Report of the .Pharmacy Executive Board Meeting October 20, 2015

Members Participating: • • • • • •

Louisiana Board of Pharmacy representative Malcolm Broussard, chair NABP Chairperson Joseph L. Adams, at-large member .Pharmacy Regulator Advisory Committee representative Virginia Herold National Association of Pharmacy Regulatory Authorities (NAPRA) representative Ronald F. Guse International Pharmaceutical Federation (FIP) representative Luc Besançon NABP President Edward G. McGinley, Executive Committee liaison

Others Participating: Carmen Catizone, Melissa Madigan, Nancy Tay, Larissa Doucette, Gertrude “Gg” Levine, Deborah Zak, Chandra Agyeman, and Emily Gostisha, NABP staff. Introduction: The .Pharmacy Executive Board was established by the NABP Executive Committee in accordance with NABP’s contractual agreement with the Internet Corporation for Assigned Names and Numbers (ICANN). Informed, in part, by the expertise and strategic input provided by the .pharmacy advisory committees, the Board makes recommendations for review and approval by the NABP Executive Committee. Recommendations may concern strategy and national and international standards that are consistent with the mission and purpose of the .pharmacy Top-Level Domain (TLD) and the interests of the global public health. The Board met via webinar on October 20, 2015. Executive Board Recommendations Recommendation No. 1 Board members recommended that, when reporting numbers of .pharmacy domain names registered, NABP consider indicating how many physical pharmacies are represented by the chain pharmacy registrants. Background: Board members opined that including the total number of physical pharmacies represented by each registrant would better reflect the breadth of the .pharmacy TLD’s adoption in the pharmacy community. While a chain pharmacy might have only one .pharmacy domain name

registered, that website might represent, or serve as a point of sale, for hundreds of brick and mortar pharmacies within that chain. In some cases, however, a chain pharmacy might use a central processing facility that dispenses all prescriptions ordered through the website for the entire chain. In that case, the number of physical pharmacies may not provide an accurate representation of the pharmacy chain’s online activity. Staff will take into account varying business models when tallying and reporting registration numbers. This recommendation was made following the summary of numbers and types of .pharmacy domain name requests and registrations that have been completed so far. • Number of domain name registrations: 227 • Number of companies with registered domain names: 43 • Pharmacies using* a domain name: 20 • Veterinary pharmacies using* a domain name: 7 • Number of application closures with refunds: 1 • Number of denials: 4 * “Use” of the domain name, in most instances, is limited to redirects from the .pharmacy site to the organization’s current website (eg, azboard.pharmacy redirects to pharmacy.az.gov) The 227 registrations were also categorized by type: • Pharmacies: 160 • Veterinary pharmacies: 21 • Information sites: 2 • US Boards: 26 • Canadian Boards: 7 • Organizations: 7 • Manufacturers: 4 Of the 43 companies with registered domain names, 74% of them were approved through the VIPPS (23%), Vet-VIPPS (23%), and e-Advertiser Approval (28%) programs. The remaining 26% were approved through the .pharmacy application process. Recommendation No. 2 Board members recommended that, when tracking and reporting numbers of registrations, NABP should also take note of the number of registered domain names that resolve to active .pharmacy websites that use their .pharmacy domain as their primary website. Background: Board members suggested that active .pharmacy sites being used as the registrant’s primary website provide a better reflection of actual adoption of the .pharmacy TLD. Staff agreed to track and report these numbers as adoption of the .pharmacy TLD increases.

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Recommendation No. 3 Board members recommended that NABP survey the pharmacies that have registered .pharmacy domain names to determine what activity they have observed on their .pharmacy sites and what their experiences have been with the domain. Background: Board members expressed interest in the experiences of pharmacies that have registered .pharmacy domain names, eg, whether they are using the names, what activity they have observed on the sites, if they are tracking site visits. NABP staff commented that the Association has been delaying a survey of registrants until more of the .pharmacy websites become active. Currently, most of .pharmacy domain names registered are not connected to a website. The majority of those in use redirect to previously existing (.com) sites. It was mentioned that a survey could also be used to investigate why registrants whose domains remain inactive have not put them to use, or why those registrants who redirect their .pharmacy domain name to their .com website opt not to use the .pharmacy domain name as their primary website. Recommendation No. 4 The Board advised that NABP proceed with caution when entering into national standard-setting partnerships with countries with more lax pharmacy regulations than the US and other developed countries. The terms of such partnerships, Board members said, should ensure that appropriate standards are being met by applicants located in those countries but also doing business in other countries. Background: This recommendation was raised following a summary of NABP’s outreach to establish partnerships with regulators in other countries, and the interest received from countries including the Philippines, Nigeria and India. NABP representatives noted that the Association is working with attorneys who specialize in international affairs and will move forward with any such partnerships only if the NABP Executive Committee is comfortable with the terms of the agreements. Currently NABP has informal relationships with regulators in Great Britain, Ireland, Spain, Australia, and Hong Kong to evaluate applications from applicants located or doing business in those countries. NABP is in discussions with NAPRA about establishing a formal agreement for NAPRA to evaluate Canadian applicants. Staff mentioned that, while discussions continue with regulators in the European Union, the focus there remains on implementation of the “common logo” and likely will remain so for the next several years. Meanwhile, NABP continues to raise awareness of .pharmacy among EU regulators. Recommendation No. 5 Board members recommended that NABP consider including a presentation during the next NABP Tri-Regulator Symposium to educate health care practitioners on the problem of illegal online drug sellers and the solution that the .Pharmacy TLD Program offers.

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Background This recommendation was raised following a summary of professional outreach efforts NABP has undertaken in 2015 and has proposed for 2016: • March 2015: Exhibition booth at American Pharmacists Association (APhA) Annual Meeting, San Diego, CA • May 2015: Table top display at NABP Annual Meeting, New Orleans, LA • July 2015: Exhibition booth at Cardinal Retail Business Conference, Las Vegas, NV • August 2015: Presentation at Asia-Pacific Economic Cooperation Meeting, Cebu, Philippines • September 2015: Presentation at FIP World Congress, Düsseldorf, Germany • October 2015: Presentation for Cardinal Security Staff, Columbus, OH • December 2015: Exhibition booth at American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting, New Orleans, LA • March 2016: Exhibition booth at APhA Annual Meeting, Baltimore, MD • May 2016: Table top display at NABP Annual Meeting, San Diego, CA • June 2016: Exhibition booth at Canadian Pharmacists Association Annual Meeting, Calgary, Alberta, Canada • June 2016: Exhibition booth at McKesson IdeaShare, Chicago, IL • July 2016: Exhibition booth at Cardinal Retail Business Conference, Chicago, IL • July 2016: Exhibition booth at Amerisource Bergen Thoughtspot, Las Vegas, NV • December 2016: Exhibition booth at ASHP Midyear Clinical Meeting, Las Vegas, NV At this point in the meeting, the question was posed to the Board: What outcomes should NABP seek to achieve? Board members noted that educating health care practitioners on the problems of rogue Internet drug outlets should be a goal. This is important, they said, because often times uninformed physicians direct patients to pursue lower drug prices from so-called Canadian Internet pharmacies, which are, in many cases, illegally operating, or rogue, Internet drug outlets. Health care practitioners also have the opportunity to educate patients about safe acquisition of medications in their daily practice, Board members said. It was thought that the Tri-Regulator Symposium would be a good opportunity to share this information with the health care community. It was also suggested that NABP could reach out directly to the American Medical Association and other health care organizations to share this information with practitioners. Recommendation No. 6 Board members advised NABP to consider targeting major pharmaceutical wholesale distributors, as well as virtual chains/service providers to independent pharmacies, in its professional outreach efforts to encourage their awareness, support and adoption of the .Pharmacy TLD Program. Background Board members noted that pharmaceutical wholesale distributors face a threat in common with .pharmacy, ie, illegal online drug sellers that threaten the medication supply chain. It was also noted that some large wholesale distributors help their customer pharmacies to develop websites and collect informatics. As such, they may be well positioned to make .pharmacy more widely 4

available to small businesses and independent pharmacies. Similarly, virtual chains are organizations (for-profit or not-for-profit) that provide many services to independent pharmacies, such as common branding, negotiation with wholesalers, and marketing support. NABP representatives noted that the Association has been in discussions with large wholesale distributors including Cardinal Health that develop website templates for their member pharmacies about potentially having NABP assess their website templates for use in the .pharmacy TLD. Recommendation No. 7 Board members recommended that NABP consider seeking endorsements for the .Pharmacy TLD Program from national organizations in the United States and other countries. Background Endorsements from such well-known organizations as the American Medical Association and the American Pharmacists Association would help to raise awareness about the .Pharmacy TLD Program, enhance its credibility, and connect NABP with the .pharmacy TLD in the public eye. Recommendation No. 8 The Board advised NABP to compile a document examining the various modes in which registrants may use a .pharmacy domain name. Background: Several options were discussed: • redirecting the .pharmacy domain name to the registrant’s existing (.com or .gov) website • cloaking the actual address of the existing website to appear as a .pharmacy domain name in the address bar • transitioning the content of the existing website to the registrant’s .pharmacy domain • redirecting website visitors from the existing website to the .pharmacy domain name. These options will be discussed in further detail in the requested document, to be distributed to the Board at a later date. Recommendation No. 9 It was recommended that NABP determine a minimum number of registrants needed in a given country before proceeding to undertake a consumer education campaign in that country. Background: This recommendation was raised following a summary of NABP consumer education efforts outside the US, and its proposed plans for 2016: • News releases distributed in eight languages to 59 countries announcing launch • Presentations to regulators abroad • Buying Safely section of website in Spanish • Promotional materials in Spanish and German • TV and radio public service announcements in Canada in 2016 • Digital advertising in Spanish and English-speaking countries in 2016 5

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Broadcast interviews in other countries in 2016

In light of this summary, the question was posed to the Board, what more should NABP seek to do. In response, Board members advised taking a measured approach to future outreach abroad, as multiple factors may affect uptake of the .Pharmacy TLD Program in various geographic regions. For instance, Board members pointed out that there may be restrictions on the kinds of information that may be legally disseminated in certain countries about health and medicine. It was also pointed out that most European countries limit the online sale of medications to overthe-counter medications, and that this factor should be considered when framing messaging there. For instance, convenience may be more of a motivator than safety under these circumstances. It was noted that timing may not be ideal to target consumers in the European Union because pharmacies in the EU member states are currently focused on meeting the “common logo” requirements. It was also noted that NABP should focus its messaging to the values of the consumers in targeted regions. Recommendation No. 10 Board members recommended that NABP define the term “Internet pharmacy” to help clarify the distinction between an Internet pharmacy that is connected to a licensed brick-and-mortar pharmacy versus a rogue Internet drug outlet or illegal online drug seller. Background: This recommendation was raised following a summary of the key messages NABP has used in raising awareness of the .Pharmacy TLD Program among stakeholders and potential registrants: • Patient safety • Exclusive online community • Cross-promotional opportunities • Cutting-edge approach • Future of online pharmacy The question was posed to the Board, how can NABP best frame our messaging to the Board members’ constituents to encourage their promotion of the .pharmacy initiative. Board members stated that the term “Internet pharmacy” is not clearly understood and is often used interchangeably in reference to the websites of licensed brick-and-mortar pharmacies and to anonymous and unapproved websites that sell medications illegally. Clarifying these terms would help, likewise, to clarify the issues and concerns involved for the pharmacy community. Recommendation No. 11 The Board reviewed the recommendations of the .Pharmacy Regulator Advisory Committee and the .Pharmacy Registrant/Supporter Advisory Committee and recommends that the reports 6

emanating from the committee teleconferences August 25, 2015, and August 26, 2015, respectively, be presented to the NABP Executive Committee for approval in December 2015.

Background: It was determined that Edward McGinley would review the report of the advisory committees at the next Executive Committee meeting.

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