Category: Workflow

Discussions of pharmacy workflow

Of Robots and Med Sync

The Sync Workflow

Medication synchronization is a popular service offered by more and more pharmacies. The premise is two fold. One: create a convenience for your patients such that they only have to stop by the pharmacy once to get all of them medications. Two: allow the pharmacy to optimize its own workflow, as refills are now able to be scheduled like an appointment. This makes upcoming work load more predictable. The theory behind this would seem simple enough. In practice, however, synchronization is a little more challenging.  Synchronization is more than just an auto-refill feature (offered by some pharmacy management systems). It involves actively validating all medications and quantities each sync period. This means a call to the patient and quick calculations of what the patient will need for the next sync cycle.

Medication synchronization at the very basic level is just a paperwork exercise. Simplify My Meds and other programs offer a paper based workflow to plan and execute synchronization. In our practice, after starting with a simple paper based system, it quickly became obvious that the operation could be very time intensive to the pharmacy staff. We realized that the process needed to be automated if we were going to move from a few dozen patients to a few hundred or even thousands of patients. There are a variety of vendors that now offer software services for synchronization. These allow the pharmacy staff to schedule and update each sync cycle. These software packages, however, are no better than the data that they extract from the pharmacy management system, and we have seen many problems arise with inaccurate or incomplete data being pulled by the vendor. This has resulted in our staff spending extra time verifying the data before synchronization can progress. The automated systems have the potential to save time, but until the data can be presumed accurate, we are still not optimizing our staff.

The workflow of synchronization ends on the prescription counter. On a given week, we are able to schedule the filling of sync patients during less busy times of the day because we know what prescriptions need to be filled several days in advance. Even with a reasonable barometer of pending workflow, we still end up congested on our prescription counter. The process could benefit from optimization.  To do this, we need to speed our fill and check cycle, and robotics are an effective vehicle to accomplish both goals.

Rosie the Robot

Awhile back I wrote about our SuperSync program which leverages our Parata Pass robotic “unit dose” packaging robot. Our Pass-208 was named Phyllis (a play on the verb fill) was originally purchased to handle nursing home business. We have more and more patients that are electing to receive their retail medications using this method, and this has helped with our congestion issues. But as fast as the SuperSync patient base is growing, our sync program overall is growing faster. We had to make a decision: Phyllis is going to be a big sister. In the coming weeks, Max (a Parata Max) will be joining the family.

The symbiotic relationship between a robotic prescription filling robot and a med synchronization program is natural. The combination is so natural that currently Parata is offering a free year of the PrescribeWellness medication synchronization software when one purchases the machine. Using Max, our pharmacy can be actively filling med sync patients overnight, and the pharmacy tech or pharmacist can check the medications and get them to the shelf for pickup first thing in the morning.

Workflow Modifications

One of the more interesting discussions we had with respect to our workflow (working toward the upcoming installation of the robot) centered around our pharmacist’s CMM (Continuous Medication Management) program.  Our normal workflow is:

[Intake] -> Data Entry -> Filling -> Final Verification* -> CMM -> Will Call

*In our practice, we are using a New Practice Model, which allows the Final Verification step for routine refills to be completed by a certified technician who has received extra training.

The CMM component for all prescriptions (regardless of the person doing final verification) must be done by the pharmacist.

In our discussions, our Medication Sync program starts with the pharmacist doing a reconciliation of the patient medications each sync period. Our workflow, therefore, could be modified to move the CMM to the beginning of the model along with the reconciliation done by the pharmacist:

CMM -> Data Entry -> Filling (overnight by robot) -> Final Verification* ->Will Call

This further decreases congestion on our counter as a significant number of prescriptions can be filled overnight and checked by a technician and moved directly to will call. The only issues are

  1.  how to segregate new prescriptions from refills at the robot level and
  2. How to segregate Sync refills from non-sync refills

Both of these issues can probably be solved by minor modification to our clinical software system (PharmClin), which is used at the point of final verification.

Closing

While the OnePass packaging option (the Parata Pass 208) is gaining in popularity, we are also growing our regular sync customer base by leaps and bounds. Our goal is to have 30% of or customers on a sync program within the next 12 months. We have enrolled 150 new patients in the last couple of months and currently are at more than 250 sync participants. This change in our workload has lead to some issues with congestion on our prescription counter. Leveraging robotics in our workflow is one way we hope to enhance our workflow. The main goal, as always, is to be sure our pharmacists are free on the counter to perform CMM on every patient picking up prescriptions, making every encounter with the patient count.

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.

Managing Diagnosis Collection on the Fly

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

Certainly of Diagnosis

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

Diagnosis Source

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

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

A Diagnosis Workflow

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

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

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

 

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

 

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

 

 

 

 

 

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

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

 

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

Continuous Medication Management (CMM) and the Profile

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

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

A dispensing profile

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

PMS Profile
Example Profile from Pharmacy Management System

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

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

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

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

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

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

Our clinical pharmacists were also interested in being to quickly spot

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

A Clinical Profile

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

PharmClin Profile
Example profile from a clinically based system

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

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

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

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

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

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

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

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

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

Notes on PharmClin

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

Rx: MTM in small, frequent doses.

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

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

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

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

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

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

Old School is Still Cool

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

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

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

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

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

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

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

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

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

BACKHIPAA ramifications

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

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

Addressing Compliance

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

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

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

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

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

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

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

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

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

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

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