Category: Workflow

Discussions of pharmacy workflow

Major Interactions

Recently, pharmacies failing to address significant drug interactions has made national headlines. But while the pharmacists that failed to address these interaction are certainly at fault, to some degree we all share in the fault. Today’s healthcare world is regularly pushing providers to do more for less. The payor and the patient both want low cost, and with respect to pharmaceuticals, they often getting what they want.

The public’s frenzy for low cost pharmaceuticals has fueled the fire. Pharmacy reimbursement is almost exclusively based on the drug product dispensed, and reimbursement today often barely covers drug cost. Pharmacists are generally not paid for their clinical expertise.  In order to stay competitive, pharmacies have to increase prescription volumes while using fewer pharmacists. Instead of using a pharmacist to perform continuous medication monitoring or drug utilization review, pharmacies are increasingly relying on computers to help the pharmacist identify problems with drug regiments.

Today, pharmacies almost exclusively use a type of software generically referred to as pharmacy management system. Besides handling the record keeping for dispensing prescriptions, the package also includes screening for drug interactions, therapeutic duplication, drug allergies, and drug / disease issues. The problems identified by a software package like this will range from trivial issues with no clinical relevance to life-threatening problems. Because of the enormous volume of alerts generated by these systems, alert fatigue is a real concern.

But while computers can generally find problems, at this point they still lack the clinical expertise to make the important judgements required. A pharmacist still needs adequate time to evaluate the implications of the sometimes lengthy list of potential problems. Given the time, pharmacists can help ensure a patient will have positive therapeutic outcomes while minimizing the associated risks. To emphasize this, let us look at a brief tale from the counter.

We start out with a patient taking Oxybutynin and Nortriptyline. They have been taking this combination for some time now. Looking at the most recent refills, the only item noted by the computer based screening is a late refill on one of the medications. No drug interactions were flagged by the computer, but as it turns out this is not necessarily accurate. If the pharmacist looks at these two medications in a dedicated drug interaction reference, they find that there actually is an interaction:

Pharmacologic effects and plasma concentrations of Nortriptyline HCl Oral may be decreased by Oxybutynin Chloride ER Oral

The interaction is considered a MODERATE risk, with a delayed onset. The reference also notes that there is not a lot of documentation to support this interaction. In this case, the pharmacist recognized the interaction without the aid of the computer screening. The interaction poses minimal risk as the nortriptyline dose is generally titrated to the desired effect. The intervention might involve a brief discussion with the patient explaining the issue.

But the plot thickens: more recently, the oxybutynin was discontinued and a newer medication started. Myrbetric does flag as a drug interaction in the pharmacy management system, but again the system did not display an alert because it was set to only display moderate and severe interactions. The reference used by the software classified the interaction as minor.

But when using a dedicated interaction reference, the story is quite different: the interaction significance is classified as major.

Pharmacologic effects of Nortriptyline HCl Oral may be increased by Myrbetriq Oral. Elevated plasma concentrations with toxicity (e.g. QT prolongation/Torsades de Pointes) may occur.

Note that the effect on the nortriptyline is opposite that of the other drug. The overall risk is much higher for this type of interaction, and one of the listed consequences is Torsades de Pointes, a rare but very significant heart arrhythmia that can be fatal. Fortunately, the pharmacist was given adequate time to consider the new therapy, spotted the interaction, and addressed it with the patient and prescriber.

So the national headlines decrying pharmacists missing important interactions also serves to highlight how important having a pharmacist exercise their clinical judgment is to patient care. Perhaps the there is another interaction that needs to be addressed:

Interaction: poor reimbursement decreases pharmacist staffing.
Significance: Major
Onset: Delayed
Documentation: Strongly suspected

Effect: Ability of pharmacists to perform clinical activities is negatively impacted by current pharmacy reimbursement model focused on inexpensive drug product.

Be sure you make every encounter count!

Not Documented? Not Done!

The other morning, before my staff arrived to work for the day, I took a phone call from one of the group homes we service. They wanted to know if we had received an order for a dose change on a patient’s sertraline. I looked in our systems and concluded that we had not yet received an order. It turns out that I was mistaken. Deconstructing my mistake illustrates a time honored saying: If you didn’t document it, you didn’t do it!

Where’s Waldo?

Like any busy work environment, knowing where to look for information is the key to success. There are limited ways the  order in question, a prescription, can arrive:

  • A faxed in prescription
  • A mailed in prescription.
  • An electronic prescription
  • A phoned in prescription
  • A hand-written prescription brought in by the patient

Once an order has been processed, documentation should be found on the pharmacy management system (PMS). At our pharmacies, the old prescription would be discontinued, and a new prescription would be entered with the new directions. This is what I expected to find if we had processed the order.

Our pharmacy also uses a clinical documentation system, PharmClin, to document all activities as they relate to drug therapy. Any notes or pending issues related to a dose change should be documented in this system. This additional documentation is very valuable to us as it allows us to document many of the important details that complete the clinical story as they relate to the patient’s drug therapy.  PharmClin makes this information easily accessible and retrievable.

I went searching. I found no unprocessed orders. The original order on our PMS still active, and no new prescriptions for sertraline were present. There were also no notes in PharmClin related to a dose change of sertraline. In other words, I did not find Waldo. Based on a lack of evidence, we did not appear to have the order yet.

When my staff pharmacist arrived, I mentioned the call and was informed that she was aware of the order and that it had already been addressed and picked up. I was flummoxed! How could this be? As it turned out, the situation was a lot more complicated than the phone call suggested.

The Details

The patient was taking 200 mg of sertraline daily. The previous day, prescriber decided to switch the patient to escitalopram. My pharmacist correctly identified that the patient should not simply stop taking the sertraline without some attempt to taper the dosage over time and contacted the prescriber’s office. She was told that the prescriber did indeed tell the house staff to taper the dose of the sertraline and provided a flow sheet of the taper. In other words, there was no prescription written to decrease or taper the sertraline. As Homer Simpson says, DOH!

Continuous Quality Improvement

Multiple mistakes were made here. My first mistake was not asking additional questions of the house staff that called. I made the assumption that we were looking for a dose change for sertraline and failed to see the new Rx for the escitalopram. The other omissions were made before I received the call: the sertraline order was not discontinued in the PMS, and the communication with the prescriber was not documented in PharmClin.

The scenario above an epidemic in today’s healthcare environment. The patient is told something by a primary provider, and other providers do not receive notice. The communication from the prescriber to the pharmacy, a form of documentation, was missing. Despite this, my staff pharmacist who dealt with the problem discovered all of the details after they spent time on the problem the previous day. But like the first omission, her documentation was incomplete and largely missing.

Having an tool like PharmClin to document clinical interventions is a great asset to a pharmacy. But if the tool is not used, the benefits are lost. Pharmacists across the country make outstanding interventions every day. The fact is, however, that they largely fail to document their work. In a small pharmacy with few employees, mentally keeping track of issues like this might be manageable, but eventually the system will fail. In a larger pharmacy with many more employees and patients, a systematic documentation system is a must. Remember…Do It. Document it. Done! This is how you can make every encounter count!

 

 

Compliance: Working the Numbers of PDC

Every month I await the e-mail from PQA telling me that my latest EQuIPP scores are ready. If I want to impact my scores, I need to understand the numbers behind them. Today I thought I would remind everyone how the EQuIPP compliance score, the PDC or Percentage of Days Covered, is calculated for a pharmacy.

While compliance might seem like an easy topic, it is far more complicated: compliance for patients is aggregated into a score representing the overall compliance of all patients in the pharmacy. Several assumptions are being made in order to do this.

Defining Patient Compliance

If I miss a dose once a month, most would consider me compliant. But what about missing one a week? A line needs to be drawn somewhere, and EQuIPP has arbitrarily drawn this line at 80% of days covered. This means that someone missing 5 or fewer days worth of medication in an average month is considered compliant. According to PQA, compliance is a binary (YES / NO) attribute. Either the patient is compliant, or they are not compliant, in any given month.

But EQuIPP cannot tell if a patient takes a drug 80% of the time. They are relegated to using claims data. Percentage of Days Covered (PDC) is calculated based on dispensing data from the pharmacy. PDC accounts for early or late refills by looking at the total number of days worth of drug the patient has in their possession during a period of time. For example, if a patient fills a 30 day supply of medication, and then refills the prescription 25 days later (5 days early) the second month, and 40 days later (10 days late) the third month, the PDC would be calculated based on the previous two fills as:

60 days of medication / 65 days elapsed * 100 = 92% — Based on the EQuIPP definition, the patient is compliant.

Note that the assumption is that the patient is out of medication when the refill is processed. This assumption can create erroneous calculations when used over short periods of time. In the example above, this assumption may actually overstate compliance as the patient has only taken 50 days worth of medication in 65 days and was just picking up a refill before going on vacation. It can take several months for the PDC to stabilize and more accurately reflect patient compliance. This creates additional questions for which I don’t have good answers.  For example: what is the start date for the calculation? For a new patient to the plan, it will be their first fill date after they enter the plan. But for a patient that did not change plans, how far back is the first fill date? I am assuming that the PDC is using calculating compliance over some defined period of time, probably 6 to 12 months.

Defining Compliance for the Pharmacy

Every patient included in the EQuIPP measures will be labeled as either Compliant or Non-Compliant for a given month. From this pool of patients, the pharmacy’s compliance rate is calculated. This is simply the number of compliant patients over the total number of patients. A rolling 6 month average of this calculation is the number seen in the EQuiPP dashboard.

Improving Your Measure

As many have observed, the easiest way to impact a pharmacy’s PDC for a given drug category is to target patients just falling short of the 80% threshold for compliance. Consider a pharmacy with a Diabetes PDC score of 80% with 100 patients enrolled. The CMS threshold for this measure is currently 82% and the Top 20% threshold is 92.5%. In order to move the pharmacy above the CMS threshold, two patients that are currently non-compliant need to become compliant. Likewise, moving 13 patients into compliance will move the pharmacy into the top 20%. Targeting patients with compliance between 75-79% will have the best chance for quick and easy success for the pharmacy.

To do this, a pharmacy has to identify the low hanging fruits: the patients falling just short of 80% compliance. The EQuIPP platform has the capability to show you outliers, but in practice, we have not found this very useful. Other products (Mevesi, PrescribeWellness,  McKesson and others), have platforms to help you identify the outliers. These tools are retrospective in nature because they generally use data that is pulled from your dispensing system at regular intervals. All of these tools are designed to be used outside the dispensing workflow to create a list of potential patients to target.  Once you have the list, you need an implementation plan to put the data to work. Other tools, like PharmClin, flag patients during the dispensing workflow, allowing you to target the patient in real time, avoiding the need for additional implementation. I prefer real-time identification of patients for two reasons: it takes less time and effort to identify the patients needing targeting and the data is always current. 

Taking Action

If you are starting with a list of targets, you will need a battle plan. One possible tactic is to place a note or flag on the patient record to alert the pharmacist or technician that the patient is a target when they initiate a new prescription or refill. This allows the pharmacy staff to approach the patient at the time they pick-up the medications. Another method is to contact patients outside the prescription workflow by appointment or by phone. Ultimately, the goal is to initiate a conversation with the patient.

At this point, with the patient in front of me or on the phone, I tend to be careful with how I proceed. Remember, claims data gives us very little real information. The patient may not actually be non-compliant: they may have a very valid reason for their compliance history. For this reason, I always try to be neutral when starting a compliance conversation. I might ask, for example:

I see that your refills for metformin are less frequent that I would expect. Has the dose the doctor wants you to take changed?

We often find perfectly reasonable reasons for PDC based compliance problems. Physician samples, dose changes not communicated to the pharmacy, and alternative drug supplies are commonly seen explanations found in our practice. If the dose has changed, we can fix the compliance problem by getting a new prescription from the prescriber. For other explanations, I simply document the intervention with the patient and revisit compliance in 3 months. Our use of the clinical documentation system PharmClin makes the this easy and automatically allows us to schedule a follow-up for the problem.

Sometimes, I find that the patient doesn’t tolerate the drug well, and has backed off of the dose as a result. The physician may have instructed the patient to do this temporarily, with instructions to gradually increase the dose. Metformin is a common example. Finding this, I work with the patient and prescriber to ensure that the patient achieves the desired outcome without unnecessary effects. This might mean helping the patient with their gradual dose increase, or recommending a different drug entirely. Either way, the “compliance” problem can be both documented and successfully addressed.

Addressing Non-Compliance

Most pharmacies use a medication synchronization program to address compliance problems. While this is a valid plan, it is most appropriate in the case that a patient forgets to order refills or stop in to pick up refills. I am careful and investigate a host of other possible reasons that the patient doesn’t refill their prescription on time before asking them if they are interested in synchronization.  Again, I proceed with caution. Is the reason financial? Might the reason be related to the time of administration or restrictions on what can or cannot be taken with the medication? I work hard to understand the reasons before creating a patient specific plan. If the issue is financial, finding a less expensive alternative might be needed. If the patient simply struggles with getting to the pharmacy, offering our delivery service is a reasonable intervention. Finally, if the patient forgets to order refills or has difficulty remembering to pick up medications at the pharmacy, the benefits of synchronization are a great way to help the patient become more compliant.

MedSync

One final note about medication synchronization. While this tool can be very successful in addressing compliance issues, the reasons for its success in our pharmacy are not what you might think. Filling a prescription on a regular frequency will, of course, correct the claims based PDC score. But in our pharmacy, med synchronization’s success comes from the increased level of engagement our staff have with the patient. By calling the patient each month, we can ascertain if any changes have been made and gather important informant about any problems the patient is experiencing. Additionally, we are able to approach the patient about other topics including what their therapeutic outcomes are and if they are meeting them. In short, we work hard to make every encounter count!

Sharing the EHR

Back in December, Drug Topics published Kroger pharmacy’s shared EHR pilot project a success, which described a study completed by an Ohio chain and a local family practice provider. The essence of this study was to observe the benefit of giving a select pharmacy access to the medical provider’s Electronic Health Record (EHR).

This study was certainly not unique, though. Many pharmacies have created similar collaborations. Our pharmacy, for example, has access to our shared patients with a local hospice and a nursing home. The advantages described in Drug Topics are certainly real. Access to a this additional information enables the pharmacist to better ensure that patient is receiving the most effective and safe therapy, and that the desired outcomes are met.

But not all is rosy in these scenarios. The current lack of integration between pharmacy management systems and EHR of the office or organization creates an extra step in the clinical workflow for the pharmacist. Any documentation the pharmacist has to make must be made both in the EHR and the pharmacy management system.

The problem is not limited to the exchange of information between the pharmacy and the office. Collaboration between general practitioners and specialists is hampered by the lack of communication between different vendor’s EHR implementations. This single fact represents one of the biggest reasons that the facsimile (fax) still remains a predominant tool in healthcare. Paper is a common denominator as the document can be scanned into the EHR.

Our Experience with the EHR

In our pharmacies, or employees regularly have multiple systems running on their workstations. This includes our pharmacy management system, our clinical management system (PharmClin), MTM management systems like Mirixa and Outcomes, and multiple EHR windows for the offices with which we routinely collaborate. This requires significant attention to detail and a bit of computer savvy.

Any given problem found by our pharmacists is entered into at least two different systems. Fortunately, many of these systems are free-text based, and our pharmacists can simply copy and paste information between applications to minimize the extra work required to complete documentation on all platforms.

A bigger problem, however, is the reciprocal communication channel. The doctors and nurses at the remote offices do not have a way to easily pull information from the pharmacy’s prescription system. The most common information prescribers are interested in is an accurate medication profile. In lieu of a two way exchange, a copy of the patient’s medication profile with all of our notes by our clinical documentation system (PharmClin).

Despite the challenges of working with multiple EHR products, the benefits still far exceed the associated cost. The improved communication allows our pharmacists to better identify problems in the patient’s drug therapy, monitoring plans and therapeutic goals.

As we continue to navigate the currently evolving transition in pharmacy toward a care centered model, we are continuing to look for new ways to improve communication with the providers. This means that we are constantly connecting with the providers in an attempt to improve our communication.

Five Trends in Pharmacy that You Should Watch

Tele-pharmacy

For they un-initiated, tele pharmacy is a relatively new concept. With pharmacies being unable to sustain a practice in areas without sufficient population density, many rural communities are left without access to a pharmacy. Tele-pharmacy is a potential way to bring a pharmacy back to an under-served population by decreasing the cost of running a pharmacy.

The math, however, appears to be suspect. Running any pharmacy includes significant overhead: technician salaries, rent, drug product, and pharmacy specific computer systems. Tele-pharmacy adds additional costs in the form of software and network requirements, while reducing only one expense: the pharmacists salary. Implementing a tele-pharmacy would only be able to lower the cost of running a pharmacy by some fraction of a full time pharmacist’s salary. Keep in mind a pharmacist still needs to be accessible to check prescriptions and counsel patients. The concept of tele-pharmacy simply allows one pharmacist to manage more than one site.

The physical lack of a pharmacist at a pharmacy is a scary proposition, both personally and professionally. The number of hours our pharmacists spend face-to-face with patients each day is significant. This type of accessibility is what enables our pharmacists to optimize each of our patients care. Tele-pharmacy limits that access significantly. If tele-pharmacy is limited to locations not served by a traditional pharmacy, I understand the compromise. But this technology is being pushed as a method to combat the ever decreasing reimbursement pharmacies are seeing. Give the questionable savings this technology provides, tele-pharmacy is troubling.

New Practice Model

In states like Iowa, the Board of Pharmacy is piloting the use of technicians checking the work of other technicians. This is strictly limited to refills; pharmacists still must perform final verification on new prescriptions and counsel the patient. The goal of the program is to free the pharmacist from the final verification process so they can focus on patient care. This model makes a lot of sense, and when used in this way actually can increase overall accuracy and significantly enhance patient care in the pharmacy.

The concept, however, is could be significantly abused if decreasing business expenses in the form of salary savings were allowed to supplant the current goal of freeing the pharmacist to perform patient care. Like tele-pharmacy, this technology could ultimately be used to significantly decrease patient access to pharmacists. The development of this trend deserves continued scruitny.

Mail Order Pharmacy

Mail order pharmacies leverage automation to create an extremely efficient work-flow. They are highly tuned dispensing centers, and the pharmacists working here perform final verification on mind-boggling numbers of prescriptions each day. Patient communication is limited to patient initiated phone calls to a pharmacist-staffed call center.

Mail order prescriptions has a place in the pharmacy world. It offers a limited service with certain advantages appealing to some patients. On the other hand, mail order pharmacy cannot provide acute care. This creates a significant fragmentation of care, as the local pharmacist has little knowledge of the patient and their conditions when presented with a new medication.

Mail order pharmacy presents a unique set of challenges for pharmacists out in the community. The increased risk for significant drug mis-adventures mail-order creates is scary.

Prescription ATMs

For lack of a better description, technology has been able to create a robotic pharmacy in a box. These units are being sold to physician offices and clinics. The machine contains a limited formulary of medications and is designed to provide the patient with their initial supply of both acute or maintenance medications.

The potential for problems is significant with this type of technology. While medical professionals are certainly in proximity of the units, there is no pharmacist involved to screen for drug therapy problems the prescriber may have missed. Counseling is limited to whatever the prescriber managed to fit into their encounter.

While the restricted formulary and the limitation to the first fill limit the damage such technology might cause, certainly there are going to be cases where a pharmacist’s knowledge would be beneficial. Unsupervised dispensing is both frightening and potentially dangerous.

Central Fill

Central fill is becoming increasingly popular with smaller chain pharmacies. It leverages the efficiencies of a mail-order pharmacy with a local pharmacist as long as the patient does not need the medication until the next day. A central fill pharmacy typically will heavily leverage automation, requiring few technicians and pharmacists. Central fill could also be leveraged with a medication synchronization program to further enhance efficiencies.

Besides the advantage of efficiency, central fill has the potential to free the local pharmacist to spend more time working with patients at the time they pick up their order. In fact, using a model like this could ultimately create an almost office-like pharmacy practice. If a high percent of patients were synchronized and picking up all of their medications at the same time, the pharmacist could sit down with every patient  to perform continuous medication monitoring.

While the potential for central fill to advance the profession of pharmacy exists and is exciting, it also has a dark side. Central fill could also be used to create a mail-order like workflow, removing access of the patient to the pharmacist. Pharmacists need to be aware of this potential and address it before occurs.

Diminishing the Value of the Pharmacist

While some of the trends above are already embedded in our healthcare system, others are just appearing. Every one of these, however shares a common trait: they either do not value, or have the potential to diminish the value, of pharmacists.

If this is the value the public puts in the profession of pharmacy, maybe I am in the wrong profession. Fortunately, I hear the exact opposite repeated time after time, day after day. When given the option of access to a pharmacist, most patients jump at the opportunity. Why, then, does the public and our elected officials regularly look to take the pharmacist out of pharmacy?

Without pharmacists, medications become terrifying. Without a pharmacist, you just have medication. The pharmacist is the care component of medications. Don’t let anyone take the pharmacist out of your pharmacy.

 

Why yes, we ARE are messing with your workflow

During a recent discussion with a pharmacy management systems (PMS) vendor, my business partner was describing our workflow and how we leverage the pharmacist. The goal was to help the vendor understand what we would like to see their software enable: a patient centered workflow. Their immediate comment was “you are messing with our workflow!”

That was the point. The PMS workflow has evolved over the years into a single focused entity: to fill a prescription. The patient, as a focus, is largely gone from every system currently marketed. PMS feature lists are generally focused on increasing efficiency of the dispensing process, tracking the prescription from beginning to end. Every PMS offers an some “clinical” screening for therapeutic duplication, drug and disease interactions, allergies, and compliance, but these are limited in scope to the prescription being filled at the time.

Standard Workflow
Figure 1

Figure 1 above represents a typical prescription focused workflow. The steps typically involving the pharmacist are shown in a brown box, with steps traditionally handled by technicians colored green. This is a traditional assembly-line type workflow, but notice that the pharmacist has to jump-in at several locations. Modern pharmacy management systems minimize work to reduce the impact of this to the pharmacist

The Workflow of the Future Pharmacist

In order to modernize the pharmacist’s workflow, patient-wore clinical information needs to be infused into the final verification step. This includes a summary of addressed and unaddressed clinical issues like drug-drug interactions, drug-disease interactions, therapeutic duplications, compliance issues, clinical outcomes, and monitoring currently being monitored. This information should not be limited to just the drug being checked: modern pharmacists emphasize patient care instead of just checking the prescription.

This workflow might be represented by Figure 2 below.

Modern Workflow
Figure 2

The difference in this workflow is the injection of all clinical data at the final verification step. Unaddressed issues with other medications are presented to the pharmacist to be addressed as necessary. Additionally the pharmacist is given the opportunity to document the intervention(s) at this point. These interventions become a part of the clinical record and are available for the next time the patient is reviewed.

The data injection and the documentation steps–the basis of the commercial product PharmClin (Patent Pending)–are as simple as they are innovative. This expansion of the final verification step creates a patient-focused process that we call MTM-on-the-run. While this workflow might seem daunting to some, with some basic training and a well engineered software package, the process is quite satisfying.

Taking it to the Next Level: An Ultra-Modern Workflow

The truth be told, there is really no reason that technicians could not be used for the entire Intake to Will-Call workflow. In some states, including Iowa, some pharmacies are studying technicians checking another technician’s work (performing the final verification step). The purpose of this type of workflow is to free up the pharmacist to focus more on the clinical aspects of the practice. In this case, the workflow might look more like Figure 3 below.

UltraModern
Figure 3.

Notice above that the pharmacist is still tasked with the data-entry check for new prescriptions. This is currently still required in Iowa under the special rules covering this type of workflow. As a pharmacist, this workflow is very liberating. Instead of being mired in the details of checking between one and twenty prescriptions, the pharmacist can focus on the clinical profile information for each patient represented in the order. They can review previous intervention notes and create new notes. When the patient or their representative arrives at the pharmacy to pick up medications, the register clerk can summon the pharmacist to counsel on any new medications and/or follow-up with interventions flagged by the pharmacist that performed the clinical review.

Change is Coming. Don’t Look Back, We Aren’t Going There…

Giving up participation in the dispensing workflow is a scary proposition for some pharmacists that have spent entire careers performing little more than this function. When we talk to pharmacists at meetings, it is obvious that there are two types of pharmacists: those that look forward to moving to a model like this,and those that don’t know what or how they would perform in a new, modern workflow.

But this much is certain: reimbursement for product (dispensing) is not going to magically return. Maximizing efficiency through a technician driven workflow with added efficiency through robotics or other technologies will free the pharmacist to be a pharmacist. Pharmacists need to apply their clinical knowledge to care for patients. The days of paying a pharmacist to perform final verification of a prescription (a dispensing function) are rapidly coming to an end.

While I will not claim to know what pharmacy will look like in a few years, I am certain of two things. Firstly, it will be very different than the current dispensing-driven model. Secondly, pharmacists will be increasingly paid for their contribution to patient care or they will be be missing entirely from the flow chart. Make every encounter count today, so you can continue to do so tomorrow.

Baby Maximus Arrives

Several weeks ago, this blog discussed our use of a Parata Pass robot and our implementation of SuperSync. At that time, we announced (somewhat like proud parents) that our Parata Pass (named Phyllis) was going to be a big sister. Well Maximus (a Parata Max) entered our pharmacy almost 2 weeks ago and this blog post will address the details of preparing for and implementing automation in our retail pharmacy space. We will discuss the results of the implementation as they relate to improvements in workflow and our MedSync program in a later post.

The Purchase Details

Before finalizing the purchase, several decisions were made with respect to features that would be shipped on the machine. A couple of these decisions were made without a complete understanding of implications. And while a better understanding might not have changed the decisions made, I believe that these questions deserve a bit of discussion as it might benefit someone else down the road.

Vial Sizes. The Parata Max has the ability to label, fill, and cap, and sort prescriptions (start to finish). It is truly a marvelous example of modern automation. The machine can be equipped to use two different vial sizes. Our machine shipped with the standard 13 dram / 30 dram vial size combination. This is well suited for most retail implementations. The other option is the 20 dram / 40 dram vial size combination. This combination may be better suited for pharmacies that deal in a significant 90 day fill business. Be sure your choice of vial sizes matches your needs as changing the vial configuration is not something  that is easily accomplished after the machine ships.

Standard vs. Locking Cells. The second item that was discussed prior to placing the order was the option of locking cells. The sales person emphasized the use of locking cells as being important for scheduled (e.g. narcotic) medications. While locking cells are useful for this, they also offer an additional safety feature. With locking cells in the machine, the user (often a technician) can only have ONE cell open at any given time, minimizing the chance that a mistake is made during the filling process. Proper training, of course, also minimizes this risk, and ultimately the added cost was not worth this for us.

The Delivery Game Plan

Like any major addition to a pharmacy workflow, a lot of work was required after the purchase of the equipment but before the delivery and installation. This is very similar to parents preparing a nursery for a new arrival. A lot of attention is paid to details beforehand knowing that after the delivery there will be a lot going on. Parata, of course, has a detailed handbook of requirements that needs to be followed. These included:

  • Adding a dedicated power outlet on its own breaker for the robot
  • Network access near the installation point
  • proper space around the installed robot (three feet of open space around three of four sides and one foot on the end)
  • consideration of workflow

In our case, a small remodel was necessary to make space for the machine. The delivery crew visited about 1 week before installation to be sure the equipment could be brought into the space and all installation requirements would be done by the time they arrived for installation. I’m not sure they were confident that everything would be done in time, as the “nursery” looked far from complete at that point. Like most remodeling projects, this one finished the night before the installation was to occur.

The Arrival

After much anticipation and preparation, the big day finally came. As this was our second delivery, we were likely a bit more prepared and relaxed. Unlike the delivery of Phyllis 2 years earlier, which involved the equivalent of a c-section, Max breezed into the pharmacy without any problems. It was not until after delivery that a few problems surfaced. The “doctor” in the delivery room (the Parata technician) quickly discovered that Max had a birth defect. He was wired incorrectly at the factory for our installation (the power and network access points were on  the top of the machine instead of the bottom). Dr. Zach, however quickly created a temporary fix and scheduled a minor surgery the next day to fix the problem. Outside of this, installation and training occurred without any significant difficulties, and within a few days we were up and running. Like any new parents, we spent the next several days getting to know our new arrival.

 

IMG_4465 (1)
Preparing for delivery

The installation technician taught us how to change the labels, add vials and lids, and (of course) how to “feed it” (load) medications. Boy, can this boy eat! By the time the installation technician left us (three days later), we had only filled about 100 of the 186 different cells. At one week, we were filling about 50% of our total prescription volume on the Parata Max.

IMG_4473 (1)
Max in the “nursery”

Coming soon, we will share our experiences with now automation has improved (hopefully!) our workflow and our Medication Synchronization program.

Letting the Patient Update your Records

Recently I spent several weeks navigating a small health issue that involved outpatient surgery. When checking in at the clinic, the receptionist handed me a tablet and asked me to complete a History of Present Illness (HPI). I did not think too much about this until a week later, when one of my colleagues asked me what our I considered to be the most common intervention our pharmacists made when working with patients. The answer, for us, is a general form of medication reconciliation. We do it every day, though the form the intervention takes varies from case to case.

In our practice, and I am sure many others are not any different, we deal with a significant number of patients that are taking their medications according to the instructions provided by the prescriber. The problem is that these directions don’t necessarily match what was written on the most current prescription. We are routinely the last to know about changes that are made in our patient’s therapies. What starts out looking like an issue with compliance really becomes an exercise in medication reconciliation.

The thought that occurred to me was this: what if we could have the patient review their own medications from time to time and alert us to any changes that have occurred? Using a tablet type device that the pharmacy staff could configure to perform this query would be an excellent use of this type of technology, but even using a simple paper copy of the patient’s profile would be a step forward.

During the time that the patient reviews the accuracy of their profile, they could also be queried about other information related to their drug therapy. Example might include recent lab values (e.g. INR or A1C) or possible Adverse Drug Reactions (ADRs). The possibilities are almost limitless!

The Implementation

Using PharmClin (our clinical software package), a medication snap-shot of the patient’s profile can quicky be printed. By attaching this to a clip board, the patient can review the list while they wait. During the process of generating the medication list, the pharmacist can also review other desired data they wish to collect, and print these for inclusion with the profile. Many common items we use are pre-populated within PharmClin (for many important drug classes) to allow quick data entry by the pharmacist.

The goal is to provide a quick review and data collection period during the patient waiting period. When the medications are ready, the pharmacist can quickly review the information for additional questions and the patient can be on their way.

This workflow would not necessarily work in all situations. If a patient calls ahead, for example, they may be in a hurry to leave (not expecting to review their profile or answer additional questions). The workflow for medication synchronization patients, likewise might need some adaptation. For this reason, any implementation needs to be fluid, and the records to be presented to the patient should be able to be generated quickly and on demand. In cases where the patient is not currently available to perform a review, simply asking them if they might have time for a quick review at a later date (maybe the next time they pick up) could plant the seed and encourage them to make time at their next visit.

Conclusion

Taking the initiative to perform medication reconciliation is a valuable service, and this can be facilitated by leveraging the pharmacists access to the patient. Invariably, discrepancies will be discovered, leading to new interventions with both the patient and the prescriber. An implementation like this one is yet another example of making every encounter with the patient 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.

Dispensing Software vs Clinical Pharmacy

keBack when I was a pharmacy student, there were still some pharmacies that kept prescription histories for their patients on paper and typed prescription labels on an electric typewriter. The Bates Number Machine was still a staple of many practices. Today, with the advances in computers and electronics, modern pharmacies in the United States use computerized Pharmacy Management Systems (PMSs otherwise known as dispensing systems) almost exclusively.

Today’s modern pharmacy software has helped improve workflow, and ensures accuracy in the dispensing pharmacy. New features are being added to these systems regularly. Today, the point of sale (register) is usually integrated, as is the telephone system (by use of an Interactive Voice Response or IVR system). Some vendors have created iPad based delivery apps and even added limited integration with clinical services like Outcomes and Mirixa. Overall efficiency in pharmacies today is very high, in large part due to these software packages.

But today’s pharmacy systems are really still one-trick ponies. Despite all of the “new” features, these systems still are centered around the dispensing function. Most pharmacists and pharmacy owners becoming aware that dispensing revenue is significantly down (despite increased prescription volume and sales) in pharmacies today.

Right now, the profession of pharmacy is in a transition period; moving from product based reimbursement to service based reimbursement. Traditionally, the services provided by pharmacists and pharmacies have been (unfortunately) given away along side the paid drug product. The payment received for the drug product historically provided enough profit to cover the professional time the pharmacist spent with the patient. Current payment for product, however, is drying up at an alarming rate, and the transition from product based reimbursement to service based reimbursement is still only in its infancy.

The discussion of pharmacy management systems, and the transition of pharmacy as a profession, are intrinsically related. In order to move the transition of pharmacy forward (and ultimately achieve “provider” status with both the State and federally, with Medicare), pharmacists need to prove that what they do outside traditional dispensing is intrinsically valuable.

Almost every newly minted pharmacist since the early 2000’s received a clinically oriented degree, a doctorate in pharmacy (Pharm.D). Many older pharmacists have even gone back and added this degree. The application of the clinical skills vested in these pharmacists, however, is not encourage by many employers. Many pharmacies continue to emphasize dispensing and prescription volume. And why wouldn’t they, because that is (still) what gets them paid.

Despite the lack of clinical emphasis in their workplace, many pharmacists continue to employ their clinical skills. The next obstacle for clinically motivated pharmacists, is their dispensing oriented pharmacy management system, because it is not designed to document the care these pharmacists are implementing. This is a significant problem facing the profession. If we cannot readily document the value we provide, how can we move forward, and transition toward an actual professional fee, or obtain provider status?

This is a real problem for today’s proactive pharmacists, and the problem is going to grow exponentially as the expectation that pharmacists demonstrate their value to the health care system grows. Pharmacies need a way to seamlessly document their actions, recommendations, and overall value to patients and the system, and dispensing focused software is woefully inadequate.

In our practice, the answer was to create our own documentation system to accumulate the interventions our pharmacists effect every day. Over the course of almost a decade, we massaged and integrated the software to the point where every one of our pharmacists record important information and face to face encounters with patients, documenting what was done, what needs to be done, and any communication with other health care providers. Thru tight integration with our dispensing system, the software has become an extension of our business model. Today the product is known as PharmClin. The core concepts of PharmClin are fundamentally simple, but put taken as a whole, and in the context of a clinically oriented practice, the package is so powerful and innovative that it is patented.

Many pharmacists have seen PharmClin in use (by visiting our pharmacies) or have seen images of the product in slides at national meetings. When pharmacists see what we are doing and how we are using PharmClin, most immediately “get it” and want to be able to do the same things themselves. What needs to happen next, is to bring this concept to the rest of the profession. This type of activity and documentation will be a game-changer for our profession. It emphasizes how every pharmacist can make encounters with their patients count.