Future in Motion - Neighbourhood Pharmacy Association of Canada

2011 report
Future in Motion
Community pharmacy building an expanded role
in healthcare delivery
CONTENTS
4
Cover Story
While the road ahead is long,
community pharmacy has
made considerable strides
toward fully utilizing the skills
of pharmacists
13
New Partnerships
A commitment to collaboration
has come to guide some
negotiations between
government and pharmacy.
Here’s a closer look at
British Columbia
Visit www.cacds.com for information on the
Canadian Association of Chain Drug Stores:
• How to become a member
• The position of CACDS on important issues
• Upcoming events
• Latest products and services
18
Provincial Snapshot
An at-a-glance summary
of government-funded
pharmacy services
21
The CACDS 2011 Report was published in October
2011 by Drugstore Canada, a Rogers Healthcare Group
publication.
Drugstore Canada, ISSN 1199-2131, established 2008,
is published 10 times a year, by Rogers Publishing
Limited (www.rogerspublishing.ca) a division of Rogers
Media, Inc, One Mount Pleasant Road, Toronto, Ontario
M4Y 2Y5. Tel: 416-764-2000, Fax 416-764-3931. Montreal
Office: 1200 avenue McGill College, Bureau 800, Montreal,
Quebec, H3B 4G7. Telephone: (514) 845-5141.
Contents copyright © 2011 by Rogers Publishing Limited;
may not be reprinted without permission. Rogers
Publishing does not assume liability for content.
Our environmental policy is available at:
rogerspublishing.ca/environment.
President, Rogers Publishing Limited
Kenneth Whyte
Vice-President, Rogers Publishing Limited
Patrick Renard
Executive Publisher, Healthcare Group
Janet Smith
Publisher
Jackie Quemby
Managing Editor
Karen Welds
Writers
Sonya Felix, Karen Welds
Art Director
Lima Kim
Production Manager
Ajay Masih
Cover Art: Adriana3d (istockphoto)
Technology Tools
Introducing MirixaPro CanadaTM,
a web-based clinical-decision
support tool for pharmacy
services.
Plus: an update on the
Electronic Health Record
25
Time for Change
An expert in behavioural
change maps out the steps
for successful change
management
26
Moving Forward
Pharmacy associations,
regulators, faculties and head
offices are mobilizing their
resources to support
an evolving profession
30
Q&A with the Chair
CACDS Chair Sandra Aylward
reflects on how pharmacists
and their associations are
critical agents for change
2011 CACDS REPORT 3
In Higher Gear
Expanded scopes of practice and new public funding
lay down the mechanics for better patient care; now it’s
up to community pharmacy to set the wheels in motion
by Karen Welds
4 CACDS REPORT 2011
www.cacds.com
V
irtually every provincial government in Canada now
pays pharmacies for at least one service outside of
dispensing. Depending on the province, pharmacy is
being reimbursed for injections, medication reviews,
prescription adaptations or pharmaceutical opinions. And more
funded services are on the way, including programs for smoking
cessation in more provinces, the assessment of minor ailments
and support for chronic disease management.
Just five short years ago, this type of government funding
seemed a distant dream. And while the road ahead is still long, the
destination—a healthcare system that fully utilizes pharmacists’
skills and training as drug therapy experts—is finally in sight.
“It’s a recognition by health policy makers that they’ve had a
woefully underutilized resource in pharmacists at the community level,” says Nadine Saby, President and CEO of the Canadian
Association of Chain Drug Stores (CACDS). “We need to
build on the foundation that’s been laid, with private as well
as public payers, by embracing these programs and demonstrating the value of pharmacists’ services.”
The journey began almost a decade ago, when the provinces’ health ministers set down the far-reaching objectives
of the 2003 First Ministers’ Accord on Health Care Renewal.
The demands of an aging population, the growing incidence
of chronic disease, spiraling costs and provider shortages
had led to a crossroads in the delivery of healthcare. Since
then, the road to renewal has produced new technologies, expanded scopes of practice, new classes of regulated
health professionals and funding reforms (for a summary
of expanded scopes of practice and funding for professional
services, see page 18; for an update on the electronic health
record, see page 23).
“What’s most important is access,” says Michael Nashat,
CACDS Board Member and Vice-President, Pharmacy, Prince
Theodore Group. “The current system had positioned the doctor as the main solution, but there are not enough doctors, aging
patients have greater needs and medications have become more
complicated. Pharmacists and other providers simply needed to
have expanded scope.”
“The healthcare system requires pharmacy to evolve,” agrees
Steve Wilton, Vice-President, Pharmacy Affairs, at CACDS. “It is
contingent on pharmacy owners and pharmacists to take advantage of the government-funded programs. It won’t be easy because there are unresolved issues, but you can’t be fearful about
moving into an area where you might not have all the answers.
Sometimes you can’t have all the answers. We have to take action
and course-correct as we move forward.”
CACDS, the Canadian Pharmacists Association (CPhA) and
provincial pharmacy associations are offering tools and training to help pharmacists through the transition, as are regulatory
www.cacds.com
bodies and faculties of education (for more on change management, see pages 25 and 26). At the same time, it’s imperative that
pharmacists guide patients toward a better understanding of
how their changing role can directly improve health.
“Pharmacists are always at the top of the list for trusted professionals, but we need to educate the public on exactly what pharmacists can do and are doing for them,” says Rita Winn, CACDS Board
Member and General Manager and COO, Lovell Drugs Limited.
“Pharmacists can no longer afford to be the most trusted professionals. We need to be recognized as the most valued front line
healthcare professionals,” states Peter Zawadzki, Board Member
of CPhA, member of the CACDS Policy Development Committee,
and Professional Affairs Executive, Pharmasave Drugs (National)
Ltd. “Pharmacists need to overcome what I refer to as ‘humble
pharmacists syndrome’. Value starts with letting patients know
Pharmacists can no longer
afford to be the most trusted
professionals; we need to be
recognized as the most
valued front line healthcare
professionals
exactly what you do, each and every time. Pharmacists research
and resolve serious drug-related issues every day, but don’t often
tell their patients what they’ve done. On the other hand, doctors
and nurses consistently communicate the impact of their services
to their patients and in the media. The more direct we are about
the value we provide, the more patients and payers will recognize
the value we bring to the healthcare system.”
Canadian Pharmacy Services Framework
An important road map for pharmacists, associations and governments alike is the Canadian Pharmacy Services Framework.
Drafted in 2010 by practicing pharmacists and representatives
for CACDS and CPhA, the Framework was created to support
increased availability of pharmacy services. It promotes common terms and definitions of services across jurisdictions, describes labour requirements, work flows and estimated time
needed to deliver the services, and helps to facilitate funding
models for them.
2011 CACDS REPORT 5
A boost for the profession
New Brunswick pharmacy finds ready market
for vaccinations
The Framework has already proven valuable during negotiations in B.C., Saskatchewan and Nova Scotia in the establishment
of new defined pharmacy services and their funding. The Framework can be accessed on the CACDS website (www.cacds.com).
“The Framework delivers standard definitions and terminology that pharmacy can use as the basis to promote expanded
pharmacist services and to educate policy makers and payers
about them,” says Zawadzki. “Our challenge in pharmacy is to
keep unified. Sticking to a consistent message will allow pharmacists to be recognized and appropriately rewarded for the
valuable services we provide.”
The Framework is also “important for education and training
because it enables economies of scale and efficiencies,” says Stacy
Johnson, a member of the committee that drafted the document
and Director of Pharmacy Professional Services, Canada Safeway.
Provinces can share training and orientation tools, with minor adjustments to reflect the specifics of provincial legislation.
“The Framework needs to be at the heart of standard operating procedures for all pharmacies,” summarizes Winn. “It will
enable all levels of pharmacy to be clear and consistent, to prove
our value to government and private payers.”
Medication management
Several provincial governments have latched on to medication
reviews as a logical entry into paid pharmacist services. The governments of Nova Scotia, Ontario, Saskatchewan and B.C. currently fund medication review programs, and New Brunswick is
analysing the results of a pilot project (see details on all provinces on page 18).
“Governments realize that appropriate use of medication is
a smart investment,” says Paul Foley, Director Private Health,
Shoppers Drug Mart. “It has the potential to save the system significant money while improving outcomes—plus it’s a bit of a reinvestment back into pharmacy after significant funding reforms.”
“Medication management is gaining momentum because
we’re finding that patients aren’t managing their disease,” says
Nashat of Prince Theodore Group. “Pharmacists have a role to
play: they can ensure patient management, using clinical guidewww.cacds.com
When New Brunswick pharmacists gained authority
to administer injections in late 2008, Sharalyn Rigby, a
pharmacist at Lawtons Pharmacy in Saint John, N.B.,
jumped at the opportunity.
She completed the required
training and is now one of
two staff pharmacists at the
store who regularly gives
injections, most frequently
for travel vaccines.
“It’s a popular option for
people who can’t get to
their doctor,” she says, “and
Sharalyn Rigby
we are reimbursed $20 to
administer the vaccine.” Although pharmacists can’t
prescribe vaccines, Rigby does make recommendations about the types of injections travellers will need,
depending on their destination. She also personally
calls patients to remind them to come in for booster
shots. “That’s particularly important for Twinrix
because the third booster must be given six months
after the first,” she says. “People often forget but if
they don’t get the last booster, then the next time they
travel they have to start over again.”
Currently, Rigby uses the store office to administer
injections and conduct medication reviews, but in
November the store is relocating to a site with a dedicated counselling room. “It’s really exciting to have
an expanding scope of practice that not only helps
patients but is professionally rewarding for pharmacists, too,” Rigby says. “It gives us the opportunity to
get out of the dispensary and to really get to know
our patients.”
lines. Ten years ago, guidelines were not nearly as advanced or
comprehensive.”
Sitting down with patients to focus their attention on their
health in this way “initiates that first discussion that there is more
to managing medications than just getting prescriptions filled.
Government is starting to understand the scope of what’s possible,” adds Sandra Aylward, Chair of CACDS and Vice-President,
Professional and Regulatory Affairs, Lawtons Drugs and Sobeys
Pharmacy Group.
Similar programs south of the border demonstrate an impressive return on investment. For example, North Carolina hired selected community pharmacists on contract and trained them to
conduct ChecKmeds reviews with seniors enrolled in Medicare.
The fee schedule includes follow-ups with physicians. After its
first year in 2008, pharmacists had educated 15,000 seniors and
savings were estimated at $10 million—or a return of roughly $14
for every dollar invested.
2011 CACDS REPORT 7
MedsCheck in Ontario
Ontario’s MedsCheck is the most established medication review
program in Canada, launched in April 2007. While the government has not released estimated savings, it has signalled its
support of the program by expanding it in September 2010 to
include specific services for diabetes education, home visits and
long-term care residents. In September 2011, the government
announced that MedsCheck programs for complex regimens,
medication reconciliation, chronic disease management and
home diagnostic training are under development.
“The Ontario government supports the role of the pharmacist
as part of an integrated team that provides an
enhanced level of care to their patients,” says
Diane McArthur, Assistant Deputy Minister
and Executive Officer of Ontario Public Drug
Programs. “The government’s MedsCheck program, now in its fifth year, continues to see an
increase in the number of Ontarians receiving
the medication review service. We are looking
for opportunities to expand this service and
continuing to increase the value of the MedsCheck program.”
For their part, pharmacists and pharmacy
head offices in Ontario are adjusting professional and business practices to take advantage of these funded services. The Ministry
of Health and Long-Term Care reports paying pharmacies for
50,660 standard MedsCheck reviews and Follow-Ups in June
2011, compared to 36,239 in January, as well as almost 35,758
reviews at home, for diabetes or long-term care, up from 22,537
in January.
community pharmacist. As ministries of health change the fee
structure to support clinical interventions by pharmacists, the
timing is perfect.”
With that in mind, CPSI and ISMP have struck collaborative
relationships with CACDS, CPhA and the Canadian Society of
Hospital Pharmacists as part of a concerted effort to put paid
medication reconciliation services on the agenda.
Indeed, public funding has already begun: Saskatchewan began paying community pharmacists $25 for medication reconciliation services in May, and Ontario has indicated it will fund
medication reconciliation services, possibly under its existing
Making the time for medication
reviews and other expanded services
won’t be easy; pharmacists need to
find a way to be very efficient at
everything they have to do
MedsCheck program.
“Reconciliation should be bundled in with medication reviews, they operate on the same principle. There are obvious and
immediate safety and utilization benefits,” says Sandra Aylward
of Lawton’s.
Medication reconciliation
Change management
Community pharmacists also have an integral role to play in
medication reconciliation, an area gaining momentum with
hospitals, regional health authorities and public payers. In Canada, studies show that 40 to 50 per cent of patients experience
unintentional medication discrepancies or potential errors upon
admission to hospitals, and 40 per cent experience discrepancies at discharge.
Early this year the Canadian Patient Safety Institute (CPSI),
in partnership with the Institute for Safe Medication Practices
Canada (ISMP Canada) and Canada Health Infoway, hosted the
first summit to strategize on the implementation of MedRec, a
system-wide, national medication reconciliation initiative.
“Canada is a leader in medication reconciliation,” says Marg
Colquhoun, Project Leader at ISMP Canada. “We have tools
and resources for acute, long-term and home-care institutions,
and now we have a tremendous opportunity to bring in the
Making the time for medication reviews and other expanded
services is not easy. “You need to find a way to be very efficient
at everything you have to do,” notes Winn of Lovell Drugs, which
recently hired a pharmacist to specialize in providing at-home
MedsCheck reviews. You also have to be realistic.
“Change management is a huge process,” says Winn. “I use the
analogy of getting fit: you are gung ho at the start, then you drop
off. Then you pick it up again, manage for a bit longer, then drop off
again. It takes time for something like this to become sustainable.”
Financial sustainability is another matter. “It’s a catch 22—in
order for government programs to become financially viable
you need to do a certain volume, but you’re losing money to get
there,” says Winn. “This is compounded by fact that we have to
use it or lose it.”
“Current funding for professional services may not be enough,
but it’s definitely a start,” says Foley. Resource management is
www.cacds.com
2011 CACDS REPORT 9
Filling the gaps
This Toronto pharmacy draws upon available
resources to meet patients’ needs
key. “When you build in the cost of labour to deliver these services, the use of technology and regulated technicians becomes
very important.”
Whether you work in an independent pharmacy or a large
head office, the most successful innovators in professional services will also be smart business people—or they’ll hire the business expertise they’ll need.
Quantifying a new value
As the revenue model for retail pharmacy expands beyond the
delivery of product to the provision of service, the door opens
to quantify a new value for the profession based on outcomes
and savings to the healthcare system. Unfortunately, the mechanisms to do so are not yet in place.
“The government is tracking pharmacists’ services, but not
measuring their outcomes,” says Foley. “Many pharmacies and
chains have taken it upon themselves to measure outcomes in
some way, but we need government to do it also.”
Until that happens, the priorities of CACDS and provincial
pharmacy associations are to meet with governments to determine which pharmacy services promise the best value to payers
and patients “in terms of quality, access, safety and cost-effectiveness. These are the filters we use to address return on investment,” says Aylward of Lawton’s and Sobeys Pharmacy, who was
a member of the team that met with the Nova Scotia government
over nine months in 2010 and 2011 to identify such services and
how they should be reimbursed.
“It was a very thorough, very good process,” says Aylward, “and
the real benefit of it was the mandate was approved by the minister, and the resulting report was a joint one. We’ve laid the foundation of an ongoing partnership by meeting their policy objectives. Now we’ll build on that by measuring outcomes.”
To help in delivering that measurement, CACDS has obtained exclusive Canadian rights to MirixaProTM, a web-based
clinical-decision support platform that can report aggregate
patient outcomes (for details, see page 21). Once that platform
has been adapted to the Canadian market, it will be available to
all pharmacies with a pricing structure based on a cost-recovery
business model.
When you arrive to open your pharmacy and find patients
already waiting for a monthly diabetes screening clinic, it’s
a humbling experience, says Akil Dhirani, pharmacist/owner of Village Square Guardian
Pharmacy in Toronto, Ontario. “It
shows how much need there is
for such services and the important role community pharmacies
can play in healthcare.”
When Dhirani switched
from hospital to community
pharmacy a few years ago, he
decided to focus on diabetes
Akil Dhirani
as a niche that would make use
of his experience with clinical services and interprofessional collaboration. He works closely with doctors from
the neighbouring health clinic and brings a nurse in to
the pharmacy once a month to screen patients for blood
sugar, cholesterol, blood pressure and general well-being.
“It’s easy to combine this screening with a MedsCheck
medication review,” he says, adding that he’s able to
provide MedsChecks on a daily basis as patients request
them. “The new payment for MedsCheck for Diabetes is
welcome funding support when I sit down with patients.”
As a member of Drug Trading, he has access to an annual fund to conduct clinics that are free to patients as well
as relationships with suppliers who contribute educational
material in various languages. He also manages his labour
costs by hiring pharmacy interns from the University of
Toronto’s program for international pharmacy graduates.
“There is so much we can do to take a load off of physicians that would be good for taxpayers and patients,” he
says. “I’m looking forward to taking on more.”
“It is going to take time for the critical mass to emerge for these
government-funded services,” says Saby of CACDS. “Fortunately,
enablers such as MirixaPro CanadaTM and other technologies,
practice legislation and technician regulation are falling into
place. It is essential to maintain our course by embracing these
enablers, doing the research and the training, transitioning our
business model, and pursuing innovation. The evolution of pharmacy has begun.”■
Find the answer at www.mirixacanada.com
Charting a course,
together
Leaders in government and pharmacy are
lauding British Columbia’s Pharmacy Services
Agreement as a big step in the right direction.
Here’s how they did it.
by Karen Welds
W
hen representatives for the British Columbia
Pharmacy Association (BCPhA) and the British
Columbia Ministry of Health sat down to negotiate in the fall of 2008, they agreed that much more
than the dispensing fee had to be put on the table. They released
an interim agreement in December to meet contractual obligations, and then, joined by the Canadian Association of Drug Stores
(CACDS), they set upon the larger task of crafting what would become the Pharmacy Services Agreement (PSA).
Announced in July 2010, the PSA maps out a three-year path
to establish new funding for pharmacists’ services, while also
meeting government’s mandate to control drug plan spending
(for details, see page 18). It is the first agreement of its kind in
Canada—and hopefully not the last.
Bob Nakagawa, Assistant Deputy Minister of Pharmaceutical
www.cacds.com
Services at the Ministry of Health, describes the PSA as “a partnership. It has set the stage for a good, ongoing relationship between pharmacy and government.”
Participants in the negotiation process outlined the following
10 key elements that laid the foundation for that partnership.
1. Build trust
“Trust is absolutely the critical element,” says Marnie Mitchell,
CEO of the BCPhA. “The question then is, how do you develop
trust? Pharmacy has to be the initiator; we have to demonstrate
that we are going to be a good partner.”
In B.C., this began well away from the negotiating table, when
BCPhA agreed to help distribute a consumer health guide in 2004.
The government saw the value not only of using pharmacies as
a distribution network, but also of enabling interaction between
2011 CACDS REPORT 13
consumers and pharmacists. “It was a good start, and both sides
still reference it during discussions,” says Mitchell. “The goal is to
help government achieve what they need and to realize a value
for pharmacists and patients as well. When it comes down to the
tough talks, you are on a much better footing.”
“There can be many different ways to partner—all governments have the desire for that,” agrees Darcy Stann, Board Member of CACDS and Director of Regulatory Affairs, Canada Safeway. “It’s through such partnerships that you meet and develop
relationships with the people who will eventually be on the other
side of the table. The problem in the past and in other provinces
is there were no personal relationships with that level of trust.”
“Relationships aren’t built overnight, and they’re not built
when you’re in conflict. You need to build the foundational
pieces,” says Bob Nakagawa of the Ministry of Health, who has
come to know Stann, Mitchell and other pharmacy leaders over
the years. “There was a lot of credibility, trust and integrity at the
negotiating table.”
2. Keep confidentiality
Members of the negotiating committee—two government representatives, Mitchell, three BCPhA Board Members and three
CACDS Board Members—maintained confidentiality until an
agreement was reached.
“That really opened up the dialogue and gave everyone a much
more comfortable position,” says John Tse, one of the BCPhA
Board Members and Vice-President of Pharmacy, London Drugs.
Over the course of approximately 18 months, the committee gave general updates to the rest of the CACDS and BCPhA
Boards, but no details. No information was passed on to association members, although regular communication did occur.
The ability to maintain confidentiality without alienating those
you represent is also a matter of trust. “Provincial pharmacy associations may need to work on that within their own internal
cultures,” suggests Mitchell. “The Board has to trust the committee, and the membership needs to trust its association.”
3. Set terms of reference
Before talks began, Mitchell developed a document that clearly
stated “both parties’ positions and what can and cannot be discussed,” says Tse. “In the past, we would have loose terms of reference but nothing this specific.”
“It established clarity from the outset so there would be no uncertainties or misinterpretations,” says Mitchell.
Terms of reference also help establish consensus for pharmacy.
“Before you initiate discussions with government, everyone has
to be clear on what will be talked about and what won’t be talked
about,” says Mark Dickson, one of the three CACDS representatives
and National Director, Pharmacy, for Pharmasave Drugs. “It is also
important to be upfront with government and detail what you are
not going to talk about and why, to prevent misunderstanding.”
www.cacds.com
What is the significance of the
Pharmacy Services Agreement?
“For pharmacy in B.C. this is ground-breaking. We’ve
never had such a comprehensive agreement, including
money carved out to enable the community pharmacist
to practice to a fuller scope. Government recognizes
the value of the knowledge of the pharmacist.”
Bob Nakagawa, Assistant Deputy Minister of Pharmaceutical Services, British Columbia Ministry of Health
“The length of agreement gives pharmacy a defined
period of time to transition to a new business model.
We should congratulate government for making the
statement that pharmacy needs to transition to a new
business model and for putting out the funds to make
that possible.”
Darcy Stann, Board Member, Canadian Association
of Chain Drug Stores
“The provincial government and pharmacy are prepared
to commit ourselves to doing things together on an
ongoing basis. Government is bound to it.”
Marnie Mitchell, CEO, British Columbia Pharmacy
Association (BCPhA)
“The PSA expands our position on the healthcare team
in the eyes of patients, government and other providers.
It not only recognizes pharmacists, it pays them for
their services.”
John Tse, Board Member, BCPhA
4. Pick the right people
CACDS joined the discussions at the government’s request.
“CACDS brought a lot of value to the process: the breadth of their
representation of retail pharmacies, their experience from discussions with other provinces, and an understanding of the impact or implications of things being proposed,” says Mitchell.
“You’re going to see more national players at provincial tables,
since what happens in one province influences what happens in
others,” adds Stann.
Also important, of course, are the individuals themselves.
“When you have people at the table who are open-minded and
upfront, you’ve got a formula for success,” says Nakagawa. As
well, “people in government look to hear from people who are
clearly committed to their profession yet also understand the
economic realities. Pharmacy associations should identify these
pharmacists and use them as part of negotiations and to build
long-term relationships.”
5. Remember the common ground
“The need to achieve common understanding was bigger than
expected,” notes Dickson. “We have to be able to translate our
2011 CACDS REPORT 15
What can individual pharmacists
do to support positive government relations?
“Connect at the local level with your member of
provincial parliament or legislative assembly. Try to
understand their perspective and look for ways to
connect. If you can bring a positive result, they’re
more likely to return the gesture.”
Marnie Mitchell, CEO, British Columbia Pharmacy
Association (BCPhA)
“If it’s your party, work on your local representative’s
campaign. It helps you learn the political process, and
it establishes a relationship.”
Darcy Stann, Board Member, Canadian Association
of Chain Drug Stores (CACDS)
“The most important thing pharmacists can do is be
a professional and provide consistently good service
to each and every patient. Every politician is also a
consumer—I’ve been at the table where discussions
are influenced based on whether the payer has had a
good or bad experience with a pharmacist.”
Mark Dickson, Past Chair, CACDS
For tools that help pharmacists advocate for their
profession, go to www.pharmacyworx.com
objectives into the bigger picture for government. The place to
go for that is to translate everything to the patient’s perspective.
That’s our common ground.”
For example, don’t argue about why something is important
for pharmacists, but “explain why it’s important for patients and
how pharmacists can help achieve that,” says Dickson.
6. Share information
Information and analysis were key drivers of discussion. “We
needed a lot of information from B.C.’s PharmaNet database,”
says Tse. “In the past they shared the data but it was much more
aggregate. This time we were able to slice it in different ways.”
To that end, CACDS also brought forward proprietary data on
the costs of professional services in order to enable economic
modeling. “Good analytics have historically been a failing on our
side,” says Dickson. “As much as we are passionate about patient
care, we need to be equally informative about the financial impact of proposed actions.”
7. Compromise
“The reality is that the agreement is not a financially beneficial
deal for pharmacy—we are taking a profitability hit. The important part is that the time frames for adjustment are reasonable
and we have had input into how funding is reinvested to support
new professional services,” says Dickson. In other words, it’s a
process of give and take.
”You really have to understand the other party’s challenges and
www.cacds.com
perspectives and listen to find the middle ground,” says Tse. “And
no matter what they say or do, never walk away. You can take a
breather, but don’t cut off talks or make threats. The momentum
must come from the desire to find a solution for both sides—the
alternative is that government will force change upon you.”
“Always recognize that government is trying to do what’s good
for the public,” adds Nakagawa. “For example, the whole generic
drug-pricing situation was untenable and had to be addressed.”
8. Communicate with members
CACDS and BCPhA regularly communicated with pharmacists
during negotiations, even though they had to maintain confidentiality. “Silence starts to get interpreted,” says Mitchell. “If information isn’t fed regularly, something will be created or invented.
Therefore we kept putting out messages, even if it was a bit of a
broken record.”
The associations also promoted communications by asking
members for feedback on related issues. “Input from members is
critical,” stresses Mitchell. Communication to different contacts in
government is also important, in the event they need to respond to
rumours brought forward by media, pharmacists or consumers.
Once the agreement was made, BCPhA, CACDS and government issued joint statements to pharmacists and the media, and
participated in a series of town hall meetings that were also available as webcasts. While they expected negative feedback from B.C.
pharmacists due to the complexity and scope of the agreement,
people “were by and large quite pleased,” reports Mitchell. She
suspects this was partly due to members’ anxiety over events in
Ontario, where generic pricing had been slashed and professional
allowances eliminated; however, she also credits the joint communication efforts and the agreement itself, which clearly recognizes—and compensates—the value of pharmacists’ services.
9. Make the commitment
The committee met face-to-face about once every six weeks from
January 2009 to June 2010, weathering the competing demands
of a provincial election and the 2010 Winter Olympics. Those
who represented BCPhA and CACDS appreciated the full support of their employers. “This was my top priority, ahead of my
job,” says Tse, adding that “our role was to negotiate what was
good for community pharmacy, not specific chains.”
10. Look forward
When asked about obstacles to avoid, several emphasized the need
to leave the past behind. “You must avoid bringing up ancient history. It detracts from the realm of what is possible,” says Dickson.
“It was what it was—now we have to move forward,” agrees
Nakagawa.
As well, pharmacists need to keep their eyes on the bigger
prize. “We can’t get lost in the details, which can be hard for
pharmacists since we tend to be detail-oriented,” says Dickson.
“Instead, focus on the ‘big blocks’ at the negotiation table, then
leave it to the subcommittees or working groups to work out the
details. You are there to build the foundation.” ■
2011 CACDS REPORT 17
The future is now
From coast to coast, provincial governments are implementing, and reimbursing,
pharmacist services that directly contribute to more accessible primary care
Provincial summary of government-funded professional services*
Province
Status
Fee
Nova Scotia
Advanced Medication Reviews
Basic Medication Reviews
Injections or immunizations
Prescription adaptations
Prescription renewals for continuity of care
Therapeutic substitutions
Emergency prescribing
Minor ailments
Lab tests
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Pending
Pending
Pending
$150.00
$52.50
$10.73
$14.00
$10.73
$26.25
Pending
Pending
Pending
New
Brunswick
Immunizations
Emergency prescribing
Injection of medication via intramuscular, subcutaneous, intradermal or IV
Implemented
Implemented
Implemented
$12.00
$9.40
$9.40
Newfoundland
& Labrador
Refusals to fill
Emergency prescribing
Implemented
Implemented
$7.15
$7.15
Prince Edward
Island
Prescription renewals for continuity of care
Implemented
$8.20
Quebec
Pharmaceutical Opinions
Prescription renewals (packaged)
Prescription renewals (not packaged)
Emergency prescribing
Refusals to fill
Implemented
Implemented
Implemented
Implemented
Implemented
$18.65
$16.56
$25.20
$16.99
$8.44
MedsCheck
MedsCheck Follow-Ups
MedsCheck for Diabetes
MedsCheck for Diabetes Follow-Up
MedsCheck for Long-Term Care
Implemented
Implemented
Implemented
Implemented
Implemented
MedsCheck at Home
MedsCheck at Home Follow-Up
Pharmaceutical Opinion
Prescription adaptations
Refusals to fill
Pharmacy Smoking Cessation Program
Implemented
Implemented
Implemented
Pending
Implemented
Implemented
$60.00
$25.00
$75.00
$25.00
$90.00 (annual) and $50.00
(quarterly)
$150.00
$ 0.00
$15.00
Pending
$15.00
$40 for first consult; $15/primary
follow-up (3/year); $10/secondary
follow-up (4/year)
Pending
Pending
Pending
Pending
Ontario
Name or description of service
MedsCheck Complex Assessment
Medication Reconciliation
Chronic Disease Management
Home Diagnostic Training
18 CACDS REPORT 2011
Pending
Pending
Pending
Pending
www.cacds.com
Provincial summary of government-funded professional services*
Province
Manitoba
Name or description of service
Status
Fee
Expanded scope of practice legislation pending passage of regulations
Pending
Pending
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Medication Assessments
Emergency contraception prescribing (with training)
Emergency continuation of existing prescription
Non-emergency continuation of existing prescription
Refusals to fill
Prescription renewals or refills
Adjustment of dosage form
Medication reconciliation
Smoking cessation
Minor ailments
Advanced prescribing services
Pending
Pending
$60.00
2 x dispensing fee
$10.00
$6.00
Dispensing fee plus 50%
$6.00
$6.00
$25.00
$2.00/minute up to $300.00 per
patient per year
Pending
Pending
Alberta
Injections or immunizations
Emergency prescribing
Prescription adaptations
Lab tests
Advanced prescribing services
Implemented
Implemented
Implemented
Implemented
Implemented
$10.93
Pending
Pending
Pending
Pending
British
Columbia
Prescription adaptations
Therapeutic substitutions
Refusals to fill
Injections or immunizations
Medication Reviews – Standard
Medication Reviews – Pharmacist Consultation
Medication Review follow-ups
Prescription renewals for continuity of care, chronic disease
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
Implemented
$10.00
$17.20
2 x dispensing fee
$10.00
$60.00
$70.00
$15.00
$10.00
Saskatchewan
* Note this chart is current as of October 12, 2011.
www.cacds.com
2011 CACDS REPORT 19
Technology
solution
Introducing MirixaPro CanadaTM, the webbased platform to help patient-focused
expanded services become a reality in
pharmacies across Canada
by Karen Welds
P
harmacists in Canada will soon
be able to tap into an exciting
new online tool for the delivery
of a wide range of patient services, such as medication reviews and immunizations. MirixaProTM, embraced by pharmacists in the U.S. and Australia, is coming
to Canada under an exclusive licensing
agreement with the Canadian Association of
Chain Drug Stores (CACDS).
“This is the tool we’ve been waiting for,”
says Darcy Stann, CACDS Board Member and Director of Regulatory Affairs,
Canada Safeway.
“We have a tremendous opportunity
to move towards expanded services, and
www.cacds.com
this is a tool to help achieve that,” agrees
Bobbi Reinholdt, also a CACDS Board
Member and Senior Vice-President, Pharmacy, Loblaw Companies Ltd.
CACDS has entered into an exclusive
agreement with the Mirixa Corporation,
the creator of MirixaProTM, to adapt and
distribute the web-based platform (see
“MirixaPro CanadaTM quick facts”). The association’s objective: 100% availability to
all community pharmacies across Canada.
“We know that technology is a key enabler for expanded services. Based on our
research, MirixaProTM is the right technology,” says Nadine Saby, President and CEO
of CACDS. “There’s nothing like this in
2011 CACDS REPORT 21
MirixaPro Canada™
quick facts
Canada right now. Other systems contain
certain aspects, but there’s nothing with
the full scope of MirixaPro CanadaTM.”
Distribution will be based on a costrecovery model, which “mitigates financial risk for the buyer and removes control
from a for-profit third party,” says Justin
Bates, Director, e-Health, at CACDS. “It’s
a standardized, clinical-decision support
tool that enables effective patient care
across all provinces.”
CACDS is also working with vendors
to develop the integration piece that will
seamlessly connect MirixaPro CanadaTM
with existing “fill and bill” dispensary sys-
Hooked on technology
Just seven years ago, Nirvishi Jawaheer
didn’t even know how to open an email.
But today, the pharmacist and owner of
a Jean Coutu franchise in Montreal, Quebec, has become a technology whiz who
uses an iPad to look up information and
make notes when counselling patients.
“My iPad and iPhone are both loaded with
knowledge-based software, which has
16 different programs for everything from
pregnancy to medication interactions,”
she says. “Having the information at my
fingertips saves me a lot of time and is
really helpful, especially when I visit
patients in their homes.”
Jawaheer is eagerly awaiting the implementation of MirixaPro CanadaTM, a webbased clinical decision support platform
that the Canadian Association of Chain
Drug Stores is customizing for Canadian
pharmacies (see main article). “We fill a
large volume
of prescriptions every day
and MirixaPro
CanadaTM will
make it easier
for us to educate patients
and document
their progress,”
she explains.
“I love having
Nirvishi Jawaheer
access to the
latest technology and can’t wait to use
it in my practice. These programs help
us to take charge of our patients’ needs
and to follow professional guidelines for
documentation.”
22 CACDS REPORT 2011
tems. “The interface is vital, and will save
pharmacists tremendous time and effort,”
says Anthony Silva, Director, Technology
Initiatives at CACDS.
“The standard interface also means
that when pharmacists move from one
job to another, which they do a lot, they
don’t have to worry about learning a new
system—and management doesn’t have
to worry about the high cost of technology
training,” adds Stann.
MirixaPro CanadaTM will also reflect
the objectives of the Canadian Pharmacy Services Framework, which provides
consistent definitions of services and an
understanding of the work flows involved
to ensure consistency and reliability (for
more on the framework, see page 5). It
will also initially contain modules for expanded services for which payment already exists in some provinces, such as
medication reviews, prescription adaptations and immunizations. More will be
added over time.
“The more we have a single system,
the more that system can be enhanced
over time to give pharmacy what it needs,
which is operational efficiency, professional support and a business model built
on professional services,” says Stann.
CACDS’s endorsement of MirixaPro
CanadaTM will also send the message that
“you don’t need a different tool in every
chain in every province,” says Reinholdt.
“Professional services need to be consistent across all formats, and we need to leverage those areas where there is a shared
need, where differentiation doesn’t matter. MirixaPro CanadaTM is a solution for
the profession.”
Last but not least, the non-competitive
platform gives the profession access to
aggregate data that can be used to both
measure health outcomes and demonstrate the value of pharmacists’ services
to public and private payers. “Epidemiologists and other researchers can use the
findings. The real winners are the rest of
the healthcare system,” says Stann.
“This is not just technology for the sake
of technology—it has a purpose,” says Reinholdt. “We will collect the data and go
back to the provinces to show the return
on investment for our services.”■
• The National Community Pharmacists Association, which represents more than 39,000 chain and
independent pharmacies in the U.S.,
established Mirixa Corporation in
2006.
• In 2009, the Pharmacy Guild of Australia, representing 5,000 community
pharmacies, became the first national
pharmacy association to purchase an
exclusive licence to adapt and distribute MirixaPro™ to its marketplace.
• The Canadian Association of Chain
Drug Stores (CACDS) will become the
second national pharmacy association to adapt MirixaPro™, under an
exclusive agreement.
• CACDS will pilot the Canadian
version of the system in the first half
of 2012 .
• MirixaPro Canada™ will initially include modules that support expanded
services for which payment already
exists in some provinces, such as
medication reviews.
• MirixaPro Canada™ will reflect the
definitions and work-flow analyses
contained in the Canadian Pharmacy
Services Framework (CPSF), a Blueprint for Pharmacy implementation
plan component led by CACDS, with
the support of Canadian Pharmacists
Association and numerous other
pharmacy stakeholders.
• At the pharmacy level, MirixaPro
Canada™ core functionalities include:
- Evidence-based counselling and
adherence support in accordance
with available clinical guidelines,
including recommendations for
lifestyle modifications, self care and
preventative care;
- Standardized documentation
processes for interventions, development of care plans and follow-up;
- Standardized documentation
for expanded services, such as
medication reviews
- Documentation and communication tools to collaborate with physicians and other providers; and
- Development of a Canadian
database of pharmacy services.
www.cacds.com
Electronic health record:
one province at a time
Ten years have passed since Canada’s provincial
health ministers established Canada Health Infoway to support the development of a network of
electronic health record (EHR) systems, compatible
from coast to coast. Since then, the federal government has committed more than $2 billion in funding,
roughly matched by the provinces and territories,
towards an estimated total cost of $10 billion. Once
fully implemented, the EHR is expected to generate significant savings annually due to anticipated
reduced healthcare costs (including fewer adverse
drug events) and improved efficiencies.
Infoway’s 2010 Annual Report states that, as
of March 2010, EHR systems were available to
22% of the Canadian population through authorized physicians. It forecasted an availability level of
46% by the end of the year, falling just short of its
target of 50%. It is targeting 100% availability by
the end of 2016 (assuming continued funding).
Six core elements comprise the EHR: a client
(i.e., patient) registry; a provider (i.e., physician) registry; a drug information system (DIS, which captures all medications dispensed at all locations);
diagnostic imaging; laboratory test results; and
hospital clinical reports or immunization records.
For the DIS, Infoway estimates that 43% of all
information for dispensed medications is now captured and stored electronically, and 33% of retail
pharmacies have access to a DIS. These results vary
significantly by province, however; in B.C. and P.E.I.,
for example, 100% of pharmacies have access to a
DIS. Here’s a province-by-province snapshot:
Quebec The development
of a regional DIS that is
fully Infoway-compliant is
well underway, although
the timing for implementation is to be determined.
Nova Scotia The province
is close to completing its
planning process, with
implementation anticipated
in 2013 and 2014.
New Brunswick The prov-
British Columbia
B.C.’s PharmaNet system was Canada’s first
integrated DIS, implemented years before
the creation of Canada
Health Infoway. As a
result, work is ongoing
to make it compatible
with Infoway standards. The province
is also focused on
electronic prescribing,
which is expected to
become available in
2012.
www.cacds.com
ince’s DIS is being built to
meet Infoway standards,
with expected implementation in 2012.
Alberta Work is well underway to
upgrade the province’s existing
Pharmaceutical Information Network
to meet Infoway’s DIS standards,
and pharmacies should start coming
online by the end of 2011.
Manitoba Work to upgrade the province’s Drug Programs Information
Network to become an integrated
DIS is at the early stages, as the
province focuses more of its efforts
on other components of the EHR.
Saskatchewan The province’s Phar-
Ontario Canada’s largest province
maceutical Information Program is
approaching compliance with Infoway
standards, with rollout to pharmacies
expected by the end of 2011 or early
in 2012.
is still at the planning stage and
expects to have a DIS, complete with
e-prescribing, in 2014 or 2015.
Newfoundland The
province is piloting its DIS
with a limited number of
pharmacies; full implementation is scheduled to
occur through 2012.
Prince Edward Island
P.E.I. was the first province
in Canada to develop a
DIS based on Infoway
standards, implemented in
September 2008.
2011 CACDS REPORT 23
Building blocks for change
Behavioural change consultant Peter Sheahan explains how successful
change management is powered by the people
by Karen Welds
C
hange management is a dedicated field of study for psychologists and engineers alike, and research repeatedly shows that
its absence is the leading cause of failure for major initiatives.
In fact, a growing awareness of the implications of change management has resulted in a whole new business sector—that of companies
helping other companies implement change.
But what, exactly, is change management? In very simple
terms, it is managing the “people side” of change. Peter Sheahan,
an internationally renowned behavioural change consultant and
founder of ChangeLabs, spoke at the annual conference of the Canadian Association of Chain Drug Stores in June. Here’s a synopsis
of his thought-provoking presentation.
Identity-based decision-making
Successful change management focuses on the individual, not the
change. Whether it’s a New Year’s resolution to get fit or legislation
that expands pharmacists’ scope of practice, it all begins with the personal decision to change.
Decision-making, in turn, is most
powerful when it “taps into what someone aspires to be,” says Sheahan. “If you
were to distill everything down to one
concept, the one thing that drives human behaviour is the gap between who
Peter Sheahan
we are and who we want to be. We call it
identity-based decision-making, and it’s the most underutilized
change-management tool.”
All too often, daily pressures or uncontrollable events get in the
way of identity-based decision-making. The brain rationalizes this
by diminishing or even dismissing the aspiration. Yet aspiration
never fully disappears, and the most successful companies are
those that communicate a clear aspiration to employees.
One step at a time
Once the aspiration is in place, employers “need to scale back and get
very, very specific,” says Sheahan. “In pursuit of this, we will do this.”
It could be a particular service offering or a new technology—
do one thing, and do it right. Staff feedback is essential throughout. “You need to connect closely with your stores and employees, making frequent visits to determine their reality. Incorrect
www.cacds.com
assumptions kill the change
process,” emphasizes Sheahan.
Bring in the incentives
Traditionally, companies begin
with incentives to motivate the
individual to change. While incentives can play a role, they need to be “part of a deeper, more important journey” that’s driven by identity-based decision-making.
“Incentives are anchored in rationality, and people are not always rational when it comes to major change. First, you need to
engage their emotions,” says Sheahan.
When using incentives, “always leverage the positive, even
when issues related to the change are on the down side,” he adds.
As well, offer an incentive for no more than six weeks at a time—
after that, it becomes a “given” in the minds of employees.
Rally the mentors
In any given group of 100 people, about half are neutral or undecided about change, about 20% say they’re not interested and perhaps five per cent are “dead set against it,” says Sheahan. That leaves
about 20% who are interested, and five per cent who have already
embraced the change.
Among those who are already active and most interested,
employers can recruit and support mentors to serve as practical guides for the remainder of the “interested” group, suggests
Sheahan. “Once they’re fully engaged, use more of these ‘catalysts’ to convert the neutral group.”
As for the 25% who are not interested? If dismissal is not an option, you’ll need to put them in positions where they contribute to
the company’s requirements, without interfering with the change
process. “Otherwise, they are destructive,” states Sheahan.
Expand your partnerships
As part of his closing comments, Sheahan urged retailers, manufacturers and distributors in the room to consider new ways to partner. For
example, manufacturers and retailers can enter into revenue-sharing
arrangements for higher-margin, higher-risk inventory.
“It is time to collapse the barriers in the supply chain,” says
Sheahan. “You are all at the same table now, and you can’t navigate through this type of change alone.”■
2011 CACDS REPORT 25
Making
change happen
Associations, regulators, faculties, owners and
head offices step up to support pharmacists
who are ready to expand their role
by Sonya Felix
W
hile expanding scopes of practice and new funding
for pharmacist services are positive developments,
the rapid pace of change and a long list of uncertainties can temper the desire to celebrate. Pharmacists and other pharmacy stakeholders need to rework professional
and business practices before they can take full advantage of their
expanding role in the delivery of primary health care.
“The building blocks for the future are being put in place, but
there is a lot of work ahead,” says Nadine Saby, President and CEO
of Canadian Association of Chain Drug Stores (CACDS). “Change
is hard and while it ultimately rests with the individual, support is
there from retail head offices and pharmacy associations.”
The need to adapt—and adapt quickly—is particularly acute
on the business side. The traditional model based solely on the
distribution of medication is no longer enough, due to recent
government policies that reduce generic drug prices and lower
or even eliminate professional allowances. “In the past decade pharmacists haven’t had to push to do well but now there
is a real economic necessity to be creative and innovative,” says
26 CACDS REPORT 2011
Zubin Austin, Associate Professor at the Leslie Dan Faculty of
Pharmacy, University of Toronto. “I think we’ll be happily surprised at the outcome.”
Training tools available
Pharmacy faculties, regulatory bodies and professional associations
understand that community pharmacists need support as they move
into a new role. “We look at enhancements and expansions to scope
of practice as tools that will help pharmacists to fulfill their potential
in healthcare,” says Ray Joubert, Registrar of the Saskachewan College of Pharmacists. “But the ability to embrace change is all about
capacity and we need to make sure that the new demands don’t impose added burdens. As a college we are consulting with members
and we’re definitely feeling pressure to help.”
Regulatory bodies and pharmacy associations are also rolling
out training programs that teach the new skills required under
an expanded scope. This past June in Saskatchewan, for example, almost half of the province’s pharmacists trained for the new
minor ailments program. In B.C., more than 1,200 pharmacists
www.cacds.com
have become certified to administer injections since that authority became available in 2009. In Ontario, although legislation is
pending for injection administration, the Ontario Pharmacists’
Association has already graduated the first group of pharmacists
from its new injections training program. Last year, Dalhousie
University in Halifax developed an injections training program
for pharmacists in New Brunswick and Nova Scotia.
Associations and regulators also recognize the need for less
tangible change-management skills. The Canadian Pharmacists
Association and the Canadian Society of Hospital Pharmacists
already has a waiting list for its new ADAPT program launched
in August. The online, interactive, 19-week course helps pharmacists enhance patient care and medication management skills by
exploring such topics as evidence-based clinical decision-making, validated documentation practices, collaboration with other
providers and the implementation of patient care plans. A new
workshop from the B.C. Pharmacy Association addresses ways
to incorporate new clinical pharmacy services into existing community practices, while a continuing education course by the
College of Pharmacists of B.C. focuses on how to better utilize
professional judgement.
Such training programs give pharmacists the confidence they
need to shift from a role driven by distribution, where patient
counselling is tied to prescriptions as they are dispensed, to a
role driven by patients’ overall medication and healthcare needs,
where pharmacists consult with patients and other providers
to make recommendations for drug therapy and self care. Marshall Moleschi, Registrar of the Ontario College of Pharmacy and
former Registrar of the College of Pharmacists of British Columbia,
recalls that “in B.C. the change started with a small group of pharmacists. Then we saw more people become willing to step up
as they gained confidence. It’s much like riding a bike—it takes
practice and the more you do it, the more natural it becomes.”
For future pharmacists, faculties are adjusting admissions
requirements and curricula to better prepare students. “It’s not
enough to have the right GPA for admission anymore,” says Austin of the Leslie Dan Faculty of Pharmacy at the University of
Toronto. “Now we test for communication skills, conflict management and stress management. We’ve also introduced longer
clinical rotations and service learning where students volunteer
in healthcare organizations so they can talk to patients and develop better sensitivity to their needs.”
Faculties are also developing programs in direct response to
new legislated authorities. “We’ve developed an immunization
program that’s given through the continuing education department, and now we are determining how best to incorporate prescribing authority,” says Neil MacKinnon, former Professor and
Associate Director, Research and Graduate Program, at Dalhousie
University’s College of Pharmacy. Aside from the obvious skill sets
involved, it’s a “fairly complex process” to ensure students can apply the appropriate decision-making skills to assess patients’ needs
and make recommendations. “We don’t want to train pharmacists
to be diagnosticians like physicians, but they need to develop confidence to prescribe according to their own scope.”
www.cacds.com
Techs and technology
The regulation of pharmacy technicians is one major initiative considered critical to enable a stronger focus on professional services.
All provinces are at various stages of registering licenced pharmacy
technicians, with Ontario being the first to do so as of December
2010. British Columbia and Alberta began registering techs this
summer. In those three provinces, 45% of pharmacy owners and
managers say they plan to actively encourage selected pharmacy
assistants to become licenced, according to the Trends & Insights
2011 Survey of Pharmacists.
Technology is another vital enabler, on two levels. First, automated dispensing equipment and robotic systems significantly
improve efficiencies and free time for patient care; second, specialized software is necessary to support, document and meas-
One patient at a time
Retail pharmacy partners with health organization
to build bridge for patient education
As pharmacy manager at a Loblaws supermarket located in
an ethnically diverse neighbourhood in Etobicoke, Ontario,
Carlos Rubio-Reyes knows the importance of convenience
for busy customers. He’s also aware of the importance of
early detection of chronic disease. He’s recently been able
to combine the two using assessment programs for diabetes
and cardiovascular health that
are free to patients.
The “Get Checked Now”
program, created by Loblaw
Companies in partnership with
the Canadian Diabetes Association (CDA), includes a blood
pressure check, an assessment of diabetes risk factors,
Carlos Rubio-Reyes
an information brochure and a
one-on-one consultation with the pharmacist to discuss
lifestyle issues. For those who need more information, the
pharmacy and CDA also offer diabetes education sessions, which include cooking demonstrations and store
tours with a dietitian.
As part of Loblaw’s “Healthy Heart Check” program,
consumers receive a blood pressure check and cholesterol test followed by a pharmacist consultation.
While advertising draws people to the programs, RubioReyes also approaches patients when counseling about
prescriptions or over-the-counter medications. “If there is
any indication that they are at risk of diabetes or heart disease, I can offer to do a risk assessment on the spot.”
It takes additional time to do these consultations,
as well as MedsCheck medication reviews, but RubioReyes says technology and other supports from head office help. “It’s great to be able to provide programs that
are convenient for patients,” he says. “I am anticipating
the next changes in scope of practice that will allow us to
offer more services and even better patient care.”
2011 CACDS REPORT 27
ure clinical decisions and health outcomes. CACDS recently
signed an exclusive licensing agreement to bring MirixaProTM to
Canada, a web-based platform for clinical decision support and
documentation that will be customized for the Canadian market
(for details, see page 21).
A new business model
While an expanded scope opens up major opportunities, the loss
of dispensary income poses major challenges. Particularly hard hit
is Ontario, where the government’s ban on professional allowances
is taking a big chunk out of operating budgets. Pharmacies in other
provinces with slashed generic prices are also feeling the pinch.
The result is a Catch-22 scenario, where stores try to cut costs by
reducing staff and store hours, then struggle to find the resources
to offer new services.
“It’s critical to remain profitable through the transition,” says
David Montisano, Vice-President of Total Health, a chain of 37
owner-operated pharmacies in Ontario. “You can’t rely on professional allowances any more so you need to look for other ways
to make money by raising the dispensary volume and emphasizing paid services. Although we now have to run a tight ship
on human resources and everything else, I’m excited about any
opportunity to do more and welcome any changes that will help
us be more profitable. But we will need more reimbursement for
services to be successful.”
No one can expect to replace all the money that’s lost in the
short term, says Jeannette Wang, Chief Pharmacy Officer, Remedy’s Rx. “But paid services can replace some of it and demand
for these services is only going to rise. Pharmacy owners who are
ahead of the curve have already accepted the reality and put into
place what they need to do to survive and prosper. Now we need
to help others along the continuum to make sure the positive
mentality spreads.”
Russell Cohen, Executive Vice-President of Industry and Government Affairs at Katz Group Canada, agrees. “We need to accept the evolving healthcare landscape and realize that we’re
heading towards crisis mode across the country and that government budgets are stretched. Pharmacy can be either part of the
problem or part of the solution and we see ourselves as part of a
solution. We’ve been talking about a greater role in healthcare
for years and now we’re there! It is time for pharmacists to decide
how to respond. Yes, start-up costs to implement pharmacy services can be high, but I believe that expanded scope and patientfocussed services will eventually be profitable in the future.”
Retail pharmacy head offices are pursuing a range of supports
and resources to help pharmacy staff. The hiring of regulated
pharmacy technicians and greater use of robotics and automated
dispensing equipment will boost efficiencies in the dispensary
and improve work flow; store designs and renovations, including
private counselling rooms, are putting more emphasis on health
care; and new or upgraded software will simplify documentation
and the development of patient care plans.
Changing mindset among private payers
While provincial governments are clearly starting to recognize the
value of pharmacy services, private payers are remaining relatively
quiet so far. “It’s still a chicken and egg scenario,” says Cohen.
“There is a role for the private sector to pay for pharmacy services
but there is definitely a gap between the way public and private
payers see it.”
Marilee Mark, Vice-President of Marketing, Group Benefits
at Manulife Financial, agrees that pharmacy’s expanded scope
of practice can be viewed as an opportunity for private payers—
with certain considerations. “The biggest challenge for payers is
added fees,” she explains. “Anything billed as an enhanced service needs to be separated from regular dispensing fees so it is
clear where the value is. Unless they can see return on investment, many employers aren’t willing to pay more.”
Private payers can see the potential for pharmacists to support
chronic disease management and provide one-on-one health
coaching, “but to manage quality this type of service needs to be
done through a PPN [preferred provider network] or through a
separate specific agreement that lays out more detail. We aren’t
seeing this yet,” adds Mark.
Pharmacy needs to do a better job explaining what they can
offer, says Francois Joseph Poirier, Partner at Mercer Human Resource Consulting. “As payers become more educated on what
pharmacists can provide, then perhaps there will be more interest. But the nature of Canada’s health and drug system is that
plan sponsors don’t want more of the healthcare costs transferred to them.”
Still, he notes that some pharmacy services such as on-site
dispensing of drugs and preventative care clinics could be immediately useful for employers. “The price tag on some new
drugs runs to five or six digits and it could be useful to have a
pharmacist help sponsors better manage those costs. But that’s
not likely to happen under the current pharmacy model unless
pharmacists become very innovative.”
It will take some time yet before private payers feel comfortable enough to incorporate pharmacy services into their drug
plan management strategies. In the meantime, they’re keeping
a close eye on how pharmacy progresses with expanded scopes
and the development of new services. “We are absolutely willing to talk to pharmacies as we look for the best opportunities to
bring value to our clients,” says Mark. “There is definitely potential there but we need to see more transparency on costing and
understanding of needs.”
Pharmacy is just beginning its transformation into a new practice and reimbursement model. It will take hard work, commitment, patience, vision and optimism. “We need to be proactive
and have a positive perspective as the culture shifts from a product focus to a patient focus,” says Cohen. “At the end of the day,
it’s about providing better health care to patients and if we do it
right, then our businesses will benefit.”■
Q&A with the Chair
The next level
CACDS Chair Sandra Aylward reflects on how CACDS and individual
pharmacists are rising to the opportunities of a profession in transition
You have participated in a number of negotiations between
pharmacy and provincial governments. What have you
learned so far?
We’ve learned the value of not assuming that provincial governments—elected officials or bureaucratic staff—understand all the
complexities of our profession and our business. It is worthwhile—
critical—to provide a good grounding in both the nature and scope
of our pharmacy practice as well as its economic elements before
new models can be considered.
Similarly, in each province, pharmacy representatives have to
quickly get a clear understanding of the government’s priorities
and mandate and how they pertain to the negotiation. We also
need to understand the nature of the current political environment and its potential for distracting from or, at worst, interfering in the negotiations.
It’s surprising how easily a disconnect can occur between
pharmacy and government when it comes to the financial assessment of a current situation or a proposed model. Your understanding of “the numbers” depends on the information that
you have, its currency, how you define the variables, and the assumptions you make (or don’t make). Both parties need to come
to a shared understanding of the baseline—and then resist the
urge to take “short cuts.” A careful consideration of all possible
variables is key to a successful outcome. This process is detailoriented, and can be difficult for “big-picture” thinkers. It takes
time and commitment on both sides.
We’ve also learned that what happens in one province influences other provinces. We have to focus on achieving the best
possible, sustainable model and migrating each province to its
guiding principles, in order to establish a new, viable version of a
“normal” operating environment, and get on with the expansion
of the services and role that pharmacists offer Canadians.
Why is it so important for individual pharmacists to become
more involved in the future of their profession? How can they
do so?
Like many pharmacists (and other Canadians), initially I was not interested in getting involved in “politics.” However, I now realize that
30 CACDS REPORT 2011
politics is, at its heart, citizen engagement.
That engagement can vary significantly
based on the individual, from being informed about issues generally and voting,
to running for office.
Tools such as Pharmacyworx (www.
Sandra Aylward
pharmacyworx.com) help us become
engaged, whether before elections or between elections. The fact
of the matter is that we each have a role to play—as individuals,
as members of the community, and as pharmacists within our
communities. Our ideas and opinions can help to shape better
government policy, and as professionals we will benefit from
taking the small step of introducing ourselves personally to candidates and elected officials and letting them know that we care
about health-related issues. It can feel awkward at first—it did for
me—but then you realize: “This is how democracy works—this
should be part of how pharmacy works.”
You’ve just begun a two-year term as Chair of CACDS. What
do you look forward to accomplishing during your tenure?
In a word: evolution.
It’s an exciting time for CACDS. We have over 15 years of experience advocating for our profession and our business. We’ve
developed strong relationships across the country with everyone
in the pharmacy profession and a reputation as a credible and
resolute advocate for community pharmacy in Canada.
I’m looking forward to the continued evolution of CACDS. We
will become even more inclusive as we represent those who are
responsible for the delivery of pharmacy services in communities
across this country. We will continue to advance the discussion
about how pharmacy can play a new and enhanced role in front
line healthcare, by developing support tools, demonstrating the
value of pharmacists’ services and bringing a strong, collaborative voice to discussions on pharmacy policy and funding.
As the past few years have so clearly demonstrated, pharmacy is experiencing a time of tremendous transition. CACDS is
committed to evolve in response in order to continue to fulfill
our purpose. ■
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