Category: Clinical Pearls

Clinical pharmacy pearls for the thriving pharmacist

The New Community Pharmacist

In the past three years, I have seen more changes occurring in healthcare and, in particular, pharmacy, then I have seen in my entire career which now spends almost 30 years.  The changes are coming rapidly and frequently to the point where it is becoming scary, challenging, and intimidating to pharmacists in all settings. One of the more significant changes is in how healthcare is being reimbursed.  The old fee-for-service is no longer the standard.  We have quickly moved to a system that utilizes value-based purchasing as the new standard.  In this system, payers purchase services based on value and the performance of providers.  Payers are looking to reduce their overall healthcare spend while simultaneously improving healthcare quality.  This includes sharing the risk of healthcare costs with providers, including pharmacists.  This also means new opportunities for pharmacists, including community pharmacists.  With these opportunities, though, will come new responsibilities.  Community pharmacists will have the responsibility to ensure that their patients are achieving therapeutic outcomes through the use of safe and effective medications.  This is not a responsibility to be taken lightly, nor is it one that will allow community pharmacists to stay passive.  We must change our practice setting, and what we do day-to-day for our patients.

From a practice setting perspective it means several things.  First, community pharmacies need to make sure that they are being freed up to provide patient care services, and not just dispensing a product to the patient.  This may require additional staff, and training of existing staff.  Community pharmacists should move to a technician-driven, pharmacist-managed dispensing process.  Also, it may require investment in technology whether it be a “state of the art” pill counter, or a more sizable investment in a robot for automated dispensing.  Another area to look at is what is allowed under state board of pharmacy rules in regards to a tech-check-tech system.  As mentioned previously, the intent of these changes is to make sure the pharmacist is freed up to review patient medication profiles, identify and resolve drug therapy problems, and document their activities.

Community pharmacists may need to make an investment in clinically oriented and/or residency trained pharmacists, especially if the current practice does not have a clinically oriented pharmacist on staff.  Being responsible for therapeutic outcomes is an extremely important role for pharmacists.  It requires current therapeutic knowledge, clinical skills, problem solving, and critical thinking.  Pharmacists need to become interventionist, meaning that once the drug therapy problems is identified, they also provide solutions to resolve these problems. This requires communicating clinical recommendations regarding drug therapy changes to other providers.  Community pharmacists should ask themselves the following questions with each patient, and every medication the patient is taking:

  • Is the patient achieving their therapeutic outcome?
  • Is the patient’s medication effective?
  • Is the patient’s medication safe?

If the answer to any of these questions is no, then a drug therapy change may be warranted.

Re-engineering a practice also means critically evaluating the physical layout of the practice.  Community pharmacists need to think about where they will counsel patients during the dispensing process, and if the space provides some level of privacy.  Also, a patient care area to perform Medication Therapy Management Services (MTMS) and other clinical services is important.  This space should allow a more intimate discussion where the patient does not feel rushed or concerned about privacy.  These patient care areas are where patients and pharmacist can have more in-depth discussions regarding the patients medication regimen, questions/concerns the patient may be having, or providing clinical service such as immunizations.

Lastly, the new community pharmacists needs to be documenting their patient care activities including the drug therapy problems found during the dispensing process when pharmacists are performing their prospective drug utilization review (pDUR) now referred to as continuous medication monitoring (CMM) services, or while providing MTMS or other clinical services.  This documentation needs to be completed real time. Drug therapy problems identified should be documented along with an action taken, and the results of the actions taken.  Patient charts, electronic or hard copy, should be kept for all patients, and these charts should includes all interventions pharmacists have made to improve their patients’ therapy.

The new community pharmacist has a lot of responsibility, but also becomes a more integrated healthcare team member.  With healthcare change will come a plethora of new opportunities, but community pharmacists need to by ready to accept them. The new community pharmacist needs to make every encounter with their patients count.

Follow-up on Performance Payments

Last week, one of the Medicare Part D plans using Mirixa for Medication Therapy Management (MTM) “dropped” a new batch of “Star Measure” alerts to our pharmacy. These have been previously discussed here on this blog.

This “drop” was not unlike previous iterations our pharmacy has seen; the patients highlighted for possible compliance issues were exclusively patients residing in group homes. Each of the patients have staff working with them to ensure that they take their medications, and all of their medications are in compliance packaging (either OPUS cassettes or other systems to enable the staff to make sure that all doses are given). Every time the patient misses a dose, the staff report the incident to us, and we document the pertinent details in our clinical documentation system (PharmClin). Needless to say, if a patient is severely non-compliant, we would know quickly (because we would be receiving calls several times a week).

If it is not obvious by now, every one of these Star Measures cases were a false positive. Each patient was, and continues to be, nearly 100% compliant (as a percentage of days covered or PDC). So why were these cases brought to our attention? The answer relates workflow.

The workflow required to handle the large number of prescriptions dispensed on the same day each month to a large group home population requires a fairly involved process that is mostly automated by our pharmacy dispensing system. Even with this automation, billing may be delayed by up to 10 days for some prescriptions*. Keep in mind that it is the billing that is delayed, not the delivery of the medications.

Discussion

What is surprising is how quickly the plan and Mirixa identified what they perceived as compliance issues. We received the notices just short of 2 weeks after the due date of the prescriptions. That is just short of amazing, and some of our patients would consider this type of “short leash” offensive (and even an invasion of their privacy) if they were aware of how tightly the benefit manager is tracking them.

In this case, the delay in billing within our workflow resulted in sixteen “opportunities” to document and collect some “clinical” reimbursement from the program. Each of these cases is an opportunity to earn $12 by responding to the case (without respect to outcome). There are, however, two caveats about this program that should be noted.

  1. Each of these $12 interventions will be withheld from the performance incentive paid to the pharmacy (by the plan) at the end of the year (assuming we exceed drug specific patient compliance metrics). In other words, each $12 is effectively just an “early” performance payment.
  2. The Mirixa system for addressing these issues is time-consuming. If a pharmacist completes the intervention completely (updating each medication and answering all prompts), it takes a minimum of fifteen minutes to complete the intervention (not counting any patient contact time). This is not cost effective, as it does not come close to covering the time spent by the pharmacist.

The Pearl

These Star Measure interventions (or SSI Performance Network Program) are a much more focused intervention than a complete Medication Therapy Management Program encounter (MTMP). The reimbursement level (at just $12 per incident) reinforces this statement. To handle these interventions efficiently, make a call to the patient (this does not merit a face-to-face) and ask some open-ended questions. Patients can become defensive when approached about compliance, so it is wise to deflect this initially, noting that there are many possible reasons for this (like physician samples, dose changes, side effects etc) and let the patient fill in the rest of the story. For example:

We have noticed that your refills of lisinopril have not been as frequent as we expected. Often, changes are made by the prescriber, and the pharmacy is the last to know. How are you currently taking the medication? What difficulties, if any, are you having with the medication?

At $12 per intervention, break-even time (at a pharmacist salary of $50/hr) for this case is 14 minutes, so this phone call has to be efficient. You need only to establish if there is a real problem and a brief explanation. The phone call might take three to five minutes to complete.

Data entry must also has to be efficient. A tip for pharmacists working this type of problem in Mirixa: do not spend time updating the medication profile. It is not obvious, but leaving this portion of the intervention unfinished will not prevent (at least for now) the intervention from being completed.  By omitting this information (and only addressing the fields that relate to the compliance issue at hand), a pharmacist should be able to complete the Star Measure intervention (call and data entry) in less than 10 minutes. This is much more in line with the actual reimbursement being offered.

Footnotes

* July 2015, with the observed holiday of Friday July 3rd, is a worst case scenario of delayed billing.

Creating a Slack Based Workflow

Whenever visitors tour our pharmacy, one of the most common comments has to do with the level of our staffing. We typically have a minimum of 4 pharmacists working on any given day, with as many as 7 on select days. The use of extra pharmacists (what we call our slack resources) allows the flexibility to accomplish many ventures other “stripped down model” pharmacies cannot. This article will describe our workflow and the benefits it brings to a pharmacy practice.

Technician Driven

The most important part of our workflow is freeing the pharmacist to focus on the patient. This is accomplished by leveraging excellent technicians to do all data entry and filling processes. In our case, our pharmacy is involved in a pilot project allowing technicians that have received additional training to check refill orders without a pharmacist final verification of the product.

The Pharmacist Belongs on the Counter

Another important philosophy in our workflow is that the pharmacist needs to stay in the dispensing workflow. Even if the pharmacist is not doing the final verification step (for example, in the tech check tech pilot program above) the pharmacist is still reviewing the patient’s profile and clinical record in real-time. The pharmacist is tasked with creating and documenting interventions that need to be addressed with either the patient and / or the prescriber. By being on the counter, the pharmacist is accessible to gather information directly from the patient as needed to make clinical recommendations.

The pharmacist on the counter has one of the more difficult jobs in our practice. Their responsibilities include:

  • Final Verification of the drug product (all prescriptions, or for new prescriptions if a tech-check-tech program is in place)
  • Clinical profile review. Each patient’s records are reviewed any time a prescription is filled or a patient contacts the pharmacy with a concern or question.
  • Identify issues that need to be addressed at the point of sale (compliance, high risk medication use etc) and flag these for follow-up with the patient
  • Gather patient information specific to any issues identified
  • Document the additional information gathered
  • Schedule appropriate follow-up as required
  • Contact the prescriber by phone or fax regarding any problem(s) identified as needed

This is a significant amount of work to put on one person, and when the pharmacy becomes busy, this pharmacist needs a resource to delegate work. This is our slack pharmacist.

The Slack Pharmacist

It is important to develop a workflow that leverages this person to maximize their impact. It would be inefficient to have this resource sitting and waiting for the hand-off from our prescription counter. Our slack pharmacist’s responsibilities also include medication reviews for our patients residing in nursing homes we service, and our assisted living community patients. They are also involved in vaccination programs and other clinical services like cholesterol screenings, site visits and our medication sync program.

Our slack pharmacists are located a few feet from our prescription counter, in semi-private cubicles. This workspace allows the slack pharmacist to work individually with a patient, and to have ready access to the clinical records system and many of the other tools they use (blood pressure cuff, Cholestec machine, immunization supplies, injection supplies, patient charts etc). This proximity means that the counter pharmacist can easily hand-off patient care activities, SOAP note completion, physician calls and faxes during a busy time on the counter.

Pharmacists Enable Care

If it isn’t obvious by now, our practice places a significant emphasis on the talents and capabilities of our pharmacists. What visitors notice immediately after they count the number of pharmacists at our practice is that every single pharmacist is quite busy.  Taking care of patients is not possible if you don’t have the resources available, and simply filling prescriptions is not patient care. The pharmacist has excellent access to their patients, and they need to capture every encounter and make it count.

Creating the Capacity for Patient Care

We are often asked how our practice evolved into what it is today with it’s diverse service offerings, a significant staff of pharmacists and technicians, and our ability to generate revenue beyond just dispensing medications.  It started almost a decade ago when Mike and I decided to change our model of community pharmacy practice.  Creating the capacity to provide patient care  services was not an overnight fix, rather it was an evolution based on trial and error, feedback from staff and patients, and market forces.  This is not saying that our practice developed out of random happenings, but rather we had laid a foundation for which we could easily adjust, improve, and add services as deemed necessary.

To create a capacity for patient care, we began by moving our practice to a technician driven dispensing model, repurposing pharmacists so that the majority of their time was spent evaluating patients’ medications, resolving drug therapy problems, and communicating with both patients and providers.  This required changes in job descriptions and responsibilities, new positions being developed, and staff training.  We put a lot of our focus on the dispensing pharmacist. Pharmacists traditionally focused performing final verification. In our practice, the pharmacist was asked to becoming a clinical interventionist–identifying and resolving drug therapy problems “on the run” in which we now called continuous medication monitoring (CMM).  To make this transition, we had to develop a different documentation system, because our dispensing system, much like all the others, is great for making sure we have all the information needed for dispensing a product, but very limited in terms of documenting patient care.  The system we created is now called PharmClin, and it leverages the information from our dispensing system and creates a clinical record, making it easier and more efficient for the dispensing pharmacist to provide CMM.   Moving the pharmacist into this new role also required education and training on how to quickly clinically assess patients’ medications, develop an intervention to resolve medication issues, and document their patient care activities.  Obviously, creating the technician driven dispensing process helped to free up the pharmacist more to focus their activities on patient care.  We saw the need to create a new position for a pharmacist to oversee the operations of our dispensing system.

In addition to the changes in dispensing, simultaneously we remodeled our pharmacy to include two patient care areas.  These areas are used to provide clinical services beyond the CMM process.  Services included immunizations, medication therapy management services (MTMs), adherence programs, health promotion services, and case management.    As our services continued to expand and more and more patients enrolling in them, it was time about adding some new positions.  We created a community pharmacy resident position, but quickly realized that we also needed to hire another pharmacist to oversee all of our clinical services.  Not only do these pharmacists manage our clinical services, but they serve as a resource for our dispensing pharmacists providing us with “slack resources” for more in-depth problems uncovered by the dispensing pharmacists, or providing more in-depth counseling to patients as needed.

Other features of our practice that help support our patient care services a marketing plan that we review monthly.  Every month we determine which services or practice areas we want our marketing efforts to focus on and what media we will use to “spread the word”.  We hired a marketing professional who oversees our marketing efforts.

We have remodeled our pharmacy several times in the past decade with each remodel planned to improve patient care processes. We created two patient care areas which also serve as offices for our clinical manager and our community pharmacy resident.  We expanded our dispensing counter to give our dispensing pharmacists more room for their CMM activities.  We also created a patient counseling area at the end of our dispensing counter.

We have implemented tech-check-tech services as part of a new practice model program in Iowa to free up our pharmacists to provide clinical services.  We also have implemented new technologies in the practice to improve our efficiencies including using a Parata robot, the Eyecon medication counter, an interactive voice response (IVR) system,  and automated programs that help with our medication synchronization program and help with patient selection into medicare plans.

With all of these changes, the following list provides the current patient care services we offer at Towncrest Pharmacy

Clinic Services: Med Check Program, Medication Adherence Program, Influenza and Pneumococcal Vaccinations, Zostavax Vaccination, Tdap Vaccination, Pharmaceutical Case Management (PCM), Medication Therapy Management (MTM), Nursing Home Consulting, CPAP service/Education, Ostomy Consultations, Drug Information Service, Compounding, Employer based health screenings

–Wellness Center: Cholesterol screening, Blood glucose screening, BP screening, Height and Weight, BMI

Specialized Focused: Mental Health, Wellness, Geriatrics, End of life/palliative care

As we have mentioned before, our practice has evolved to have this type of capacity to provide patient care services to all of our patients. Although it didn’t happen overnight, we realized that we had to make the initial changes to provide the foundation.

Residency Project: What Types of Interventions are Pharmacists Performing and Documenting with a New-Payer Model?

Background/Intro: Studies have continually shown that community pharmacists can impact and improve patient outcomes if they utilize clinical skills during the dispensing process. The question that arises is: How can we change current reimbursement models to reward pharmacies for the clinical and cognitive services we provide in the dispensing role?

Traditionally, as highlighted in previous article, pharmacy reimbursement has always been product-based. Reimbursement is based off ingredient costs (AAC, AWP, etc) and dispensing fees. Depending on the PBM contracts accepted, the type of cost used to calculate reimbursement and dispensing fees vary drastically. Due to non-transparent costs and minimal dispensing fees, pharmacies lose money on prescriptions. Community practices have therefore adapted to this by become volume-driven because no one pays for the value/costs associated with problems identified and addressed by dispensing pharmacists.

The most common way that pharmacy gets paid for clinical services are for select Medicare Part D patients through Mirixa and Outcomes MTM platforms. These interventions and medication reviews take 30-60 minutes and are usually performed by a pharmacist outside of the dispensing role. But the question still stands: How can we be reimbursed for interventions we perform on a daily basis during dispensing and performing a thorough prospective DUR?

Towncrest Pharmacy has collaborated with a local payer to initiate a pilot project that pays the pharmacy a professional fee in addition to a dispensing fee for each prescription dispensed for patient’s enrolled in this specific health plan. The objective of my project was to evaluate the different types of interventions that were performed and documented for the pilot project patients.

Methods: Data from April 1, 2014 to October 31, 2014 was extracted from PharmClin. Descriptive variables were collected for patient’s age, gender, and number of medications; Frequencies and descriptive statistics were tabulated for each intervention and drug therapy problem (DTP) documented.

Results/Discussion:

Patient Population: Interestingly, this cohort of patients compromises only 7-8% of Towncrest Pharmacy’s total patient population and only represent 3% of Towncrest’s total prescription volume. A majority (77%) of these patients were 18-64 years age category with an average age of 49 years, and only on an average number of 4 medications. Despite not being a high-risk population, 75% of the patients had a pharmacist documented intervention with the total number of interventions being n = 483. The interventions were further categorized, based on the options available in PharmClin. See Below:

Graph

Table

Discussion: Of the documented interventions, half involved prescription counseling (n = 241; 49.9%) and nearly 30% (n=144) of interventions identified various drug therapy problems. As counseling is required for any new prescription in the State of Iowa, this figure was not surprising. However, the most common DTP assessed by pharmacists was medication adherence (n = 119; 82.6%). This number has significance as 3 of the 5 current criteria for CMS Stars Ratings relates to adherence (statins, diabetes medications, and ACE-I/ARB/DRI). This makes it vital that pharmacists in the dispensing role are taking advantage of every encounter with the patient to address issues; forcing the dispensing pharmacist to change their mentality from “right person, right drug.” Instead, pharmacists are assessing the medication profile as a whole to evaluate the safety, efficacy, and appropriateness of therapy during the prospective DUR process. We have continually made improvements to PharmClin to assist in this process and flag for potential problems.

Conclusions: Pharmacists can make critical clinical interventions during the dispensing process. Better clinical documentation of interventions and reform of current reimbursement models can help shift community practice to focus on delivering quality health care.

SuperSync: the Super Hero of Adherence

To say that Medication Adherence is a hot topic in many pharmacies is an understatement. With the Proportion of Days Covered (PDC) being the focus of three of the five CMS performance measures for pharmacy, medication synchronization services are being adopted by many pharmacies. Synchronization is one strategy to improve patient compliance, making it less likely that the patient runs out of medication.

At our pharmacy, the synchronization is often referred to “not-so-simplify my meds” because of all of the details that have to be managed by the pharmacy to successfully synchronize, and maintain synchronization, of a patient’s medications. Companies like Prescribe Wellness, and Ateb (and others) offer cloud based software solutions to help pharmacies manage what turns out to be this less than trivial task.

But synchronization only address one aspect of patient compliance by making it less likely that the patient will be without one or more medications. The patient still has to remember to follow their mediation regimen, and sometimes this obstacle is daunting. Pharmacist can coach patients to improve their compliance or even suggest changes of therapy to the prescriber to simplify the patient’s medication regimen (e.g. changing a person from simvastatin, that has to be taken in the evening, to atorvastatin, that can be taken with the rest of the patient’s medications). When these types of interventions steps fail to improve a patient’s compliance, however, it is time to call in a super hero: SuperSync.

Med Planners

One of the best ways to help a patient take their medications correctly is the make the job of taking the medications less burdensome. An easy way of doing this is to recommend the use of a medication planner. Filling a planner, however, is a fairly tedious process for some patients. The pharmacy can assist (though it does need to abide by state and federal regulations with respect to labeling if applicable). Depending on how this service is managed, it is even possible for the pharmacy to charge a fee for this service.

SuperSync: Synchronization plus Packaging

One novel way to approach medication packaging for the synchronized patient is to do away with the prescription vial entirely. Packaging systems like the Parata Pass system create a prepackaged, commingled, multi-dose strip package with each day and time divided into a perforated strip of bags. The patient’s next doses are always the next bag on the strip.

Methods like this work very well in combination with medication synchronization. The patient’s medication are simply entered in the pharmacy management software and sent to the robot for packaging. The pharmacy trades vials, caps and labels for the disposables used by the packaging system.

Cost Analysis

One significant question, however, is if a program like this will save a pharmacy money, or cost them more in time and materials. The analysis below represents reasonable approximations to the cost of this type of program.

Traditional Prescriptions

The cost of a typical prescription vial with a lid varies by size, with the more common small 8 dram vials / lid costing roughly $0.25 each. Larger vials can cost upwards of $1.00, though these are much less commonly used in most pharmacies. Label costs add about $0.02 to $0.08 each, depending on stock and size of the order. Overall, each prescription filled costs the pharmacy about $0.30.

Disposable Costs: Traditional
Approximate monthly cost for vials, lids and labels for patients receiving 6 to 12 chronic medications.

The cost per month for vials, lids and labels, given a typical patient being synchronized in our pharmacy is about $3 per month.  When dispensing 90 day supplies, the cost per month is reduced only marginally, as the more of the larger vials are required, adding expense.

Strip Packaging (commingled)

The primary costs associated with this method are packaging paper (the cellophane that becomes the bag) and the ribbon (which creates the printing on the package). The cost of the robotic equipment is not being included in this discussion in a similar way that labor costs were not included in the cost analysis of a traditional prescription. The per-bag cost for a strip-package is about $0.021 (the decimal is important as there will be numerous bag in any given order).

The number of bags in an order will depend on the number of medications, and the number of times each day a patient takes a medication, and the number of days being packaged. Each bag is capable of holding up to four different medications (this is a practical limitation based on the size of print and the amount of information that has to be included on each bag per pharmacy labeling regulations) and seven tablets/capsules (this being limited by the volume each bag can contain).

Strip package costs.
Monthly cost of cellophane bag stock and ribbon based on the total number of bags required per day.

Because each bag can hold any combination of 4 medications and 7 tablets / capsules, the typical day will include 1 to 4 bags. For example, a patient taking 6 medications (representing 7 tablets), all in the morning, would require 2 bags per day to allow for the printed requirements to fit on the packaging. If one of those medications were twice a day, they would require 3 bags per day. Patients with medications taken three or four times a day will have as many as eight bags a day. This means that the average cost to the pharmacy in disposable overhead is about on par with traditional prescription vial based packaging for most patient needs.

Kryptonite for SuperSync

The biggest disadvantage to a packaging system like the Parata Pass being married to a synchronization program is the potential for therapy changes. If a patient has a medication change, the entire strip is potentially rendered incorrect. It would need to be re-packaged, adding additional costs in labor and overhead. It is important to keep this in mind when selecting patients for a SuperSync type program. Policies and procedures also have to be developed to handle this type of change, as even the most stable patient can have a change that effects their meds when they are packaged in this manner.

Workflow and Equipment

The two biggest challenges with using a SuperSync process are:

  1. Purchasing the equipment and
  2. creating a workflow that is efficient and seamless.

Equipment like the Parata Pass are capital purchases involving many tens of thousands of dollars both in up front costs and reoccurring maintenance fees. Traditionally, this type of packaging has been used mostly in nursing home type pharmacies. The congruence of packaging and synchronization, however, makes it appealing for retail pharmacies as well. I am aware of more than a few pharmacy practices that are adopting this type of packaging for all of their ambulatory patients. Workflows that leverage both synchronization and robotics like the Parata Pass have the potential be extremely efficient.

Tie-Ins and Prescripton Drugs

Pharmacies are being paid less and less for prescription drugs, and adequate reimbursement for clinical services is still not a reality. At the same time, pharmacies are being evaluated on performance, and this requires investments in the practice. Keeping the bottom line balanced means that today’s pharmacy owner needs to maximize efficiency in their pharmacy department and find new revenue streams to help fill the widening gap between overhead and drug product reimbursement until reimbursement for services can add significantly to the bottom line.

Chain drug stores rely on extensive front ends to buoy pharmacy department sales. Independent pharmacies often cannot leverage an extensive front end in the same manner. This does not mean, however, that the independent pharmacy cannot use their front end to support their overhead during this paradigm changes in pharmacy.

Don’t try to beat the Big W

Over the years, I have emphasized that the chain pharmacies around me are not my competition. They do things in ways we would never consider. Conversely, they do not generally have the flexibility and latitude to attempt things an independent pharmacy could try. So, when selecting products for the the front end (over the counter) section of the pharmacy, it is always a good idea to strive to find products that the chain pharmacies not or cannot stock. Quality merchandise is also something that will set an independent apart from a retail chain pharmacy. The trick, however, is to jump-start the sales of these products.

While an independent pharmacy might shy away from mass market merchandise, there is no reason that the independent cannot look at some of the common retail strategies used by the chain drug stores. Of specific interest today is the use of tie-ins at the point of sale. Tie-ins are those items hanging next to the thing you were looking for. In a grocery store, grated Parmesan cheese might be hanging on the shelf right next to the spaghetti sauce. If you are looking for one, you are more likely to impulse purchase the other.

The Prescription Tie-In

An independent pharmacy can take this strategy and really make it shine by integrating the pharmacists clinical knowledge during the final verification phase of each prescription checked in the pharmacy. Many drugs either are dependent upon, or deplete specific vitamins / minerals or other nutrients from the body. These nutrients can become tie-in marketing opportunities for the pharmacy. While this is not a new strategy, this strategy can be optimized and made successful with a little advance planning. The result can be a significant boost to revenue to help offset the decreases seen with prescription drugs.

Examples of possible tie-ins might include:

  • Recommending a Coenzyme Q10 supplement for patients taking HMG Co-A inhibitor (e.g. atorvastatin, lovastatin, pravastatin etc).
  • Recommending a pro-biotic to patients taking a broad spectrum antibiotic
  • Recommending a vitamin and mineral supplement to patients taking diuretics

Strategies

  • Be selective: choose a product line that is unlikely to be stocked by , or unavailable at chain stores. This might be a premium brand with a high quality standard.
  • Start Simple: There are dozens of classes of medications that have potential tie-ins for supplement sales. Rather than overwhelm the pharmacy staff and the patients, start with a few select classes and grow the program from there
  • Think Clinically: While there are dozens of class of medications with potential tie-ins for supplement sales, some of these are better documented than others.
  • Research before you sell: Be sure you understand the mechanisms and pathways. Having this knowledge helps earn the patient trust and understand that you are providing more than just product, but knowledge.
  • Train your staff: Be sure that all of your staff understand what the program is and how it is going to be executed. Be sure that the pharmacists are familiar with the research done above.
  • Document: If a patient is flagged for consultation about their medication and, after considering the pharmacist’s rational for the recommendation to purchase a supplement, the patient declines, document the outcome.
  • Plan follow-up: Do not flag the same patient for consultation and recommendation of a supplement every time they come into the store. Remember that this is a professional consultation. Instead, document the outcome in a manner that all pharmacy staff will know when the consultation was made, the patient’s response, and when to follow-up (e.g. approach patient in 6 months to re-visit the topic)

Our pharmacy is beginning the implementation of this type of program. We have chosen Ortho Molecular Products as our “premium” brand of supplement. One advantage for choosing Ortho Molecular is their “Pharmace Replete” program designed to help tie-in sales. This includes materials that my be helpful to a pharmacy wanting to implement this type of program.

Documenting Adverse Drug Reactions on the Fly

Every medication has the potential for unwanted effects, but some medications deserve a little more attention from the pharmacist. While pharmacists both understand and advise patients on potential and realized ADRs on a daily basis, few take the time to maximize their impact and, further, to document this important clinical work.

A Continuing Medication Monitoring (CMM) Workflow

Every pharmacy has a workflow. Many “traditional” pharmacies focus their workflow on the dispensing role of the pharmacist, and this does not put the proper emphasis on the potential of the pharmacist to make meaningful clinical interventions. In order for pharmacists to establish their relevance in a modern healthcare environment, pharmacies need to redesign their workflows to transition the pharmacist a dispensing focused role to a interventionist role.

Technicians play an important role in allowing the pharmacist the flexibility to engage with the patient as an interventionist.  While the pharmacist is still required to complete the final verification step in most states, technicians can be leveraged to handle many of the non-clinical tasks the pharmacist traditionally has done. Some states even allow technicians to check other technicians for routine refills, further freeing the pharmacist to concentrate on clinical issues. It is the view of the authors of the Thriving Pharmacist, though, that the pharmacist should stay in the prescription workflow. This is because by being available on the counter, the pharmacist has best access to the patent, an attribute that will be leveraged heavily below.

We have also added pharmacists to our staff to achieve what we sometimes refer to as a “slack” pharmacist. This pharmacist is not tasked with working the counter (performing the final verification and CMM). Their job involves a working on a variety of other services in our pharmacy. This pharmacist also serves as a pressure-release valve for the pharmacist performing CMM. If a patient needs additional education, counseling, or one-on-one time with a pharmacist, the “slack” pharmacist can be used to hand-off duties during a busy time of the day. These also include completing documentation for more clinically involved interventions started during the final verification and CMM stages of the workflow.

Identifying Potential ADRs

The pharmacist acting as an interventionist needs to focus not only on the prescription(s) being filled at the present time, but also in the entire patient profile. For this reason, having access to a clinically-tuned profile is helpful (see the discussion “A Clinical Profile” in “Continuous Medication Management (CMM) and the Profile“). Armed with a easy-to-use profile, the pharmacist is almost ready to bring ADR screening into the workflow. One last preparatory step if helpful, though. As stated earlier, every drug has potential ADRs. It is often useful to start with a subset of drug classes on which to focus and to create a protocol to follow. Once this is decided, and the appropriate information is communicated to the appropriate pharmacy staff, the hunt is on.

Example Program

In working with a local Quality Improvement Organization (QIO), our pharmacy decided initiate a new, focused, ADR screening program centered on three classes of medications with significant ADR risk. These three classes were:

  • Diabetic Medications
  • Anticoagulants
  • Narcotic Pain Medications

These categories of medications were updated in our clinical documentation system to be flagged (color-coded) in order to alert our pharmacists to focus in on these medications with respect to ADRs. While the focus of our initial efforts could have included any number of different categories with significant potential ADRs, these categories have significant  issues and are well represented in our practice.

ADRs were further divided into two categories

  • Potential ADRs – Things that the patient may experience but are not yet identified or confirmed
  • Confirmed ADRs

New intervention categories matching the above were added to our clinical documentation software (PharmClin) to document ADR related pharmacist activity.

During the final verification stage of the prescription workflow, our pharmacists review the complete clinical patient profile, including a screen for drugs in the selected class, looking for potential ADRs. With the color coding of these classes of drug classes, this is a quick step. The pharmacist can then create an intervention in the documentation system focused on the drug(s). This intervention can then be printed and added to the will call with the patient’s prescriptions for pick-up.

ADR
Example printed tag to include with patient will-call. Pharmacist can then document presence of ADRs with any specific notes.

It is at the point of sale where the pharmacist has the opportunity to have the greatest impact on patient care. The register clerk, seeing the note in the above patient’s order, calls the pharmacist over to the register. After a quick review of the printed note, the pharmacist can ask the necessary questions to quickly ascertain if the patient is experiencing unwanted effects from the medication. Based on what is discovered, the pharmacist can initiate a variety of possible outcomes:

  • If the results are negative, or not a serious issue, the pharmacist can then make notes on the printed intervention, and, when they have a few moments on the counter, complete the intervention with the gathered information.
  • If the patient needs additional counseling or education, the pharmacist can move them to a semi-private counseling area and hand-off care to the “slack” pharmacist.
  • If information needs to be forwarded to the prescriber, a detailed SOAP note addressing the issue along with specific recommendations for the prescriber can be created (again, the “slack” pharmacist may be called into duty).

Discussion

The process described is not unique, nor is it particularly innovative. Pharmacists in a variety of practice settings can and do uncover the existence of ADRs and work with the patient to enhance outcomes. The key point, however, that differentiate the discussion above from many more traditional workflows is the documentation of the actions taken in a clinical record. If it is not documented, then the value of the pharmacist is essentially lost.

Conclusion

Pharmacists are capable of impacting patient care every day. The profession is renowned as being one of the most accessible health care providers. It is not, however, until pharmacists start to document their interventions that they will be recognized as true interventionists. This step is critical to the advancement of the pharmacist to provider status. Having a clinical records system is becoming critical to make every encounter with the patient count.

Claims Data is Not Clinical Data

I have always been critical about the use of prescription claim data in measuring adherence, though I understand that it is one of the only mechanisms readily available to estimate adherence. Discussions that emerged from “The Rewards of Performance” led to a closer examination of Mirixa SSI claims this quarter.

For those that don’t know, the Mirixa SSI  Retail Stars Adherence Intervention Program alerts pharmacies of patients with poor compliance (percentage of days covered or PDC) taking one or more medications being emphasized thru the EQuIPP measures. These alerts are based entirely on claims data. The pharmacy is paid $12 for each case completed and $2 if the pharmacy attempts to complete the case and the patient declines to take part.

I asked my clinical director to summarize the SSI activity our pharmacy has seen during the first quarter of 2015. Here is what she reported:

  • We received 12 SSI Retail Stars Adherence Interventions Program notices
  • Each one of these required an average 20 minutes of pharmacist time
  • Many of these 12 , once the discussion started, required the pharmacist to do a medication reconciliation to address the issue.
  • All 12 (100%) of these SSI cases WERE FALSE POSITIVE adherence issues

It is quite clear, for at least the first 12 cases this year at our pharmacy, claims data does not tell a compelling story about compliance. Consider some examples:

Falsely Identified:

Patient fell and broke his hip in late Feb. He underwent surgery and was hospitalized for 3 weeks. Patient is also a part of pharmacy’s synchronization program. We will be re-syncing medication at upcoming fill.

Falsely Identified:

On 9/16, our pharmacist discussed the change from simvastatin to atorvastatin with the patient. He asked if he could finish simvastatin left at home (as suggested by his doctor). We agreed this was fine (as the change was not prompted by an ADR to simvastatin). The 9/12/14 fill of atorvastatin will obviously last >90 days since he finished simvastatin first. We continue to monitor his compliance regularly with all medications.

Falsely Identified:

Last 3 refills were appropriate: 12/6/14, 1/5/15, and 2/2/15. Reviewed patient profile as Mirixa Platform identified non-compliance for Simvastatin, Metformin, and Lisin/HCTZ. Compliance issue was falsely identified and last three fills/refill history looks appropriate. Intervention was documented into Mirixa Platform. Patient reported no issues with medications at pick-up

Falsely Identified:

Per Pharmacy records, compliance is appropriate and claims were billed through new processor. Refill history: 1/2/15, 2/9/15 Patient was recently hospitalized a couple of weeks ago.

Falsely Identified:

Refill dates include: 1/5/15,1/19/15,2/2/15,2/16/15,3/2/15. This non-adherence falsely-identified.

Falsely Identified:

Reviewed patient profile as Mirixa Platform identified non-compliance for Glipizide. Compliance issue was falsely identified and last three fills/refill history looks appropriate (11/10/14, 1/10/14, 3/2/15). Patient fills 60 days at a time. Intervention was documented into Mirixa Platform. Patient reported no issues with medications at pick-up

Falsely Identified:

Patient’s record shows adequate and timely compliance. All medications are lined up to fill around the 25th each month. Pharmacy refill history shows refill dates this year of: 12/26/14, 1/21/15, and 2/25/15.

Falsely Identified:

Pharmacy dispensing software indicates that medication is being filled appropriately with last 3 refills dates of: 12/4/15, 1/7/15, and 2/6/15. Additionally, patient is enrolled in pharmacy’s medication synchronization program and medications are reviewed by pharmacist monthly for ADRs, changes, and promotes adherence.

The use of claims data to alert a pharmacist to a potential problem is a benefit to both the PBM and the pharmacy. Unfortunately, the reliance of pharmacy quality measurements (i.e. EQuIPP) on PDC taken from claims data is seriously flawed. Some might consider our first quarter to be an aberration statistically. This is not the case. Our in-house compliance screen (see “Addressing Compliance“) routinely finds that a significant number of  apparent compliance issues have legitimate explanations. The current mechanism for evaluating pharmacy is certainly flawed, and new measures that actually measure the impact that pharmacists can have on patient outcomes are desperately needed.

Side Note:

In “The Rewards of Performance” it was pointed out that the example plan withheld money paid for SSI cases by Mirixia from performance payments for overall EQuIPP based measures. This is essentially double jeopardy for the pharmacy. With a payment of a mere $12 per case (if completed), a pharmacy spends more on pharmacist salary than they are being paid for the case. To aggravate the matter, the pharmacy’s PDQ may already being hurt by the compliance in question, possibly reducing their performance rating and reward. Now it is becoming apparent that the claims based compliance may not have been an actual problem to start. Withholding the amount in the performance payment just adds insult to injury.