During a recent discussion with a pharmacy management systems (PMS) vendor, my business partner was describing our workflow and how we leverage the pharmacist. The goal was to help the vendor understand what we would like to see their software enable: a patient centered workflow. Their immediate comment was “you are messing with our workflow!”
That was the point. The PMS workflow has evolved over the years into a single focused entity: to fill a prescription. The patient, as a focus, is largely gone from every system currently marketed. PMS feature lists are generally focused on increasing efficiency of the dispensing process, tracking the prescription from beginning to end. Every PMS offers an some “clinical” screening for therapeutic duplication, drug and disease interactions, allergies, and compliance, but these are limited in scope to the prescription being filled at the time.
Figure 1 above represents a typical prescription focused workflow. The steps typically involving the pharmacist are shown in a brown box, with steps traditionally handled by technicians colored green. This is a traditional assembly-line type workflow, but notice that the pharmacist has to jump-in at several locations. Modern pharmacy management systems minimize work to reduce the impact of this to the pharmacist
The Workflow of the Future Pharmacist
In order to modernize the pharmacist’s workflow, patient-wore clinical information needs to be infused into the final verification step. This includes a summary of addressed and unaddressed clinical issues like drug-drug interactions, drug-disease interactions, therapeutic duplications, compliance issues, clinical outcomes, and monitoring currently being monitored. This information should not be limited to just the drug being checked: modern pharmacists emphasize patient care instead of just checking the prescription.
This workflow might be represented by Figure 2 below.
The difference in this workflow is the injection of all clinical data at the final verification step. Unaddressed issues with other medications are presented to the pharmacist to be addressed as necessary. Additionally the pharmacist is given the opportunity to document the intervention(s) at this point. These interventions become a part of the clinical record and are available for the next time the patient is reviewed.
The data injection and the documentation steps–the basis of the commercial product PharmClin (Patent Pending)–are as simple as they are innovative. This expansion of the final verification step creates a patient-focused process that we call MTM-on-the-run. While this workflow might seem daunting to some, with some basic training and a well engineered software package, the process is quite satisfying.
Taking it to the Next Level: An Ultra-Modern Workflow
The truth be told, there is really no reason that technicians could not be used for the entire Intake to Will-Call workflow. In some states, including Iowa, some pharmacies are studying technicians checking another technician’s work (performing the final verification step). The purpose of this type of workflow is to free up the pharmacist to focus more on the clinical aspects of the practice. In this case, the workflow might look more like Figure 3 below.
Notice above that the pharmacist is still tasked with the data-entry check for new prescriptions. This is currently still required in Iowa under the special rules covering this type of workflow. As a pharmacist, this workflow is very liberating. Instead of being mired in the details of checking between one and twenty prescriptions, the pharmacist can focus on the clinical profile information for each patient represented in the order. They can review previous intervention notes and create new notes. When the patient or their representative arrives at the pharmacy to pick up medications, the register clerk can summon the pharmacist to counsel on any new medications and/or follow-up with interventions flagged by the pharmacist that performed the clinical review.
Change is Coming. Don’t Look Back, We Aren’t Going There…
Giving up participation in the dispensing workflow is a scary proposition for some pharmacists that have spent entire careers performing little more than this function. When we talk to pharmacists at meetings, it is obvious that there are two types of pharmacists: those that look forward to moving to a model like this,and those that don’t know what or how they would perform in a new, modern workflow.
But this much is certain: reimbursement for product (dispensing) is not going to magically return. Maximizing efficiency through a technician driven workflow with added efficiency through robotics or other technologies will free the pharmacist to be a pharmacist. Pharmacists need to apply their clinical knowledge to care for patients. The days of paying a pharmacist to perform final verification of a prescription (a dispensing function) are rapidly coming to an end.
While I will not claim to know what pharmacy will look like in a few years, I am certain of two things. Firstly, it will be very different than the current dispensing-driven model. Secondly, pharmacists will be increasingly paid for their contribution to patient care or they will be be missing entirely from the flow chart. Make every encounter count today, so you can continue to do so tomorrow.