Prescription drugs — most Americans take at least one prescription drug and 50 percent take two. Another 20 percent take five or more. With the growth in prescription drug use, the role of the pharmacist has changed.
Listen to an interview with Mark DiParlo, a registered pharmacist and director of pharmacy outpatient services at the UVM Medical Center. Mark explains the different kinds of pharmacy services and how they differ at hospitals compared to your local drugstore or grocery store pharmacy. A transcript of the interview is also available below.
UVM Medical Center: The man with all the answers today is Mark DiParlo, a registered pharmacist and director of pharmacy outpatient services at the UVM Medical Center. Thanks for coming.
Mark DiParlo: Thanks for having me.
UVM Medical Center: First of all, just give people the big picture of what’s available for outpatient pharmacy here.
Mark DiParlo: At the university, we’ve grown into a number of outpatient retail sites. We have an outpatient pharmacy at the Ambulatory Care Center, at the main campus, one at the 1 South Prospect Street campus, and one at the Fanny Allen campus in Colchester. We have a Home Infusion Pharmacy and we now have a specialty pharmacy, which also has morphed into some mail order services.
UVM Medical Center: All right. We’ll break all those down in a minute, but in terms of when you walk into one of these outpatient pharmacies, it’s everything you get at your local drugstore, but there are differences.
Mark DiParlo: There are differences. We don’t have a lot of over-the-counter products. Our clinic locations are relatively small in comparison to having lots of over-the-counter products and candy or health goods. We service mainly prescriptions for the community and for employees and for people being discharged from clinics after procedures.
UVM Medical Center: Your pharmacists perhaps play a different role would you say than a pharmacist at other locations?
Mark DiParlo: We do have a number of pharmacists here who have a diverse role in the hospital setting and we interact with the pharmacists who are actually working on the floors in the hospital for discharges and discharge planning, making sure that people get their high tech or high touch medications and education properly before they’re discharged from the hospital.
UVM Medical Center: The education piece is obviously critical because some of these are complicated medications and taking them can be a little complicated.
Mark DiParlo: That’s correct. That’s why we have the initiative right now with even the specialty pharmacy where we’ve put a pharmacist into a clinic in a number of different clinic sessions, including oncology and rheumatology, so that those pharmacists can actually interact with the patients when they come into the clinic itself.
UVM Medical Center: That’s cool. Specialty pharmacy, generally, what does that mean?
Mark DiParlo: Specialty pharmacy is for people who have disease states that are taking expensive, many times injectable, high risk medications that need monitoring. When they come into the pharmacy or come into the hospital, the pharmacist will meet with them and they’ll go over any type of side effects that they might be having, any injection site issues if it’s an injectable, do the teaching for the injection site, and work with the physician to make sure that there’s compliance with these medications so that they are taking it appropriately and then monitor that. Then we have patient care coordinators who are pharmacy technicians who work on the back end to make sure that the patients can afford their medication and can get their refills in a timely manner and to make sure that there is any communication between the clinic and the pharmacy staff going back and forth with that patient to make sure that they’re successful with their medication therapy.
Many times, the specialty products are really expensive, so it takes more of a team approach to manage those types of patients.
UVM Medical Center: Give me an example. Is this chemotherapy?
Mark DiParlo: Yep, it could be chemotherapy. It could be the new hepatitis C treatment, which is $30,000 for one bottle of medication, and it’s a 90-day supply, so 3 of those bottles, if somebody is prescribed that, there’s a lot of teaching that goes along with that just to make sure that they’re going to be compliant and take that throughout the course of therapy, especially because of its expense.
UVM Medical Center: Is it a newer thing to have your pharmacists embedded as you were describing?
Mark DiParlo: It’s a unique practice that academic teaching hospitals across the country have had. There are a number of different ways that specialty pharmacies are set up, but this is the way, because we’re a teaching hospital, that we’re hoping to continue with that from the pharmacists and the clinics have been very receptive actually having the pharmacists in the clinic setting.
UVM Medical Center: Obviously it’s so key to the health of the patient. As you say, sending somebody home without much guidance, things are not going to work.
Mark DiParlo: That’s exactly what we have found. That does happen. I think we even have interpreter services and a number of other things for when these patients are discharged so that we can make sure that they have a positive outcome to the medication therapy that they’re being prescribed.
UVM Medical Center: Just speaking in terms of your career, is it more common now for people to have to administer drugs themselves at home?
Mark DiParlo: Yeah. I think that with the prescription benefit managers out there now and in terms of how they’re going to control costs, a lot of the high tech, more expensive medications are being administered in the home setting as opposed to being in a hospital clinic. There’s a lot of injectables and there’s a lot of even site types of infusions that the nursing staff from the visiting nurses association are able to do in the home setting instead of in the hospital.
UVM Medical Center: You mentioned home infusion. That’s basically people who are discharged from the hospital, but still need some kind of IV, would it be?
Mark DiParlo: Yeah. For the most part, there’s the medication that we manage from the home infusion area are IV medications for people who have a central line, a PICC line, who might need six weeks of antibiotic therapy, and after the first week in the hospital, they can go home. We have three nurses and two pharmacists and some technicians who work in the home infusion pharmacy on a daily basis, and they’ll work with the case managers to assess those patients to see if they have a supportive teaching environment and a safe place to do that at home. Then they contract with the visiting nurse association to do an initial teach from the hospital and show them how to use a pump and how to manage the central or the PICC line that they have in, and then they will call them on a weekly basis to do an assessment of how that patient’s doing and if there are any labs that need to be taken care of and then make sure that they communicate that to the physician or to the clinic so that those patients are managed when they’re in the home setting.
They also provide enteral feeding, nutritional therapy at home, and they provide some week-long chemotherapy pumps at home, as well as pain management that we supply for the hospice population in Chittenden County.
UVM Medical Center: When you say nutritional, you mean feeding tube?
Mark DiParlo: Yep. The people who have a feeding tube and need enteral feeding at home, our nursing staff manages those patients, as well.
UVM Medical Center: That’s clearly stuff that would have been happening inpatient I would think not too long ago.
Mark DiParlo: That’s right.
UVM Medical Center: Why the move for that? Just obviously a cost issue?
Mark DiParlo: I think that it frees up beds in the hospital. The patients aren’t really sick enough to be in the hospital, so if they can be managed at home successfully and still monitored by the clinic and by the doctors when they’re there, it’s a win/win for everyone. The patients really like it.
UVM Medical Center: I want to talk about something now that’s in the news a lot: opioid problems. As I said at the beginning, there are so many people on so many drugs, and the question is raised about what’s the best way to dispose of these. I remember when we were hearing flush them down the toilet, and then other people said, “No, no, no, that’s not the way to do it.” What’s the guidance there? What are we doing about it?
Mark DiParlo: The guidance for this has changed over the course of time, and I think now with opioid crisis and the potential for diversion out there, there’s a lot of information about how to best take care of those. I think that the major impact of the environment and what would happen to the lake if everyone flushed these particular medications down the toilet is that there’s no place in the system to get those out of the waste water supply before it actually gets into the lake, especially in the environment that we live in. It’s not the best way to dispose of the medication. We’ve actually initiated a MedSave System. We have a sealed canister in each one of our three outpatient retail pharmacies and patients or physicians or employees can come to the pharmacy and drop off their medication into these systems. They’re secured and people can’t get into them. Then the sealed boxes that are in the canisters are actually taken and incinerated so that there’s no one that comes in between them.
The pharmacists can’t actually take the medication back personally from the patients, but the patients or caregivers or family members can bring the medication in and put them into the containers themselves.
UVM Medical Center: This is not just pain medication.
Mark DiParlo: This is any prescription medication and up to 4 ounces of liquid. We cannot take needles and syringes or anything that would have a sharps associated with it.
UVM Medical Center: In addition to, let’s say you have a leftover prescription for pain meds, that’s not everybody’s idea, but this is also a thing I think most people don’t do. You got to look at, see what’s expired in your medicine cabinet, and this would be a way to dispose of that, as well.
Mark DiParlo: That’s right. We used to have a National Take Back Day, and I think that that has morphed into some police stations having some of these take back canisters that they take care of that, and I think that there are a number of other retail pharmacies, chain pharmacies, that have stepped up in the last year and started to put these containers in their pharmacies, as well, to try to get these prescription products out of patients’ homes so that they don’t fall into the wrong hands or end up in the water supply.
UVM Medical Center: The other thing I wanted to ask you about is mail order pharmacy, which is a newer offering here. What’s the story there?
Mark DiParlo: We’ve just recently started a mail order pharmacy that is part of our 1 South Prospect Street location. We are mailing basically 90-day supplies of medication to our patients. We’re starting that as a slow rollout and identifying patients that are on five or more medications and sometimes complicated and have some problems getting into the pharmacy to pick things up, and we’re going to go through a process where we’re going to synchronize those medications so that they can get a 90-day supply mailed to them. We’re hoping to roll that out for all discharge patients and to the community in the near future.
One of the added benefits of this is that because it’s within the system, when someone is admitted back to the hospital, the clinicians in the hospital will have some viewing of what the medications are that the patients are taking so that they can reconcile their medical record and not have duplicates of therapy if they’re admitted and then discharged again so that we’ll be able to actually see both from the electronic medical record and the pharmacy system itself what the real time medication needs of those patients are.
UVM Medical Center: What’s the reordering process as you get to the end of your 90 days?
Mark DiParlo: At the end of the 90 days, it’s just that the system itself will flag the period of time that needs to go between refills, and then those refills will be done automatically. A phone call will be made to the patient, make sure that they’ll be around or still at the same address for delivery and then the prescriptions will be mailed out to the patients.
UVM Medical Center: Just a minute or so left. I wanted to ask you, just curious. You’ve been here for 20 years. I’m not sure how many years before that you were in this profession. It seems like it has changed a lot. What would you say are the biggest changes you’ve seen in your career?
Mark DiParlo: I think the biggest changes are that pharmacists are part of the healthcare community and that they’re realizing that their role is not just to stand behind the counter and fill prescriptions all day. We have lots of different patient interactions. We work with a travel clinic. We provide vaccines. We have these diverse pharmacies and provide patient education. We have a staff of more than 60 people now from a staff of 8 people when we started to work here. We have students from the local pharmacy college who rotate through here, both clinically and then operationally through the pharmacies, and we have pharmacists who just do clinical research.
I think that from a standpoint of just what a pharmacist does, in the last 20 years, those boundaries have been broadened quite a bit.
UVM Medical Center: I’m sure the change is not ending.
Mark DiParlo: The change is not ending. From the seat that I sit in, it’s a constant change and something that as pharmacists are hoping to get some provider status that they’ll be able to have more of a role in the clinics and in the hospital itself with the advanced practice providers that we see commonly now, like physician assistants and nurse practitioners.
UVM Medical Center: Before we go, I want to make sure people know where to find out more information on all of this: specialty pharmacy, home infusion, medication disposal, the mail order pharmacy. All you need to do is go to UVMHealth.org/medcenter, and in the upper right on the web page, you’ll see a search box. You can put in pharmacy. It’ll bring you to all of that information. For now, I want to thank my guest, Mark DiParlo, who’s director of pharmacy outpatient services at the UVM Medical Center. Fascinating, and thanks very much for coming.
Mark DiParlo: Thanks a lot for having me. I appreciate it.