Ben Bluml’s Case for the Connected Pharmacist

Speaker A: You're listening to There's a Better Way Smart talk on healthcare and technology. If you're up for energizing and story driven conversations with national healthcare leaders driving industry innovation across the country, then, uh, you are in the right place. On this episode, we're asking what becomes possible for patients when pharmacists are connected fully into the care team. A lot, as it turns out. Let's start with two startling stats. The first one is that 90% of Americans live within 5 to 10 miles of a pharmacy. The second is that the entire US population collectively passes through pharmacy doors every eight days. What does this mean? It means pharmacists are some of the most accessible clinicians in healthcare. The the problem is that they have historically been the least connected to it. And that brings us to our guest today, Ben Blumel. Ben got his start as a hospital and a health system pharmacist in the Kansas City area and he was an early leader in pharmacy informatics standards. Today, as executive director at the American Pharmacist Association Foundation, Ben heads research and innovation, designing structure and process models that enable pharmacists to deliver clinical services across care settings. Ben's work has resulted in pathways for pharmacists to be credentialed, compensated and connected into care teams. And as we'll hear on the episode today, this means a whole lot when it comes to patient care. It's great to have you on the show today, Ben.

Speaker B: Well, thanks, Melanie. It's a pleasure to be here.

Speaker A: Well, you have a clear philosophy about how care is delivered, including through pharmacists. First, I'd really just love to hear a little bit about your background and we'll get into that philosophy. But what brought you to the pharmacy world and to apha?

Speaker B: Well, I'm a, uh, pharmacist by training. While I was in high school, I had this amazing job in a community pharmacy. And uh, what I loved about community pharmacy was the connection that you had with people every day. And some of my axioms, if you will, in my practice career have really been all about doing the right thing for the patient and putting them first, empowering pharmacists as integral members of the healthcare team and figuring out ways to integrate technology into these patient centered, team based care processes and really make sure that we've got good systems level changes that are producing the types of care deliveries that we know are possible when you get all of the right pieces in place.

Speaker A: Well, I'm excited to dive into that, putting the patient first and, you know, making pharmacists integral parts of the care team with technology and so forth. But, uh, let's just even go back. Like you spent three decades designing ways m for pharmacists to do more for patients. When you started, what was the pharmacist's role and how is it different today?

Speaker B: Well, I had a series of interviews for the job at APhA. I had spent about 12 years in health system practice. And in my interview with Dr. Ganz, what he was very clear about was, is that what APHA needed from its foundation at the time was for us to focus on producing models and evidence about the role of the pharmacist in patient centered team based care.

Speaker A: So you've spent a lot of time doing that work then. And I love the focus on clinical, economic and humanistic impacts. Can you talk a little bit about where we are right now in the pharmacist world and how it might have been different from when you started?

Speaker B: The big difference today is that we've got the models, we've got a lot of evidence, and we know that there are significant clinical, humanistic and economic benefits that do come from integrating the pharmacist properly on the patient care team. And ultimately, you know, we see so many improvements in the patient's, not only care delivery, but in their lifestyle changes and the outcomes that they're able to achieve. So a lot of that depends upon the condition that we're focused on. In some cases we might be focused on hypertension, or in that case we're looking at blood pressures or cholesterol levels. We're looking at lifestyle changes and other behavioral changes that a patient makes to actually make sure that they get the most from their medications.

Speaker A: I'm sure you have some patient stories that can help put this in context. Can you tell us more about a patient who maybe their care went off track because a pharmacist couldn't see or wasn't involved?

Speaker B: I'll go back to the first project I came to APHA to do. So just imagine a scenario where what we knew about patients who were started on medications for lipid lowering was that essentially the industry data at the time said that only 32 to 38% of patients would be left taking their lipid lowering medications 24 months on. And so what we did was we implemented a program where 26 community pharmacies in 12 different states cared for a little over 400 patients and basically used a new point of care testing technology from a startup company out in Hayward, California called Calestec. And the pharmacist did a finger stick to get a CLIA wave profile for that patient. So they understood what their LDL cholesterol, their HDL cholesterol, their triglycerides, their total cholesterol looked like. And they were actually able to identify people who were at risk and who might be on therapy and were poorly controlled, or they might not be on lipid lowering therapy at all. But once they got them on their lipid lowering therapy, then the challenge was related back to that situation where most patients have a hard time remaining adherent with their therapy over time. And it's not surprising, because as a patient, how do we discover that? Well, we go to a screening event or we go to a primary care visit and we find out we have high cholesterol. And the first thing that happens is that your physician asks you to change what you're eating to change your lifestyle. And oftentimes those changes don't actually get you to your treatment goal. And so then you get started on medications. And so human behavior teaches us that essentially a few months into this, you're having to do things that you don't like. You're having to exercise, you're having to eat foods that might not be your favorite, you know, and those changes didn't actually get you to goal. So now you're spending all of this money on medications and you still don't feel any different than the day before you started all of it. And so what if your pharmacist actually had this technology that they could use in their practice to help to give you feedback, to help you understand how you were progressing and how well controlled your lipid profile is, and ultimately whether you're achieving your adult treatment panel goals or not, so that you can reduce your risk for a cardiovascular event in the future. And ultimately, with that feedback loop, with that point of care technology did for pharmacists all across the country was it helped them to inform their patients about their progress or sometimes lack thereof, and really help them to be more compliant and persist on their therapy. Because they understood that those changes, as it relates to their medication taking behavior, their lifestyle changes, the nutritional changes that they've made, are actually really making a difference. And one of those values that the pharmacist assessed was also a Framingham risk assessment. And so basically it helped people to understand, you know, whether or not their 10 year risk for a cardiovascular event, you know, was higher or lower or the same as their last visit. We had one example of a patient who had not been doing very well even early on in the program, they have monthly visits for the first few months and then the schedule backs off to more of a quarterly visit profile. And, and the story that the pharmacist told me was that basically this person hadn't been, you know, particularly compliant with their medications and they hadn't been doing a good job with their nutrition and their lifestyle changes. As the story goes, basically this person went to a baseball game the night before they had their appointment with the pharmacist and had some ballpark franks and some foods that weren't particularly healthy. Admittedly, uh, it probably wasn't a fasting lipid profile that he got the next m. Morning. But one thing that happened that's really important and I think really telling is that this patient who even with the support of a feedback loop wasn't actually adhering to their therapy, was able to suddenly have a light bulb moment that day in their appointment with the pharmacist. And he said to the pharmacist, he said, because what happened is that he had a, uh, two and a half times higher risk for a ten year stroke than he did on the quarterly visit immediately preceding that one. And so he said to his pharmacist, he said, wow, he said, if I don't make some changes, I'm not going to be here to see my granddaughter get married. And so for, for that person, it was that day when their pharmacist actually helped them to understand that these changes are largely up to the patient. They have choices that they can make and whether it's their nutrition, their lifestyle or their medication related behaviors, these feedback loops that technology can support us with in community pharmacy practices can really be a game changer.

Speaker A: It makes me think about, you know, I'm completely addicted to my health tracking devices and it's the feedback, right, that gives me the, it's constant feedback and it makes complete sense, sense that somebody who's on one of those lipid lowering medications would benefit tremendously from more than annual or, or less feedback on what that medication and what lifestyle changes are doing to their health. Well, if you go to the pharmacy is one of the places Americans visit the most. You know, I'm traveling right now, I was texting with my husband. Can you go to the pharmacy, you know, at least once a week? Right. Why? Has it historically been one of the least connected parts of the health system in terms of providing care?

Speaker B: It is ironic, isn't it? We know from the data that 90% of Americans live within 5 to 10 miles of their pharmacy. And so access is not really the problem. Another thing that we know from some data two or three years before the pandemic began, when we looked at these numbers, is that it's really astounding. The count of the population of the United States passes through the front doors of community pharmacies, albeit maybe with some duplications every eight days in the US and that's just an astounding number. And so here we have this great access. But the paradox is that people often just think of the pharmacy as only a place where they receive just a product instead of products, plus those services that provide important education and safety parameters associated with these technologies that we put into our bodies that we call medications. And I think that's where the real gap is at.

Speaker A: I don't think I've received a vaccine from my doctor in a number of years. I get them all at the pharmacy, but then that data doesn't actually reach my doctor unless I tell them. So, you know, you talked about needing to use data and technology to help drive better outcomes in general. What does that look like in the pharmacy?

Speaker B: When we think about advanced service delivery in community pharmacy practice settings in particular, we usually think of it in two different categories. So in the old days when I was trained, we called the one category the hippie dippy stuff, the health promotion, disease prevention related activities. And then on the other side of the coin we've got health management services. And so some people may refer to those as disease management services. So on the prevention side of the fence, just like you were talking about, you may be getting a vaccine at your local community pharmacy. You may be getting some kind of a health risk assessment or a, ah, screening. One of our projects, we had a group of 17 pharmacies in a community that were screening for bone mineral density readings, heal sonogram technology that we used, they did a really amazing job of, you know, putting information out there to the public and helping people understand who might be at risk. And when those patients actually came to the pharmacy for a screening, 7 out of 10 who showed up were either at higher moderate risk for future fracture. So that's a great example.

Speaker A: I can totally see it. So what information does a pharmacist need to be able to do this? Like I said, my vaccine though, that's not as big, but the doctor doesn't know. I have to tell them. So what information exchange needs to happen to make this really possible?

Speaker B: So in order for the pharmacists to actually be most effective, what we consistently see is that when pharmacists are embedded in integrated care delivery systems. So when you look at Kaiser as a great example, most of the time when I talk to physicians at Kaiser, you know, the first thing that they're talking to me about is the amazing contributions that the pharmacist on the team make. And they don't know how they would be able to deliver care without that support as part of the care delivery team. But what you've got to remember about an integrated delivery system, the pharmacist there has read, write, access to the entire electronic medical record for that patient. And so the flow of information back and forth and the ability for pharmacists to contribute to that data and to actually understand the patient's diagnosis, their condition, the history and physical and all of those things that are important to understand. The more subtle nuances of the therapeutic decision making that goes on and the ways that the pharmacist can contribute to optimizing that patient's therapy are all right there at their fingertips, and they can interact in a really seamless and productive way. The majority of community pharmacies in this country, though, aren't so well connected because they're focused with just the dispensing component of the prescribed medication. And they don't have access to the history and physical. They don't have access to those lab values and the results from different diagnostics that have occurred to help to inform good therapeutic decision making.

Speaker A: Well, let's talk about what this looks like in practice. Can you talk about your project Impact, your work with Project Impact and the Impact Care Transformation Network have pharmacists running AFIB screenings, immunizations, test and treat diabetes prevention. What made those models work and what role did data exchange play?

Speaker B: This is one of the projects that we've just completed. So let me tell you a little bit about what happened in that initiative. So that program was implemented in 40 community pharmacies in 20 different states that actually comprise the two Medicare administrative contractor regions, the Neridian Max and the Palmetto Max in the country. And that was important because we wanted to show that these high quality screening, identification and referral services, followed up with an ongoing monitoring and management program, could actually really make a difference in people's lives. So let's talk about AFIB and the terrible risk that's out there for people because more than 80% of people who have atrial fib are walking around with it and they don't even know it. And despite years and years of attempts at screening and identifying people who have afib, we still haven't found effective ways to do that. So what we hypothesized for this project called Project Impact Cardiovascular Health plus, was is that we thought, well, what if we got one payer to actually say yes to actually compensating the pharmacist as a member of the patient care team just like the other members of the patient care team? And what if we had a sponsor who enabled us for any of the patients who weren't covered by that major payer, to basically cover those costs so that we could accomplish the following. What if we credentialed pharmacists just like their physician colleagues, and we paid them just like their physician colleagues for the same CPT codes? So when the pharmacist actually screens, identifies and refers patients who have atrial fib, they would get the same kind of payment as their physician colleague. And then when they refer that patient off to either their primary care physician or their cardiologist, whatever's most appropriate, and that patient gets referred back into an ongoing monitoring and management program in the community pharmacy that the pharmacist sees that patient on a regular basis and helps them to remain adherent with their therapy. Well, here's the first thing that we found, Melanie, and this was just really incredible. So pharmacists, what they did was they started out first with a SDOH screening. So the pharmacy teams, typically the pharmacy techs, we're working with the patients to understand what their key social determinants might be beyond their medications and medication related therapies. So do they have challenges as it relates to housing or transportation or food and can they afford their medications, all of those kinds of things. There's an, actually a triaging that goes on with the pharmacy technician, who in some cases may even be a community health worker. And they get the patient plugged in to resources that they might need that are, you know, beyond just their medications. But after that first step, which really helps the pharmacy teams to meet patients where they are, the pharmacist invites the patient to consider participating in this program. And then they do a stroke risk assessment. And so they look at modifiable risk factors and behaviors that indicate whether or not a patient may be at risk. And, and then they use an over the counter device called a Cardiomobile 6 lead, and the patient can actually hold onto this device that's just slightly smaller than the size of a, you know, an iPhone or an Android. And 30 seconds later, the pharmacist can have a, uh, single lead EKG that's medical grade. And they can understand whether the patient has atrial fib or another abnormal rhythm. And so the pharmacies, because they have access to the patient's medication profile, they have, um, and they're doing the stroke risk assessment, they can understand patients who might be, you know, really benefiting most from going through this screening process. And so what we found in over 2100 patients is that pharmacists in these 40 different pharmacies that participated in this initiative, where they were credentialed just like their physician colleagues, and paid just like their physician colleagues on the team, identified people with atrial fib at over three times the rate that those people would have even been expected to exist in a normally distributed population in those geographies. And that's an absolute home run in terms of being able to help people who don't know they are at risk to discover it and to actually not only get engaged in a program that's going to help them with their lifestyle changes and their medications, but also get them referred to their physician and other specialists who may actually be able to do a good job of identifying those underlying causes.

Speaker A: I know we have talked about this and you have spent some time on with the, uh, Sequoia Project and the, uh, Pharmacy Interoperability Group and so forth. And ShareScript's clear, clearly is focused on how do we get pharmacy pharmacists interoperable with our own. Q Hen, what do you think about the chicken and egg situation? Right. So how far can pharmacists go without having this, which needs to come first at this point, to accelerate the work?

Speaker B: Usually the solutions that work tend to be hybrid solutions, and they often, in our experience, to be a, uh, both and kind of a solution rather than an either or. So I think that pharmacists need to consider, you know, starting where they're at and look at their practices and their business models and what they have a passion for, what they already have, you know, clinical expertise in and to focus on those things. But they really need to get on the information superhighway. So one of the things that we're doing in some of the work that we're doing with different states in the Rural Health Transformation Program, is that we're setting pharmacists up with a model where we're enabling them to connect to that health information superhighway through our collaboration together with surescripts and, you know, just imagine that, you know, patients who might be discharged from the hospital and just their medication reconciliation. I mean, we have all kinds of examples, you know, where basically a Patient gets admitted to a hospital, for example, and they're on an antihypertensive medication. So they've got high blood pressure, they're being treated for it. And that's one of, you know, a constellation of their cardiometabolic challenges that they're having. But that high blood pressure may have landed them in the hospital. Patient gets admitted to the hospital, and the first thing that happens is that they do a review of what medications they're on. They find out that they're on this single molecular entity antihypertensive. And they basically have to up the dose and put them on an antihypertensive that has two different, you know, active ingredients in it while they're in the hospital. And they get them in, into acute care, they get them all tuned up, they get their hypertension controlled, and they get them on a formulary medication that's, you know, specific to that particular hospital that they've been admitted to. Now it's time for discharge. And a prescription gets written for this medication that has two active ingredients in it, uh, instead of one. And basically what happens is that there's not usually a very good handoff that goes on between the discharge planner and the pharmacist in the community where the patient spends 99.9 something percent of their lives. They're not usually in the acute care setting, but there's just not good communication that goes on. And so you don't know because you haven't fully reconciled the medications from the formulary status of the hospital to switching over to what's available to the patient at the community pharmacy practice setting and is covered, you know, with their copay and their insurance. And so what if that medication actually is, you know, prescribed and present for the patient now on top of that other one? So now instead of getting the two product combination for their hypertension, they're getting their original hypertension med plus that new one. And then what happens? And let's say that this was a Medicare patient, and let's say that they went home and now they're on three different molecular entities to treat their hypertension. And what happens is they get hypotensive, so their blood pressure goes way down and they fall and they break their hips and they get admitted, uh, to the emergency room and then to the hospital for hip replacement. This is a common event, and it's something that's happening all the time, every day in this country because we don't have good coordination of care.

Speaker A: All right, let's transition a little bit to The Sequoia Project Pharmacy Interoperability Workgroup that brought together Surescripts, NACDS, NCPA foundation and the APHA Foundation. So what made 2025 last year the right moment to bring that group together? And what's a concrete milestone you hope it achieves?

Speaker B: Well, I think that the traction that the Trusted Exchange Framework and Common agreement TEFCA through the ONC is, you know, now enjoying with the number of, you know, CDAs that are actually made available through the Q hens is really important. And we saw that gathering, you know, opportunity, I believe, like your team did and others are seeing. And I think that we all have this shared belief and passion that if we put pharmacists on the health information superhighway and we make sure that they're contributing to that cause, we know that the medication misadventuring that can be completely eliminated and, or resolved is truly extraordinary. And so we think that just starting there, not even to mention all of these other models we've been talking about here during this hour, you know, if we got the pharmacist well integrated into the team and we combine together a service where essentially they're producing a med list, they're providing a cardiovascular health service like the one I described earlier. Let's say they're looking at opportunities for patients who have pre diabetes to actually be screened, identified and participate in a lifestyle change program where we know that 58 to 71% of patients who complete 24 hours worth of classes, group classes, over a 12 month period don't go on to develop type 2 diabetes if they've got pre diabetes today. I mean, that's just an astounding number. And pharmacy techs and pharmacy teams can do an amazing job of delivering those problems. What if we bundled CGM services into that where essentially you, you know, we've got people with diabetes who can get access to continuous glucose monitoring technology, which is certainly life changing technology in terms of people being able to more effectively manage their diabetes. But in some cases it's even life saving technology. And so if we had pharmacists plugged in, you know, through TUFCA so that they could exchange, you know, data with other providers, with other health systems and with health information exchanges in productive ways, we, I think, like you really believe that we could, you know, do amazing good together.

Speaker A: Well, you've been at this for, you know, 30 years. So what gives you the most hope right now that this moment might be different and that we might see pharmacists role evolve at scale?

Speaker B: Well, I saw a news release that ONC put out that said, uh, they had just crossed the threshold of exchanging over 1 billion, you know, CDAs across the qualified health information networks collectively. And so I think that that gives me a lot of hope that this is a preferred future. And one of the big challenges that's out there in our healthcare delivery system is, is that I remember years ago I was interacting with a technology company and I asked them what was their vision for how we're going to interoperably exchange data among different providers and different systems. And they said to me, they said, ben, that's easy. Everyone on Earth shall use our system. And I kind of laughed at the time, but it was really frustrating because it's like, we know that's not going to happen, right? And so the trusted exchange framework and common agreement really provide us with a better path forward. And it lets practitioners, regardless of whether, uh, a primary care physician or a primary care pharmacist or nurse, or they're in a health system or you're trying to work with population level data, with a health information exchange, moving that data around and being able to look at it in a secure, productive way, I think is going to help us all invent that preferred feature that we're seeking. And so I think putting pharmacists, you know, on the team, making sure that we've got interoperable electronic health records in our practices, and making sure that in the future patients see a situation where essentially not only do they come away from the visit having learned more about their medications, their treatment, their progress, but they've also got access to their portal that's got their ehr, and the pharmacist has contributed to it the same way that their family practices physician has, the same way that their cardiologist has, the same way that their endocrinologist has. I think that's what a better future looks like for all of our patients and for all of us as a healthcare provider team. Because in this environment today, there simply aren't enough healthcare providers on the planet to get the job done. And we've got to find smarter, more effective ways to work together. And there isn't a much better way to get that done than to make sure that we've got that seamless flow of information between and among patients and all of the other members of the healthcare team to actually make their lives better and for them to have a better quality of life.

Speaker A: Absolutely. So if every leader in healthcare could focus on one change that would better connect pharmacists to the Care team, what would it be?

Speaker B: I would say make the bold choice to actually implement an integrated electronic health record in your community pharmacy practice.

Speaker A: And it is a bold choice right now. And I couldn't agree more. We just have to make progress, right? Just have to give it a try.

Speaker B: That's right. And if you just start by focusing on something that pharmacists are already very comfortable with and very good at, let's get people's medication lists, right? And then let's evolve into all of those other services and imagine that we've got those incentive alignments for patients, providers and payers that we talked about earlier. Then you can completely transform the healthcare delivery system. And each time the patient comes into contact with any one of their healthcare professionals, we're all working from the same song sheet and we're singing the same tune. And basically we're going to help people to congruently understand that we're there as a team to support them in their important nutritional, lifestyle and medication and treatment choices as they make decisions in their everyday lives about what they're going to do or not do.

Speaker A: Well, you've given us an amazing, uh, view of what the future is and actually view of how it's actually playing out today in some spaces and looking forward to it scaling over time. Let's wrap it up. I know you've already talked about the better way for patients, but this is part in the podcast where we talk about and name it There's a better way. And so what's your better way in healthcare? What's the ideal future for patients?

Speaker B: Well, I think the ideal future for patients is that. But the right legislative changes, the right payer decisions, the right regulatory efforts in states all across the country have set pharmacists up to actually be practicing at the top of their education, their training and their experience. If we get that going and we've got pharmacists plugged in to the health information Superhighway through the ONC's trusted exchange framework and common agreement. I think that patients are suddenly going to have an app or on their phone or on their computer, or simply a printed out list that any one of their healthcare providers on the team can provide them with at any visit. And we'll all be working together in harmony to help them to achieve the intended benefits and outcomes from these important therapies that have been prescribed for them.

Speaker A: That sounds like a great future. This has been just an amazing conversation. Thank you so much, Ben, for your time and for your conversation about the future of healthcare. And the role of the pharmacist.

Speaker B: Yeah. Well, thank you, Melanie. I really appreciate this. And we're really excited to, uh, be on this journey together as we all endeavor to do more good for the patients that we serve.

Speaker A: What struck me most about my conversation with Ben is, at heart, a paradox. Pharmacies are the most visited touch point in the entire health care system, and yet for decades, the pharmacist has been the most isolated member of the care team. They dispense medications without seeing the labs or the diagnoses and without having the full picture of what's going on with the patient. Ben has spent 30 years working to change that. The afib screening project he described with 40 community pharmacies and 2,100 patients identified atrial fibrillation at more than three times the expected rate. Consider what that means at scale. More than than 80% of people with afib don't know they have it, but the pharmacist is well positioned to identify it and tell them. Then there's the lipid program and a story involving a patient who hadn't been compliant with his medications. His pharmacist ran the point of care lipid test and the numbers weren't good. The patient's 10 year stroke risk had jumped two and a half times compared to his previous quarterly visit. And he said to the pharmacist, if I don't make some changes, I'm not going to be here to see my granddaughter get married. That's not a data point. It's a human story. It's patient care. Ben's framework. Align the incentives, improve the outcomes, control the costs. Sounds simple, but it isn't. It means credentialing and reimbursing pharmacists for these kinds of services. And it means getting pharmacists fully connected into the care team. That last part is where I think we're at an inflection point. TEFCA is real. QHINs are live. What Ben's saying is that pharmacists need to be in on this and reading from the same page, just like every other member of the care team. And the reach to enable that is already here. As I said at the start of this episode, 90% of the Americans live within 5 to 10 miles of a pharmacy. Ben has showed us that there really is a better way. And it turns out it's been 5 to 10 miles from home this whole time. Thank you for listening in today. If you've enjoyed this podcast, please rate, subscribe and review. There's a better way Smart talk on healthcare and technology. With your help, we'll be able to continue to bring great conversations to the fore and to the wider listening public. Thank you.

Speaker B: M.