Author: Michael Deninger

Mike graduated from the University of Iowa with a BS in Pharmacy in 1991 and completed his Ph.D. in 1998. He has over 20 years of practice experience, over half of which is as a pharmacy owner. Areas of expertise also include technology in practice, including integration with data sources.

The Sandbox

One of the most challenging issues facing today’s health care providers is sharing information. Technologically, one might assume that it would be easy to create a system of data exchange between providers. The reality, though, is that providers may be selective with what they will share, who they may share it with, and how they share it. The primary obstacles to sharing of information are security and access, and these barriers are as much a political issue as they are technical obstacles.

 Obstacles

Security and privacy of health information is a significant obstacle. Just like breaches in major retail stores that make the nightly news (see Forbes for a list of significant breaches in 2014), health information is also under attack (e.g. Anthem, see CNN). The same technologies that enables modern transactions are also able to be exploited by criminals.  Despite recent headlines, however, current technology (when implemented properly) is capable of reliably protecting our personal data, including a digital medical record.

Another significant obstacle is the actual exchange of medical records. All health care providers ( e.g. the physician, pharmacy, hospital and laboratory etc.) maintain some type of patient record. Every procedure, prescription, or visit results in changes in that record. Each change made by one provider (say at the hospital) would, in an ideal system, be updated automatically with the patient’s other providers (e.g. the specialist, the pharmacy and the primary physician). Assuming that security of the data can be maintained without any issue, the remaining problem is a lack of a standardized format for the record. Each repository of patient information is necessarily different because every provider focuses on different aspects of patient care. The format of the records can be very different. At one extreme,  paper record (charts) are still in use, while others may leverage electronic medical records (EMRs). In essence, each provider’s records speak a slightly different language.

The Language of Health Care

Among the first organizations to recognize the importance of intercommunication between health care records were hospitals. The laboratory’s electronic records need to communicate with the electronic chart, hospital billing systems, the computerized census system and the pharmacy’s dispensing system. An entire industry was born to help facilitate this data exchange in hospitals, and with this came the creation of several standard languages, one of which is HL7 (Health Level 7).

Using computers as gateways, hospitals use tools like HL7 to link many different systems to provide a relatively seamless transmission of information between systems. But as good as this would appear on the surface, these gateways have significant obstacles of their own. Gateways are labor intensive to maintain and regularly require maintenance to keep them running. Small changes in one system can break down communication between multiple systems. To Make matters worse, there are many different dialects of the HL7 “language” so even if two systems both speak HL7, information can be lost in translation.

Politics

If one accepts that security of the data can be handled by current technologies, and that gateways like HL7 can facilitate the translation of data, one final obstacle exists. The laws that exist to protect the privacy of health information (like the Health Insurance Portability and Accountability Act of 1996 also called HIPAA) also govern the exchange of information between providers. This exchange may or may not require a written release (depending the the relationship between both providers and the patient). The provider’s access to records needs to be limited to only their patients plus any patients. It is also possible that a given provider may still want to control what data is shared, and when it is shared.

The Implications

Because of the obstacles above, providers and patients struggle to seamlessly communicate. The fax, which became widely available in the 1980’s, is still one of the primary means of communication between providers despite the proliferation of communication options available today. The ramifications are significant, and examples of the problems created by the lack of real-time communication are easy to find. From a pharmacy perspective, four common issues are:

  • A patient admitted to the hospital. The admit process requires the hospital staff to document an accurate medication history. Hospitals do not have access to the current the prescription history for the patient maintained by the patient’s pharmacy, creating a chance possibility for errors, adverse drug events and improper therapy.
  • Therapy changes made in the hospital. These changes need to be communicated to other providers (e.g. the primary care physician and the pharmacy).  The lack of standard communication between hospitals, the primary care physician’s EMR, and the pharmacy’s records can lead to discrepancies.
  • Routine changes made at a physician office. Patients are often instructed by their physical to increase or decrease doses of drugs they take without a new prescription being issued.
  • Medical information related to drug therapy. A pharmacist managing a patient’s drug therapy requires a significant amount of medical and laboratory data to ensure optimal outcomes. Without seamless access to a patient’s relevant laboratory results, relevant diagnosis and pertinent history and physical, pharmacists are limited in their ability to perform Continuous Medication Management (CMM)

Jumping Thru Hoops

Many electronic medical records and other health care provider systems have made their way to the internet. Using secure web portals, providers can access their patient’s records from a variety of locations (office, hospital, home etc). The internet has become an enabling technology for providers trying to share information. If two different systems do not communicate (e.g. the physician’s EMR and the Hospital EMR), at a bare minimum, the provider can access both systems from a single computer to update and check records. Many providers find that they maintain accounts with multiple internet enabled medical records.

A pharmacy with good relationships with several providers might be able to gain access to a variety of records to enable productive collaboration. Besides having access to their own clinical record system, a pharmacy might have access to a hospice’s EMR, multiple nursing home EMRs, and access to records from one or more laboratories. This creates a chaotic environment where information must be gleaned from multiple sources and documentation made across many different records to ensure proper communication between all providers.

Even with great relationships between providers, gaining access similar to that described above is difficult. A pharmacy might serve 10% of a medical practices patients, and access has to be limited properly to prevent improper access. Likewise, a pharmacy would only want grant records access to a provider’s patients.

Today in healthcare, communications between providers is more important than ever before. And today, the fax still dominates communication between providers. It will likely be take a long time before all providers can come to and play in the same sandbox.

Managing Diagnosis Collection on the Fly

A key factor in performing continuous medication monitoring (CMM) is knowing the indication of  each medication a patient is taking. Sometimes this is easy to decide, and other times it can be challenging. The important step, however, is documenting the information once it is known. This article will discuss strategies and workflows that we use to collect and document diagnosis information.

Certainly of Diagnosis

When documenting a diagnosis in a patient record, it is important to state the level of certainty associated with the diagnosis. For example, the indication for some drugs is often easy to guess. Statin medications (HMG-CoA reductase inhibitors) are rarely used for anything except hyperlipidemia. We refer to the pharmacists best guess for the indication as a inferred diagnosis. Sometimes a pharmacist may consider a likely indication but recognize that the possibility exists that the medication is being used for something else entirely. An example of this might be the drug metformin. While this medication is used primarily for diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes), it can also be used “off label” for Polycystic ovary syndrome (PCOS). In the case of a female patient without other evidence of diabetes in their profile, assigning a diagnosis of PCOS would be recorded as a suspected diagnosis. When the indication is specified explicitly, either by the prescriber or on a prescription, the diagnosis would be considered confirmed. 

Diagnosis Source

Similar to the documentation of the certainty of a diagnosis, it is important to note the source of the information in the patient record. We use three categories to refer to the source of a diagnosis.

  • Pharmacist — This is used to indicate that the pharmacist, using clinical judgment, has assigned a diagnosis based on their knowledge of therapeutics.
  • Patient — indicated that the patient has identified the diagnosis
  • Prescriber — is used when the prescriber has stated the diagnosis

A Diagnosis Workflow

At our pharmacies, CMM is performed at the final verification stage of the prescription workflow. After the pharmacist verified that the new prescription or refill has been filled with the right drug and is labeled correctly, they evaluate the profile a look for potential or real drug therapy problems. The clinical workflow screen displays the diagnosis associated with the drug being checked. If no diagnosis is specified, the system may suggest possible indications for the drug (see Figure 1 below). The pharmacist can assign an inferred indication to the patient quickly at this point. Here, the source of the diagnosis would be the pharmacist and the certainty would be marked as inferred. If a new prescription includes diagnosis information, this too can be added to the profile with the appropriate source and certainly indicators.

suggestion
Figure 1. A clinical documentation system making a suggestion for a possible diagnosis for the drug.

If a diagnosis is uncertain, the pharmacist has the opportunity to engage the patient when the mediation is picked up. At this point, the pharmacist could create an intervention (Figure 2) and flag the prescription for counseling, including a note (Figure 3) to clarify the diagnosis with the patient. When the patient arrives, the pharmacist has the opportunity to consult with the patient and determine if the inferred or suspected diagnosis is correct. Information received from the patient can then be used to further update the pharmacy record.

 

Intervention2
Figure 2 Documentation of an Intervention by the pharmacist to clarify a diagnosis

 

tag
Figure 3 Example of a will call tag to be placed with the prescription order to aid the pharmacist in collecting information at the point of sale.

 

 

 

 

 

Often, a patient confirmed diagnosis is sufficient for the needs of the pharmacy. Sometimes, however, the patient may not be a reliable source. In these cases, the workflow should include a method to send a short SOAP note to the prescriber requesting clarification of the diagnosis (Figure 4). Once this information is returned, the diagnosis information for the patient can be completed.

SOAP2
Figure 4 Example of a short SOAP note requesting confirmation of the diagnosis.

 

Collecting accurate, relevant patient drug-diagnosis combinations is an important step in the CMM process. Leveraging the patient at the point of sale is yet another example of making every encounter count.

Continuous Medication Management (CMM) and the Profile

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.

While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.

A dispensing profile

Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore,  optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).

PMS Profile
Example Profile from Pharmacy Management System

This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.

This begs two questions:  1) what information displayed by the PMS do we not require when making clinical determinations and  2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:

  • Original Date (because it does not related to the first date the patient started taking the drug)
  • Refill number
  • Strength and form (because it is duplicate information)
  • Price
  • Facility
  • NDC
  • Coverage / Insurance
  • RPh and Tech

Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.

Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:

  • Days Supply
  • SIG or directions
  • Recent Refill Summary
  • A selective profile representing only the most recent therapies

Our clinical pharmacists were also interested in being to quickly spot

  • Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
  • Drug interactions
  • Compliance Issues

A Clinical Profile

With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)

PharmClin Profile
Example profile from a clinically based system

Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.

Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.

Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.

Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:

  • Statins in GREEN
  • ACE / ARBs in RED
  • Diabetic medications in BLUE
  • Drugs listed as high risk (Beer’s List) in PURPLE
  • Drugs that precipitate drug interactions in ORANGE

All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.

Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.

The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.

I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.

Notes on PharmClin

PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.

Rx: MTM in small, frequent doses.

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]M[/dropcap]ore and more, we are hearing that MTM is the future of pharmacy. And while there is some truth with this statement, the reality is a lot more complicated.

MTM, as it has evolved under Medicare Part D’s parentage, is a poorly conceived service. The separation of the medication costs and the medical costs that exists within Medicare Part D gives PBMs (who manage the Part D benefit) little financial motivation to give patients access to the MTM service. This results in fewer MTM opportunities for community pharmacists. Additionally, many PBMs have brought significant amounts of MTM activities in house, using their own nurses or pharmacists to perform the minimum number of required by law. When local community pharmacists in the trenches do get an opportunity to perform MTM, they often end up spending far too much time completing the intervention and are reimbursed too little to cover their expenses.  With the recent changes in Medicare Part D and CMS’ adoption of completed patient cases for comprehensive medication reviews (CMRs) as a performance measure for community pharmacies,  this may potentially boost pharmacists access to MTM opportunities.  Unfortunately, the amount of reimbursement for a CMR will continue to be a significant challenge unless pharmacists find a way to streamline their MTM processes.

The pharmacists approach to MTM needs to change. Consider that each refill picked up by the patient is an opportunity to assess the patient’s medication therapy, identify and document problems, and take action.

Today, pharmacists need to re-train themselves to complete MTM type activities in real time. This means upgrading their clinical knowledge, leveraging documentation systems, and optimizing workflows. Once pharmacists stop thinking about MTM as a sit-down encounter that takes more than 45 minutes, it opens up a host of possibilities.

Using a bite size approach to MTM allows the pharmacist to create, over the course of a few months, a complete medication therapy management description for a large number of patients. The pharmacist gradually collects and documents the information required in a traditional MTM encounter. This collection takes place on the counter, while checking prescriptions. This efficiency means that when a pharmacy is called upon to perform MTM services for a payor, they already have documentation and results in their pocket. The MTM intervention can be done in a matter of minutes.

It should also be point out that  MTM does not need to exist only in the context of Medicare Part D. Pharmacists can look to group homes, assisted living centers, and others as potential MTM customers. Once shown the benefits of MTM groups and individuals often become quite interested in this service. Cash based MTM can become a real revenue stream for a pharmacy without requiring hours of desk time to complete.

If You Don’t Ask…

[dropcap color=”White” background=”black” style=”rectangle” size=”big”]M[/dropcap]anaging a small business is a challenge. Pharmacy is no exception to this rule, and because it is one of the few (possibly even the only) retail business that has virtually no control over what it charges for most of what it sells. Watching the bottom line often resembles an event at the X-Games.

Being savvy when it comes to money is important. A great example is the satellite radio that may be in your car. Experience has shown that the company selling the subscription for this service is willing to take less than their advertised rates for the service, so why pay more? One only has to ask (and maybe it doesn’t hurt to threaten to cancel the service along the way) to be offered a better rate. Pharmacy owners can, and should, leverage this approach with a variety of venders. Consider some of the successes seen by my stores over that last few months:

  • When approached by a software vender for a required upgrade on my almost new (2 year old) system, the vendor wanted almost $3000. Asking the appropriate questions and escalating the issue resulted in a very substantial drop in the price to update.
  • When my prescription vial supplier cold-called me and asked how things were going, I was honest: things are hard. I then immediately asked for a larger rebate based on my volume. While the sales rep was not expecting this, I was able to secure real savings (in the form of additional rebates) within a few months of starting the conversation.
  • Secondary wholesalers regularly call with offers of pharmaceuticals at prices lower than my primary wholesaler offers. Why accept their first offer? Asking “how low can you go?” regularly results in better opportunities.
  • The employees wanted a water cooler for the break room. They presented a single quote to us. A few calls later, we had both companies bidding for our business, resulting in a much lower overall cost for the service in the end.
  • Buying groups provide rebates that help a pharmacy’s bottom line. Things in pharmacy change so rapidly, with prices dropping and soaring for products seemingly every minute. If a buying group contract has not been updated in a while, it cannot hurt to approach them for a better rebate rate, at least until the buying group updates it contracts to keep up with changes.

Overall, in business, it cannot be reiterated enough: “If you don’t ask, you won’t receive.” In today’s business environment, one cannot simply accept the first offer for any service or product. One needs to leverage competition and loyalty with vendors to enhance the bottom line.  Not asking for better pricing means possibly not being in  business this time next year.

Addressing High Risk Medications

[dropcap color=”white,” background=”black” style=”rectangle” size=”big”]O[/dropcap]ne of the most challenging issues facing pharmacist is what to do about high risk medications. Patients are often reluctant to stop using high risk medications and doctors are frustrated with a lack of options. All the while, pharmacies are being evaluated by Medicare since the adoption of a performance measure that looks at the number of patients on high risk medications. Approaching high risks mediation use is a lot like approaching a grizzly bear; you don’t know until after you approach it if it is a circus bear that juggles, or a wild, angry, and hungry bear.

Given the uncertainty involved, the approach taken is very important. While there is not one right way to approach high risk medication use with either the patient or the prescriber, this article will outline some guidances for pharmacists to consider when deciding how to initiate the conversation.

 Preparation

Before venturing into the unknown, a few first steps are very helpful

  1. Determine which prescribers are writing the larger share of high risk medications. This may require reports or other data extraction from the Pharmacy Management Software.  Knowing who to deal with  ahead of time allows one to better prepare.
  2. Meet with select prescribers to discuss the issues. The goal here is to understand the issues and concerns the prescribers have about these medications. Be sure describe the Medicare Quality Measures and how both pharmacies and prescribers ratings are effected. Determine the level of engagement for these prescribers.
  3. Prepare a standard procedure. When approaching a difficult task, it helps for every member of the pharmacy team to be on the same page. Standard procedures, including standardized phrasing for notes sent to prescribers and talking points when discussing the issues with patients or family members.
  4. Start small. Working with the prescribers involved earlier, identify a small pool of representative patients to approach.
  5. Being proactive.  Resolving a drug therapy problem before it becomes a problem is a good approach for high risk medications.  In other words, by performing continuous medication monitoring and identifying high risk medications before dispensing the first fill can be a better approach.
  6. Be an evidence-based.  There is plenty of literature that discusses the risks of high risk medication especially in older patients (>65 years old).  Pharmacists have a more convincing argument when they know literature and can discuss the risks with patents and prescribers.   But how this information is communicated can impact how it is accepted by others.
  7. Be an interventionist.  What is meant here is that if the pharmacist identifies a patient on a high-risk medication, then it is important that the pharmacist take action to try to resolve this drug therapy issue.

Intervening with the patient

As health care providers, pharmacists sometimes get the cart ahead of the horse. Before making any recommendation to the patient, it is important to..

  1. Explain why the pharmacy is looking at the medications. Speak in terms of safety risk / benefit and overall outcomes.
  2. Strive to understand the patient’s situation. It is tempting to simply state that one should not be taking a given medication due to overall risk. Instead, ask questions to help identify how important this medication is to the patient and how they feel about the associated risk(s).
  3. Involve the patient in the decision on how to proceed. As a pharmacist, don’t forget that it is the patient that will have to deal with the consequences of any change in their drug therapy. Offer several options on how to proceed and seek imput from the patient. Success is more likely if the patient is involved in the decision.
  4. Initiate the plan. Decisions at this point can run the entire spectrum from the patient being unwilling to considering any changes to a willingness to try a variety of options. How to proceed from this point will hinge on your conversations with the prescriber(s) earlier.
  5. Document the plan. It is is unrealistic to expect a pharmacy to drop high risk medication to zero. Even a failure to effect a change, if documented, is a success.
  6. Follow-up. Do not forget to schedule follow-up with the patient. This is an especially important action item if any changes were made. This should also be documented in the patient record. If no changes were made, follow-up should still be scheduled for the purpose of revisiting the discussion at a later date. Six months or 1 year are reasonable intervals for this type of follow-up.

Ultimately, patient willingness to consider changes depends on a number of factors. For patients that are resistant to changes, follow-up at a later date is important. With time, the pharmacist’s understanding of the patient’s motivations will increase, leading to new opportunities to change behavior.

Old School is Still Cool

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap] recent series of issues at our pharmacy highlighted a communication gap between our staff and our patients. The story starts with the patient phoning in to refill prescriptions and being disappointed when they came to pick then up. They found several omissions in what they were expecting. It took the staff several minutes to track down why some of his order was not complete, and the inefficiency of this spontaneous fact-finding mission was even more embarrassing to me as a pharmacy owner.

I quickly looked to assess our workflow and found the one process that was likely the culprit. In our pharmacy, if a patient elects to bypass our Interactive Voice Response system (called an IVR, which allows the patient to key in prescription numbers that are automatically recorded and put in our system to be processed), and instead wants to speak with staff, the patient’s order is transcribed to a piece of scratch paper. Typically, multiple orders make it onto a single sheet of paper.

Our current workflow consisted of “scratching off” each Rx as it was completed and then shredding the paper once all orders have been adjudicated and passed down the counter to be filled. Events like expired or exhausted prescriptions, prior authorization in process, insurance denials (too early etc) and special order items were being recorded in various places in the workflow. The problem was that these notations were separated from the order once the written note and patient order were divorced. Worse yet, with our method, there was no way to be sure that all prescriptions ordered were accounted for once they reached the will call area.  I refer to this as our “order record problem.”

Anyone who knows me will immediately peg me as a tech guy. I routinely leverage technology to solve workflow and business problems. Sometimes, I am even accused of making things more complicated than they really needs to be. Here I sit, guilty as charged.

Obviously, the “old school” scratch paper could easily be upgraded with some fancy new technology, and I am just the guy to do it! But I have to consider several question first.

  • Is this really a good use of time and resources?
  • Will others be willing to use a new approach?
  • Is there an non-technological or “old-school” approach that will solve the problem at a fraction of the time and cost?

Unfortunately for the my inner techie, the answers to these questions did not lead me to a technology oriented solution. Here, “old school” really had some potential advantages.

FrontWhile considering our communications problem, I recalled that we already leveraged a Will Call Form we purchased from The Onnen Company to communicate issues with a given Rx to the patient. The solution to the “Order Record Problem” was  actually staring me right in the face. The back side of the Will Call Flags form is designed to record inbound refill calls, with 10 slots for rx numbers or drug names, a place to designate pickup (will call, delivery, mail out) and additional instructions.

A few weeks ago we put a new policy in place and educated all of our staff. We increased our stock of this form and began implementing the solution. Each phone refill request would be taken directly onto these forms. These forms would follow the order from beginning to end (pickup). The technician or pharmacist waiting on the patient now has a complete history of the order from start to finish.

BACKHIPAA ramifications

While I would categorize this new policy as a success to date, I would be remiss if I did not mention one issue that was not considered in our original plan. Each of these forms has the potential to contain Protected Health Information, or PHI. I found several employees were discarding the forms at the register trash receptacle. A quick re-training in PHI and HIPAA had to be done to ensure that all of these forms, without respect to PHI, were placed in the shred bin.

While on the surface, this problem and solution may be something that other pharmacies have already dealt with (and many may have even better solutions in place), the take home lesson for me, at least, is not to dismiss “old school” approaches. Sometimes, “old school” is best.

Software as a Service: the changing face of pharmacy software

[dropcap color=”white” background=”black” style=”rectangle” size=”big”]O[/dropcap]ver the last several years, we have watched many software companies struggle with paid upgrade cycles. As feature sets for applications have matured over the years, it has become harder and harder for companies to convince its users that they need the new features only available with the newest version.

For example, I am an amateur photographer. I occasionally need the power of Adobe Photoshop. I decided a long time ago, however, that I did not need to always have the most current version. To Adobe, I am a bad customer, as I am not supplying them with the necessary sales and revenue a for-profit company needs. If it were just me, the software companies would have nothing to worry about, but my choices with respect to upgrades have become very common, even among professionals.

Enter “Software as a Service.” This new model is slowly becoming mainstream, despite initial and continued resistance to the implied concept that we don’t own the software, but simply rent it. Microsoft Office and Adobe Photoshop are two major software platforms that are now available as subscription services with monthly or yearly agreements.

The sales pitch for “rental” or subscription software is that you will automatically receive updates as they are released, theoretically saving  you money in the long run (based on the assumption that you would always upgrade to the newest version). Because this concept has not been a huge success, some companies have even stopped selling traditional software licenses to push customers to the new model.

Eventually, I need to bring the discussion back to a pharmacy focus. You see, Pharmacy Management System (PMS) software has traditionally leveraged a subscription model: You purchase the hardware / software and then pay a monthly maintenance fee for support and upgrades. This maintenance fee is usually non-trivial and can cost thousands of dollars a year for even a small volume store.

The other day, I was speaking with my PMS vendor about a feature that I would like to see. The support person indicated that they already offer that feature. I was ecstatic. In the next breath, however, the support person indicated that this was a separate service with a monthly cost. Wait just one second, don’t I pay a steep monthly maintenance fee for upgrades and support? Why is this feature not included?

Taking a step back and looking at the pharmacy software landscape, this model has gradually crept into the marketplace. Companies like Mevesi and Prescribe Wellness along with platforms like EQuIPP offer cloud based services that integrate and extend your traditional PMS. Each of these is adding to the pharmacy overhead when the service is added. Often these services can cost thousands of dollars per year.

Many of these service packages can add a great deal functionality to your pharmacy and may be well worth their cost(s). The concern for the pharmacy owner, however, is the rapid increase in software costs in an era where reimbursement for their service and product is at an all time low. Any new feature or service must be able to create more new revenue than the service costs the pharmacy. Today’s pharmacy owner has a fine line to walk.

 

Having Skin in the Game

Independent pharmacies are in a difficult position in today’s health care climate. By themselves, they have little power to negotiate with larger companies, especially the predominant Pharmacy Benefit Managers (PBMs) that represent well over 90% of all patients in most markets.  In business, there is power in numbers. Enter the Pharmacy Services Administrative Organizations (the PSAOs).

Historically, pharmacy owners paid little attention to their PSAO. The PSAO did their job signing contracts and negotiating on the pharmacy’s behalf, allowing the independent pharmacy owner to take care of their patients. Today, however, the face of pharmacy and reimbursement has changed dramatically, bringing the PSAO into the crosshairs of pharmacy owners everywhere.

If you were to ask the upper management of a PSAO what their job is, they would likely state that they are responsible for providing access to lives for their constituent pharmacies. Pharmacy owners, on the other hand, are more worried about their bottom line. What good does having access to lives do for the pharmacy if those lives do not make the pharmacy money, or worse, lose the money [See “A Dual Edge Sword” for a related discussion].

The disconnect is clear. The PSAO, representing a large number of pharmacies, must find a balance acceptable to all of its members. The PSAO looks to:

  1. Negotiate the best possible contract terms for their pharmacies
  2. Maintain the customer base of member pharmacies to the best of their ability and
  3. Grow the potential customer base of the member pharmacies.

None of these are easy for the PSAO as they have to represent a diverse group of stores representing a variety of geographic regions and economic climates. Even though the PSAO may represent thousands of member pharmacies, the Pharmacy Benefit Managers often dictate terms. The PBMs have a monopsony like position in the market.

Pharmacy Owners, on the other hand, are much more likely to be myopic in their view of a contract. They have significant personal risk in the form of payroll and inventory. Having “skin in the game” tends focus them on reimbursement details and the bottom line. With such a difference in goals, it is no surprise that some pharmacy owners are critical of their PSAO. How can a PSAO sign contracts for its constituent pharmacies that may cause them to go out of business? To some pharmacy owners, the PSAO might be considered to be as harmful to pharmacies as the PBMs. The PSAO does not appear to have any skin in the game, and therefore appears to have little to lose.

Recently, it was revealed that a number of PSAOs had opted out of one specific Medicare Part D preferred network for 2015. Only one larger PSAO signed this contract. Obviously there was something in the contract that effectively persuaded most PSAOs from signing with the network on behalf of their member pharmacies.

In the above case, it was not just reimbursement rates that were the problem. The network contract also specified that the pharmacy needed to maintain minimum Generic Dispensing Rates (GDRs) during the course of the year. Failure to do so would result in penalties enforced at the end of the year. This type of contract is potentially catastrophic to a pharmacy that fails to meet the requirements. The resulting chargebacks from such a failure have the potential to cause significant pressure on cash flow and liquidity for the business.

a PSAO that puts its own skin in the game, however, is a game changer

So why did one PSAO elect to sign this contract? The answer is surprising. The PSAO that signed the contract decided to put some “skin” into the game itself. The PSAO determined that they were confident that they could monitor their stores and help coach stores in jeopardy, effectively working together to maintain the minimum GDR during the course of the year. At the end of the year, if a pharmacy fails to maintain the minimum GPR, the PSAO, not the pharmacy, would pay the penalty.

Access to lives is important. Access to a PSAO that puts its own skin in the game, however, is a game changer. I hope that more PSAOs realize that they need to have skin in the game as well.

Addressing Compliance

[dropcap color=”white” background=”black” style=”square” size=”large”]T[/dropcap]he pharmacist has access to their patient’s refill history. With the history, the pharmacist can assess medication persistence, which is something a prescriber cannot readily assess.

Consider the following scenario: while performing final verification and doing Continuous Medication Monitoring (CMM) you notice that the patient does not appear to be taking one of their medications correctly. The patient appears to be taking roughly half of all scheduled doses. As the pharmacist, you decide to approach the patient in order to correct this compliance issue.

Before making this intervention, however, consider that you really know very little about the situation. While your data shows non-compliance, there are many possible explanations and only one of them is the patient being unwilling or unable to take the medication as prescribed.

Before approaching the patient, consider some of the possibilities. The following is representative of issues we have seen, but is certainly non exhaustive.

  • Samples. Yes, there are still samples being handed out by physicians. If the patient is on a name brand drug, this is certainly a possibility.
  • Mail order or another pharmacy. As pharmacists, we generally are not fans of this type of pharmacy, but the possibility that the patient has another source.
  • Prescriber – Pharmacist communication. It is fairly common in our practices to have the prescriber send the patient a letter of follow-up after an office visit. Often, the prescriber makes changes to the patient’s drug therapy in these letters but fails to include the pharmacy in the correspondence.  The patient may be taking the drug correctly, but the pharmacy doesn’t know it (yet)
  • Medication hoarding. Often I find patients will have acquired massive stockpiles of their medications. Once they have done this, their apparent compliance starts to fall.
  • Drug side-effects or adverse events. The patient will be the first one to know if a medication effects them in an undesirable way.  The patient may self-adjust their dose to avoid these effects. They do not always think to share this with the prescriber or the pharmacist.
  • Therapeutic goals. Related to the self-adjusted dose for ADRs, patients often adjust their dose themselves based on how they feel. As crazy as this might seem, the patient is often justified. Many patients I have seen over the years have adjusted their blood pressure and cholesterol medication doses themselves without letting anyone know. The prescriber often assumes that the dose being taken is what they prescribed. What matters here is that the patient is attaining the goals the prescriber and patient have established.
  •  True Non-compliance. The patient cannot or will not, for one or many reasons, take the medication as prescribed.

Understanding that there are many different possibilities for the refill pattern being observed necessarily impacts the approach used. Instead of asking the patient why they are not taking their medication as prescribed, one needs to enter into a fact finding mission.

One approach that we have found useful in our practice is the use of open ended questions. Typically we explain what we have noticed and then ask the patient to fill us in on any changes. For example:

“We noticed that your refills for this medication were often late. We are often the last to know if the prescriber made any changes. How are you taking this medication now?”

By taking blame for “not knowing” about any possible changer, we have tried to make the assessment less confrontational. Generally, this tactic helps illuminate the underlying reasons for what we have observed. Most of the time, a good reason actually exists for the late refills.

Once the reason is understood, the appropriate action can be planned. Often, the persistence data is a false-positive for a compliance issue, and the pharmacist only needs to document the reasons for the late fills. If there is are true obstacles to compliance, the pharmacist can further intervene and help coach the patient to improve compliance. Of course, this too should be documented. Lastly, the pharmacist needs to schedule a follow-up to re-assess the patient. Our practice typically re-evaluates the patient’s compliance (even false positive cases) in 90 days.

Pharmacies and pharmacists have a unique opportunity. Our businesses bring our patients to us regularly. This means we can see and interact with them at a minimum of several times a year and often several times each month. Pharmacists need to make every one of these encounters count.