will AI be capable of in ten years from here? And how could that transform pharmacy

The technology is going to aid in reducing the pharmacist’s load so that they can actually practice at the top of their training.

profession?

Since its inception, the prospect of artificial intelligence has

made humans apprehensive. What if they replace us? What if they render essential human jobs extinct? Nelson suggests using the phrase "augmented intelligence" instead of artificial intelligence to emphasize AI’s true role in improvement rather than replacement.

"It's here to help us with mundane tasks that we as humans

typically don't like doing, which then frees us up to do more human things faster and better, thereby allowing us to do more complex higher-level thinking," Nelson said. "It allows us more time for compassion and empathy with our patient. No matter how good an AI model is, it's never going to be there to hold the patient’s hand when they're going through a hard time or to listen to their concerns. We're the only ones who can do that."

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

21

AI IN THE FRONT END Machine learning can enhance numerous areas in front of the counter to improve the customer experience and increase retail sales. Here are some of the most important retail applications of artificial intelligence.

INVENTORY With machine learning, AI can mine sales data, market data, seasonal trends, local events, individual customer data, and more to

LOYALTY

determine what to stock and when

The depth of AI analytics makes

to stock it to meet the precise needs

loyalty programs more effective by

of your customers and fluctuating

enabling an intricate understanding

supply and demand. That translates

of individual customers—so you

to having the right items in the right

have a better idea of what exactly

quantity at the right time.

will keep them engaged with and committed to your pharmacy.

SENTIMENT ANALYSIS AI can search the web for references of your pharmacy and evaluate the comments to determine how people feel about you, whether positive, negative, or neutral. The data can be segmented into various categories—like wait time, item availability, or pricing—so you can focus on improving specific areas that customers may feel negative toward.

PROMOTIONS Predictive analytics can be disturbingly precise. Even 10 years ago, Target’s machine learning was able to identify women who were pregnant based on their shopping data. The technology can help you segment customers to create more effective promotions—like sending a diaper coupon to an expectant mother.

IN-STORE INSIGHTS Cameras powered by AI can analyze traffic patterns in your store to learn how shoppers navigate. What path do people take? Where do

SHELF CHECKS

they spend the most time? When is the store busiest? The data can

With cameras homed in on the shelving

be segmented by different criteria, like demographics and seasons.

units, AI can prevent many problems that

Some of this technology is sophisticated enough to track facial

human employees can’t keep a constant

gestures and physical interactions with products, such as picking up

eye on—stockouts, label mishaps, and

an item and putting it back. These insights enable you to optimize

inconsistencies in inventory arrangement.

your store layout, product placement, and in-store marketing.

PRICING With access to the right data, AI can determine the best price for any given item.

It can base its recommendation on your priorities, too. Do you want a certain profit margin? Do you want to turn them quickly to prevent spoilage? Do you want volume? Do you want to match the competitor?

CHECKOUT Self-checkout machines are prevalent at the national chain and big box stores, but AI provides an even more convenient way to check out. In 2016, Amazon introduced its first brick-and-mortar grocery store. The truly groundbreaking feature was that there were no cashiers. Shoppers simply put the items in their bag and walked out. Cameras and sensors automatically recorded the purchases and charged them to a credit card. Though this

THEFT AI can quickly spot deviances from the norm that could indicate theft.

While you might assume that DayQuil

technology may be out of reach for community pharmacies now, it may become more accessible in the future.

is disappearing because it’s winter, AI notices that the demand is irregular even for the season. Its understanding is based on vast amounts of historical and real-time data, so it can be more precise in its awareness.

CUSTOMER SUPPORT Chatbots serve as the first line of response to questions customers might have about logistical or technical issues that don’t need an actual human to resolve, such as how to return a product or even the side effects of medications. In addition to reducing staff workload, chatbots improve the customer experience because they are available 24 hours a day and respond to questions immediately.

SPOTLIGHT OUTLOOK

GENETIC GOLDMINE This independent pharmacy personalizes patient care down to DNA

P

eeking into your patients’ DNA to gain insight into their

as expected, but now pharmacogenetic testing offers a shortcut.

treatment might seem like something out of science fiction.

Greenwood Pharmacy started offering pharmacogenetic

But with pharmacogenetic testing, sometimes known as

testing in February 2019 after hearing about the service at trade

pharmacogenomic testing, looking at genes isn’t just a plot from

shows. "We were interested in helping people understand how

a Jurassic Park movie. It’s accessible technology you can use to

that one piece of themselves—their genetics—can impact how

personalize patient care.

their medications will work for them in the future, in addition to

all the other things that can impact how medication therapies are

Greenwood Pharmacy and Compounding Center, an enhanced

services pharmacy located in Waterloo, Iowa, started offering

effective or ineffective for people," Nichols said. "It's the kind of

pharmacogenetic testing as a way for patients to learn more about

thing we'd learn about in pharmacy school, but up until that point,

themselves and their medication therapies.

we didn't really have a good means of implementing it."

"Since we are practicing as an enhanced services pharmacy,

Pharmacogenetic testing works by testing a saliva or blood

we try to focus on optimizing the medication therapy for each

sample from a patient and looking at a set of genes known to

individual patient," said Rob Nichols, a pharmacist at Greenwood.

influence how drugs are metabolized. By looking at variations

"This was another tool that would allow us to move closer to

within these genes, pharmacists can assess the effectiveness of the

precision medication."

patient’s drug regimen. For example, they may find that the patient

Most pharmacists are familiar with this scenario: a drug that

works perfectly for one person doesn't have the desired effect on

is metabolizing drugs faster than average and would therefore benefit from a higher dose to achieve the desired outcome. If a

another, or one patient suffers from the worst side effects while

patient has a slower metabolism, they could need a lower dose to

others don't have any side effects at all.

avoid side effects.

The reason for these differences lies in patients' DNA, which

Having a pharmacogenetic test on file can also help prescribers

affects how they metabolize drugs. In the past, physicians and

make better decisions from the beginning because they can

pharmacists would have to go through months of trial and error to

prescribe the right drug and dose right off the bat.

figure out the right drug and dosage if a medication wasn't working

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METABOLISM PHENOTYPES

PERFORMING THE TEST At Greenwood, patients who want to receive pharmacogenetic

When you perform a pharmacogenetic test, each gene tested will be classified with a metabolism phenotype.

These phenotypes indicate the enzyme activity for each gene, which in turn gives providers a clue about how patients will react to their prescribed medications.

fill out a consent form and a mini medication review. Nichols

The phenotypes are defined by the Clinical Pharmacogenetics Implementation Consortium as:

testing services can sign up for an appointment through the pharmacy's website. At their scheduled appointment, they will explained, "That's so we can appropriately evaluate all their current medications with the test and start thinking about potential future medications."

After collecting the patient's medication history, health

history, and allergy history, they swab the cheek to collect DNA data from saliva and send that sample off to a lab. After

NORMAL METABOLIZER (FORMERLY EXTENSIVE METABOLIZER)

about three weeks, the pharmacy receives results from the

These patients will metabolize drugs at a normal rate, meaning they can take the standard dose.

the pharmacist goes over the test results with the patient and

INTERMEDIATE METABOLIZER

The pharmacist also discusses the results with the patient’s

These patients metabolize drugs more slowly, meaning they could experience unwanted side effects at a

lab that break down the genetic reactions of the patient. Then discusses how it affects their current and future treatments. healthcare providers and makes recommendations.

Certain types of patients are particularly strong candidates

normal dose and could benefit from a lower dose.

for pharmacogenetic testing—those who have been prescribed

POOR METABOLIZER

effects or adverse medication reactions, and those who are not

These patients metabolize drugs even more slowly than intermediate metabolizers. This could cause an accumulation of the medication in the body. Even at a lower dose, poor metabolizers could experience unwanted side effects.

four or more medications, those experiencing unwanted side responding to their current medications as intended. Nichols has established relationships with medical practices in the area that will refer their patients for pharmacogenetic testing, including pediatricians and mental healthcare providers. "Those are the patients we work with most often," he said. "But realistically, we will work with anyone who is interested in learning more about

RAPID/ULTRARAPID METABOLIZER

their genetics."

These patients metabolize drugs more quickly than a normal metabolizer, meaning the drug could metabolize before it achieves the desired effect. They may need a higher dose to attain the desired effect.

Nichols finds that the vast majority of patients who use the

pharmacogenetic testing service gain useful information for the future, regardless of why they chose to take the test. "When we are able to gather more information about patients, we can always find something that can be implicated about their current or future therapy," he said. "It may be something that we can suggest to the provider if they need to go another route with medication choice or dosage. At the very least we're able to give some education on things they will need to keep in mind about how their future medication therapy choices will be impacted by the pharmacogenomic data."

Typically, the pharmacy receives about one referral for the

service a month, but it's a service that patients value highly.

Nichols said, "The patients we do interact with are very grateful for the breadth of information that we have regarding their genetic profile."

WORKING WITH VENDORS Since pharmacogenetic testing is done in a lab, you will have to find a company to partner with. Many labs offer pharmacogenetic testing, but they aren't all created equal. When choosing a vendor, look beyond the price point and investigate what each testing panel actually tells you. Some testing companies will give you information pertaining to 45 genes, while

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

27

other companies will only test for 30 genes. Ask vendors to provide you with a sample report so you can get a detailed idea of what kind of information you will be able to share with your patients.

"The feedback we have been getting from our patients is that

our panel is more extensive and provided at a lower cost than what they are able to find online," Nichols said.

When Greenwood Pharmacy decided on Rx Genomix as their

vendor, they enrolled with the company as a provider, which means they can send samples to the company's lab for testing. They pay Rx Genomix for each test rather than paying on a contract basis.

"It's very simple. We send the tests in and receive the lab

reports, and then we get an invoice for the test, which we pay for," Nichols explained. "It allows for really good cash flow prediction, which made it an easy decision for us to start offering the service."

On the patient side of the payment equation, some insurance

plans cover pharmacogenetic testing, but that coverage is spotty.

Greenwood offers their pharmacogenetic testing as a cash service, and the service began turning a profit just a few months after implementing it.

IMPLEMENTING PHARMACOGENETICS

WHO IS PHARMACOGENETIC TESTING FOR?

"It's still a relatively new service, but it was nice when we started to

Most patients can benefit from learning more about how

and those referrals really helped us along," Nichols said. "I would

Like any new service, one of the biggest challenges Greenwood Pharmacy faced was simply getting the word out to the community. have providers reach out to us asking questions about the service,

their genes affect their medical treatment, but certain

definitely recommend that people reach out to local providers to

conditions are more frequently treated with medications

see who is interested." Tell them about the test that you offer and

that have a pharmacogenetic implication. Patients with

the kind of results you can share with patients, because they may

these conditions may see an even greater benefit from

see a way to apply that information to their practice.

pharmacogenetic testing:

Another asset Greenwood had when starting its program

was an online scheduling program where patients book their

• Acute or chronic pain • High blood pressure • Depression • Anxiety • Mental health conditions • Diabetes • High cholesterol • Cancer Source: Rx Genomix

• Arthritis • Acid reflux • Peptic ulcer • Migraines • Thyroid disorders • Asthma/COPD • Heart attack

appointment online. "It made things a lot easier that we could predict when people were going to be interested in the service and make sure to have it available for them," Nichols said. "It definitely helped us manage our workflow a little better."

Training staff on the cheek swabbing was fairly easy, as the

skill overlaps with some of the other services the pharmacy offers.

"There's not much of a training barrier," Nichols said. "We were doing the nasal swab for patients during Covid, and transitioning to a cheek swab for the pharmacogenetic testing meant that training for that collection was really easy."

Greenwood Pharmacy is one of the University of Iowa’s

community-based residency sites, and the residents can easily perform the service. "In pharmacy school, we learn a lot about the main enzymes that pharmacogenetic tests evaluate, so our residents are already trained and knowledgeable about how to evaluate these tests," he said. Overall, pharmacogenetic testing has required no time-consuming staff training or burdensome workflow disruption.

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OUTLOOK MONEY

RISKY BUSINESS Risk management strategies for small businesses

R

isks are a necessary and expected part of running a business.

If you tried to operate your pharmacy without incurring any

risks, you would never grow or make a profit.

"One thing people don’t understand when they get into a

business is that it’s nothing but one big gamble. If going into business were a sure thing, everybody would do it," said Brenda Wells, Robert F. Bird Distinguished Professor and director of the risk management and insurance program at East Carolina University. "But the benefits of taking risks are you can make a nice return and you can build a nice business for yourself."

While risks are part and parcel with running a pharmacy, a

process called risk management balances risks with rewards and builds a more durable business.

IDENTIFYING RISKS Risk management boils down to five steps. The first step, identifying potential risks, is often the biggest hurdle to clear.

"There are so many places you can find risks," Wells said.

Start by looking at your income statement and balance sheet.

Wells pointed out the Tylenol murders of the 1980s when someone snuck cyanide capsules into Tylenol bottles in pharmacies, resulting in the deaths of seven people. "Before that, there was never even concern that something like that would happen. Then, all of a sudden, we have to seal bottles with foil and then seal the lid onto the bottle and seal the box up," she said. "New risks are always popping up. You can’t just do a risk assessment and say, ′Okay, I’m done.′ You have to constantly be looking for new risks that come into play."

"The balance sheet shows assets—things of value—so it’s a great place to start your risk identification process," she explained. "The income statement should indicate where your revenues are coming from, and ultimately those assets need to be protected, too."

Take inventory of the kinds of losses you’ve experienced in

the past. Wells said, "If your employees keep straining their backs lifting things, you’ll probably need to implement some prevention techniques to get that under control, because you could go bankrupt paying those workers’ comp premiums."

Perform a physical inspection of your pharmacy to identify

risky areas. This includes areas where patients are likely to injure themselves or areas where you could accidentally reveal private health information.

In a busy environment like a pharmacy, it’s especially important

to look for risks associated with your workflow behind the counter.

"It only takes the phone ringing while you’re filling a prescription to mess up," Wells said. "Recognize that these kinds of things can happen to anybody at any time."

Your work isn’t done after you’ve completed a single risk

management assessment, because the risks to your pharmacy are always changing. Sometimes, you can’t recognize a risk until after the damage has already been done.

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5 STEPS OF RISK MANAGEMENT STEP 1: Identify Potential Risks Take a look at your pharmacy’s finances and physical layout to identify areas of potential loss exposure.

STEP 2: Analyze Risks Determine which risks could cause severe loss and which could cause minor loss.

STEP 3: Determine a Plan Decide which tools to use to prevent and reduce losses, like safety improvements or insurance policies.

STEP 4: Implement Your Plan Put your loss control strategy in place by buying the insurance coverage you need or making improvements in the store.

STEP 5: Review Continuously assess your risk management plan and look for opportunities to improve it.

TYPES OF RISK

INTERNAL RISKS

EXTERNAL RISKS

Internal risks are things you can take steps to prevent and control.

External risks are ultimately out of your control, but you can still prepare for them with an emergency fund and insurance.

• Illness or death • Theft and fraud

• Poor economy

• Downtime caused by outdated equipment

• Regulatory changes

• Patient injuries

• Natural disasters

• Financial risks, like poor cash flow

• Changing demographic needs

BEHAVIORAL RISKS In risk management, one area tends to be a blind spot for many

procedures so employees can avoid risks in their day-to-day duties.

business owners. "Lawsuits can extend from bad behavior," Wells

said. The lawsuits typically involve HIPAA regulations and Equal

should still have insurance to back you up in case of a loss. Wells

Employment Opportunity Commission (EEOC) laws. The "bad

recommends having an insurance policy with at least a $1 million

After you’ve implemented loss control measures internally, you

behaviors" include releasing confidential health information, firing

liability limit per occurrence, which is how much you will pay for a

people, not hiring people, or not promoting people. As a pharmacy,

single event. This limit is distinct from the aggregate limit, which

you are always subject to HIPAA regulations, and many EEOC laws

how much you’ll pay in a year.

kick in with 15 employees.

your shelves and several people get hurt. That million dollars has to

Because these risks are hard to identify on your own, Wells

Wells explained, "Let’s say somebody put some bad Tylenol on

recommends seeking outside guidance on the HIPAA and EEOC

pay for all of their damages because that’s one occurrence, so it’s

regulations your pharmacy could be at risk of violating. "Even if

really not that much."

you don’t violate regulations, if someone accuses you of violating, it

could hit the news and your business will suffer," she said. "From a

actually be too low. "It’s a pretty high-stakes game. If a pharmacist

For pharmacies in particular, Wells thinks $1 million may

public relations standpoint, there’s a benefit in just knowing what

uses the wrong dosage or dispenses the wrong medication, it can

can get you in trouble."

kill somebody. So I think higher limits are better."

MINIMIZING RISK

BRINGING IN AN EXPERT

Once you’ve identified the risks in your pharmacy, the next step

One problem for every business owner is overlooking risks because

is mitigation. This is typically accomplished through loss control

their perspective is inherently limited. "Sometimes people are too

practices and insurance.

familiar with their setting, and they don’t see the problems," Wells

said. "I used to have my students choose a business and complete

"Insurance is an expensive tool, so we like for people to

implement practices that can prevent and reduce losses," Wells said.

a risk assessment for them. It was always interesting to me what

undergrad students with almost no training would find that the

Some loss control measures are obvious. If you notice a

shelving display that could cause someone to trip, you can

business owners didn’t see."

immediately take action to fix the display and prevent someone

from falling. Other measures won’t completely prevent losses, but

expert. Your insurance company should have somebody in-house

they will reduce the impact when risks become reality. "When you

to do a risk assessment, or they can make a recommendation for

put fire sprinklers in a building, that’s not going to prevent a fire,"

someone who can. "If you go to your insurance agent and say you

To find those hidden risks, Wells recommends bringing in an

Wells explained. "But when they go off, they can stop the spread of

want a thorough risk assessment and he says he can’t help you, he

fire and reduce the severity."

shouldn’t be your agent," Wells said.

Incorporate loss control practices into your training so your

A third party will go through the standard five steps for

employees are empowered and educated enough to mitigate risks.

risk management assessment—but with an expert’s eye. After

Discuss your loss control practices at staff meetings and write

their assessment, you will have a comprehensive idea of your

your risk management measures into your standard operating

pharmacy’s risks, which will help you prepare for the future.

ELEMENTS | The business magazine for independent pharmacy | DECEMBER 2021

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OUTLOOK

RELIEF RX Pharmacy relief agencies come through during temporary staff shortages

I

n the midst of an industry-wide labor shortage, independent

FINDING RELIEF

pharmacists are stretched thin trying to ensure proper coverage

To partner with a relief service, pharmacies typically sign a contract

at their practices.

"There's a huge problem," said Linda Moran, founder and CEO

of R.Ph.S., a pharmacy relief service that serves Oklahoma, Kansas,

for a specified amount of time, and then the service can step in and connect pharmacies with the staff they need. "The norm is a year, but we build a custom contract that depends on the pharmacy's

and Missouri. "It's a supply and demand issue."

need," Moran said.

For independent pharmacies that may only have one

pharmacist on staff, finding relief is critical to keeping their

Balaguer recommends establishing a relationship before you

ever need relief so that when you do need to fill a position, it can

business running. Even the most devoted community pharmacist

be done quickly. "I think it's always a good idea to partner with an

will eventually need to take some time off.

agency and get the lay of the land early so you can understand

requirements," he said. "Get a contract in place and out of the way,

When Moran was a pharmacist, relief was provided by retired

owners in her community who would fill in for the new owner when

and then when you have a need, you can just call and ask for help

they needed help, which wasn’t often. "When I started, it was a

and don't have to worry about the contract approval process."

whole different dynamic. In the small towns, pharmacists almost

never took time off because there wasn't someone to relieve them,"

take anywhere from a couple of days to a couple of weeks. If

she said. "If they were sick or needed surgery, they would have to

a pharmacist is already credentialed and qualified to work in

close the store."

your state, you may be able to find a match within 72 hours, but

turnaround isn’t always that fast. It’s best to request relief at least

Nowadays, most independent pharmacy owners can’t afford

to close shop and don’t have consistent help to rely on. "They don't

Finding the right person to work at your pharmacy can

two weeks in advance, because it can take three to five days to get

necessarily have a list of people they can call to help keep the store

compliance done and another three to five days to make sure they

open if the pharmacist needs to take some time off," said Luis

are a good fit for your pharmacy, according to Balaguer.

Balaguer, vice president of the pharmacy staffing agency RPh on

the Go. That’s where staffing agencies like Balaguer’s and Moran’s

a pharmacist who is in the right place at the right time. "When we

R.Ph.S. has a long list of contractors that they reference to find

come in. "We're simply trying to help pharmacies stay open,

need to fill a position, it’s all about staying on the telephone and

especially the independents."

calling people," Moran said.

Both R.Ph.S. and RPh on the Go typically place relief

pharmacists into pharmacies for short stints—a few days or a

Before hiring a relief pharmacist, it’s a good idea to interview

to the candidate. "I would suggest that any time you have a

week, often for a short vacation or a holiday weekend. "Anywhere

pharmacist coming into your facility that you at least talk to them

a pharmacy needs a pharmacist, they call us and we try to match

on the phone," Balaguer said. "That way you can make sure to get

them up with a candidate who has called us looking for an

answers to any questions that you have and answer any questions

opportunity," Balaguer said.

the relief pharmacist might have, and be sure that it's a good fit."

One of the most common reasons for long-term relief is

maternity leave. "Women make up a majority of the profession

PREPPING YOUR PHARMACY

now, which means maternity leave is going to come into the

Relief pharmacists don’t have weeks to get trained on all of your

picture," Moran said.

pharmacy's standard operating procedures—they need to hit the

R.Ph.S. also helps independent pharmacies through

ground running. To make sure your relief pharmacist can handle

transitional periods. "A lot of places call us, and they've lost their

things while you're away, let the relief service know the basics of

pharmacist. Maybe they decided to go to law school or get their

your business. This includes workflow information like pharmacy

MBA," Moran said. "There's a transition before they are able to hire

management software and your typical daily volume, as well as

a new permanent pharmacist, and they want to use our services for

more mundane information like your pharmacy hours and how

a month or two months or three months."

to get into the building. "We try to gather as much information as possible to really understand what the client's needs are so

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STRATEGIC STAFFING FOR SAFETY

we can to match them up to the candidate's experience,"Balaguer said.

There are a few things you can do to make the transition easier,

like dedicating a point person to meet the pharmacist to give them an overview of the pharmacy workflow. Set up the pharmacist’s computer access and any other accounts they’ll need before they arrive. Send additional information to the relief agency or directly to the pharmacist in advance: onboarding documents, training materials, technology education, etcetera.

Communicate your expectations about the relief pharmacist’s

duties very clearly. "Maybe even provide some workplace culture

You need more than the bare minimum of staff members to keep your pharmacy running safely. When pharmacists are stretched thin, they are more prone to mistakes, which can jeopardize patient safety. Last year, CVS was fined for making errors filling prescriptions because of insufficient staffing.

To avoid potential fines and prioritize patient safety, your pharmacy should always be "fully staffed"—never overstaffed or under-staffed—and you can fill in the gaps using a relief service.

Determine the best way to keep your pharmacy fully staffed by using one of the five strategic staffing models:

dos and don'ts, because every pharmacy is different, and the last thing we want is to have a great pharmacist who is a mismatch

1. STAFFING QUANTITY

because they don't quite fit in with the culture," Balaguer said.

Forecast the total headcount you need to keep the pharmacy running and compare that to your actual headcount. If your actual headcount is less than the forecasted headcount, you're likely understaffed.

WHO WORKS RELIEF? When a relief pharmacist shows up at your pharmacy, what kind of person can you expect? "We get people who are all ages, all backgrounds, and all stages in their careers," said Balaguer. "I remember we once had a pharmacist who was an actor, and he only wanted to work two days a week, so he did relief work." Many of the pharmacists who work relief for RPh on the Go are either retirees or people who want to have a dynamic work life that involves travel.

Moran says that her base of relief pharmacists is mainly made

up of retirees and women with young children. "There are a lot more women in the industry than there used to be, and when they have young children, they only want to work a few days a week," she explained.

Relief work is ideal for pharmacists who want a lot of

flexibility in their schedule. They are independent contractors, not employees, so they can pick and choose what jobs work for them.

"We call them with a job, and if they're busy, they just say they are busy, and then we go onto the next person," Moran said. "They are in control of their own schedule."

Balaguer agreed. "I think what makes this work so attractive is

the pharmacists get paid for the hours they want to work, but they don't necessarily have to deal with the constraints of a regular job.

2. STAFFING QUALITY MATCH — ­­ PERSON/JOB Align the characteristics and qualifications of individual staff members to the characteristics and qualifications needed for a position. The better these match, the more impact your staff can have on outcomes.

3. STAFFING QUALITY MATCH — ­­ PERSON/ORGANIZATION In addition to matching the qualifications of a specific position, staff members should also align with the organizational values of your pharmacy. With this staffing model, employees can be flexible to the pharmacy's needs and perform new tasks when asked.

3. STAFFING SYSTEM COMPONENTS This model relies on a back-and-forth between an applicant and the organization where each evaluates the applicant's knowledge, skills, and abilities to come to mutually agreeable employment terms. By concentrating on professional development, the staff member can focus on organizational goals and safety policies.

They want that independence," he said. "They are running their own

5. STAFFING ORGANIZATIONS

business, a lot like the independent pharmacists we work with."

Create a staffing strategy with your pharmacy's mission, goals, and safety objectives in mind. Aligning your staffing strategy with organizational goals ensures that all of your pharmacy's core needs can be taken care of.

All relief pharmacists go through a battery of compliance

checks, including a background check, drug screen, license verification, and a check for OIG exclusions. "That's the very minimum that we need in order to get somebody to work," Balaguer said. "On top of that is anything the client needs. Part of the contract process is understanding what all the compliance requirements are for that particular pharmacy. Our credentialing team can make sure that the pharmacist we send is qualified and can do everything that you've asked for."

Sources: Staffing Organizations, McGraw-Hill; RPh on the Go

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A Division of The Selzer Company