Leveraging technology to enable a high-touch care model

It’s called medication synchronization, and the concept is simple enough — shifting patients to a synchronized, easy-to-comply-with, once-a-month prescription refill program so they can pick up all their medications with one visit to the pharmacy each month, instead of multiple trips.

Med sync has numerous benefits to patients, payers, prescribers, and, of course, community pharmacy. Early adopters are leveraging different models to increase medication adherence; to decrease gaps in therapy; to increase the number of first fills that actually get picked up by patients; to provide a higher level of patient care; and to increase pharmacist, patient and prescriber satisfaction. The increased focus on patient consultations is also an important first step in community pharmacy’s enhanced role in an outcomes-based healthcare model.

With all of the excitement, interest — and burning questions — about medication synchronization, DSN recently assembled five of the top technology providers in the industry for a virtual roundtable discussion.

DSN: How does your technology seamlessly integrate with retailer pharmacy systems?

GEORGE OWENS, SVP BUSINESS DEVELOPMENT, PDX: Business and technology are not on separate tracks but rather are intertwined. When we are talking about the new outcomes-based pharmacy business model, I think we would all agree that the core ingredient is a central patient record — one where the data has been cleansed and merged. This type of database can then be set to create a portable, interoperable healthcare data record. The ease at which patient data is transported and dispersed to various healthcare programs defines the efficiencies of that business. Healthcare data will soon be required to be interchangeable between healthcare providers, which means all of a patient’s healthcare data — including ICD-10s and labs — belongs to the patient. The patient should be able to easily access it and move it at any time. It all falls back to an integrated, well-constructed, centralized patient database, and pharmacy is the most logical healthcare provider to offer that.

MATT NOFFSINGER, SVP SALES AND MARKETING, TCGRX: Ten or 15 years ago, integration was more difficult than it is today. Automation, inventory management and workflow software have been integrated time and time again and are now commonplace. It is particularly helpful that the pharmacy systems have been moving toward more standardized interfaces, such as HL7.

MIKE COUGHLIN, PRESIDENT AND CEO, SCRIPTPRO: It is possible for technology to seamlessly integrate the entire patient/pharmacy interaction experience — from selecting the pharmacy, time and method for receiving the prescriptions to follow-up support. This can be accomplished through a unified system that is designed to cover all the bases. ScriptPro offers such a system through its Perfect Integration model that supports the entire pharmacy process. It also integrates such functions as long-term care support, compounding, 340B processing and third-party management. However, other than the large chains, most pharmacies operate with a conglomeration of systems that are far from integrated and certainly not seamless. And the large chains typically avoid the complexities of long-term care, compounding and managing delivery routes. So, this is an ideal to reach, but far from the real world. ScriptPro truly has integrated all of these functions into a seamless platform that is unmatched.

TOM MULLEN, DIRECTOR OF BUSINESS DEVELOPMENT AND STRATEGY, MCKESSON PHARMACY SYSTEMS AND AUTOMATION: Most of the medication synchronization tools on the market require an automated patient data feed from our pharmacy management system to their system. They then apply their algorithm to the patient data to determine the best synchronization option for the patient. If the pharmacy management system includes other features that support a synchronization program, then those data sets also can be sent to provide additional analysis. For example, our EnterpriseRx system includes an auto refill feature that allows the patient to enroll in an automated refill program that’s used to give the pharmacy more flexibility when managing the synchronization of a patient’s medication.

FRANK SHEPPARD, CEO, ATEB: The better a system integrates with the existing infrastructure, the more likely it is that the pharmacy staff will use the tool. With Time My Meds, Ateb’s comprehensive medication synchronization solution, Ateb leverages pharmacy data and fits well into a pharmacy’s existing workflow. Medication synchronization requires pharmacies to shift from an exclusive focus on individual prescriptions to engaging patients holistically to improve health outcomes. To ease this transition, Ateb has created the Time My Meds portal to augment the capabilities of the pharmacy management system. We believe that pharmacies do not need to undergo large changes to implement a med sync program; however, pharmacies require additional tools to effectively identify and manage patients through the process. With Time My Meds, the pharmacy management system continues to function as it would normally: process refills, adjudicate, identify drug interactions and maintain prescription history. Ateb complements this process by identifying, tracking and managing patient engagement, leading the pharmacy team through the process; thereby optimizing efficiency and yielding positive clinical and economic outcomes. Further, Ateb has integrated a staff of pharmacists and pharmacy technicians into our development teams, capitalizing on their knowledge of today’s pharmacy workflow, as well as the growing clinical aspects of community pharmacy. This ensures that Ateb makes the right judgments on how to integrate our platforms with the existing pharmacy systems. We also work closely with pharmacy system vendors to continuously improve our ability to integrate our technology as seamlessly as possible with them on the pharmacy’s behalf.

DSN: What outcomes and data are available to support medication synchronization programs?

COUGHLIN: Adherence is clearly an area that could use some focused attention, and med synchronization would seem to be a way to promote adherence by making it simpler for patients to manage their refills. ... This information would be useful.

OWENS: We can all remember the early adopters of med sync using a delivery system that placed the total dosage of several medications into a visible dose-pack on a continuous roll — up to one month’s regimen. It was originally meant for caregivers and older adults. It worked great, and everyone loved it. And I’m certain it increased persistency. The downside was the complexity of the patient’s drug regimen. If a single dose changed, the entire package needed to be re-worked. A new and much improved business model appeared through the hard work and initiative of the executives at Thrifty White Pharmacy. They established an appointment-based model, or ABM, that called the patient one week prior to their visit to Thrifty White’s patient care center to see if the patient has had any adjustments to dosage or has visited a hospital or clinic over the past month. The appointment time was used for counseling on a wide range of health topics from flu shots and vaccinations to medication information and so on. Thrifty White sponsored a research project at the Virginia Commonwealth School of Pharmacy with two Ph.D. professors conducting the research to see how well their med sync program was working. The analysis found impressive results. The white paper is available online.

SHEPPARD: Ateb has been privileged to work with Thrifty White, the National Community Pharmacists Association and others to perform controlled studies on the impact of med sync on medication adherence. The results have been phenomenal. Most Time My Meds patients achieve nearly perfect adherence rates, whether measured with proportion of days covered, or PDC; medication possession ratio, or MPR; or average days on therapy, or ADT. Countless studies have shown that the average patient fills less than half of their ongoing prescriptions for maintenance medications, yet Time My Meds patients significantly fill more prescriptions per year. Further, the impact of medication synchronization extends well beyond improved adherence with the synchronized medications; in fact, patients who are using multiple pharmacies tend to transfer more of their prescriptions to their synchronizing pharmacy. Additionally, prescribers recognize the adherence benefits and begin to send new patients to pharmacies with medication synchronization programs. Pharmacies are much more likely to recognize gaps in therapy for patients whose medications they synchronize, which also leads to more new prescriptions. Two key factors in the success of Time My Meds have been the efficacy of the pharmacy teams in adapting to serving patients in an appointment-based model and the ability for Ateb to help pharmacies quickly and meaningfully use their data. Ateb provides analytics to evaluate patient adherence metrics; help identify the best candidates for engagement; and determine who, how and when the pharmacy should be reaching out to patients. Ateb also provides the tools for the pharmacy team to measure elements that are working well and those that require change. Helping pharmacies gather, manage and use their own data is perhaps the most important means by which Time My Meds accomplishes seamless pharmacy integration.

MULLEN: There are many studies and pilot programs showing very positive results. The Centers for Medicare and Medicaid Services’ Congressional Budget Office predicts that Medicare will see a return on investment ratio of 4-to-1 due to positive impacts from medication adherence. McKesson customers piloting their own medication synchronization programs have seen refills increase from 7.4 per year to 10.2 for approximately 6,000 patients. We’ve also seen pharmacist-led adherence programs reduce hospital readmission rates by 50% in a sample size of 800 patients. The evidence of positive impact is certainly available.

NOFFSINGER: TCGRx has been particularly fortunate to work with such innovative companies as Thrifty White, who has really taken a lead in the med synchronization initiative and the deployment of adherence programs. Innovators like this have been publishing data for a long time, and now there is an abundance of knowledge on the patient benefits of med synchronization, as well as the benefits to pharmacy and the healthcare system in general. I personally feel that the National Community Pharmacists Association has taken a strong lead in helping to educate its customer base, and it has some great tools on its website.

DSN: What are the best pilot programs out there today that represent best practices?

MULLEN: We believe some of the more popular and successful programs out there today include Ateb Time My Meds prescription sync solution, RxSync program by the University of Mississippi, the Simplify My Meds program from the National Community Pharmacists Association, and MTM solutions from OutcomesMTM and Mirixa. Another promising solution available today is by RxAnte, Inc. This company provides a predictive analytics tool that helps improve the ROI of adherence programs.

NOFFSINGER: Thrifty White is clearly a leader in this regard. Bob Narveson has been committed to proving this model out and is working hard to continue providing the justification to expand med synchronization across the entire market.

OWENS: There is a wide range of med sync programs in place. In addition to the Thrifty White program, I’m impressed with what Albert Garcia, EVP at Navarro Discount Pharmacies and president of Navarro Health Services, has put in place. They do their own med sync in-house and have more than 1,000 patients synchronized. They work with managed care to improve adherence, using not only synchronization, but also text messages and e-mail reminders for refills, refill pickups and adherence consults. They have beeping caps, free home delivery, online refill capabilities and a 21-agent call center to manage patient compliance.

SHEPPARD: Ateb began building the Time My Meds portal more than four years ago and has been providing the Time My Meds solution for more than two years. Certainly, Thrifty White has been leading the charge in how med sync programs are scaled within a pharmacy chain. Bob Narveson and his team have created a culture and a vision of what pharmacy must do to make a difference, and they live that vision every day. Ateb is working with forward-thinking pharmacies that have been running med sync programs or have decided to activate med sync programs. Ateb brings tools to the table that allow pharmacies to scale the number of enrolled patients to meet opportunities in their markets. Pharmacies with existing manual medication synchronization programs that have transitioned to Time My Meds have grown patient enrollment in the program significantly. The pharmacy’s workflow starts to change from reactive to proactive once a pharmacy reaches more than 70 patients enrolled. Patients enrolled in Time My Meds have multiple chronic medications; however, there is no longer a need for the patient to contact the pharmacy to request a refill, as the pharmacy is providing outreach to the patient on the pharmacy’s schedule instead. Time My Meds adherence results are very consistent with published results from Thrifty White and VCU, showing that Time My Meds active pharmacies better manage their inventory levels if the pharmacy “knows” when the prescription is to be filled. Several powerful features distinguish Time My Meds from other med sync programs. Ateb provides quick and steady feedback regarding pharmacy performance. In collaboration with a number of our pharmacy partners, Ateb adds elements of gamification to enhance this quality. Additionally, Time My Meds has robust predictive analytics and patient selection capabilities. Time My Meds utilizes predictive analytics to identify the best patient-candidates for enrollment, as well as forecast patient adherence once enrolled.

COUGHLIN: There are a number of leading independent and health system outpatient pharmacies that have implemented the seamless Perfect Integration approach with good results. Others are looking at these operations and giving serious consideration to moving toward this model. There certainly are a lot of examples of how not to do it. I recently met with a large health system group that admitted that they let several key pharmacy people select what they considered to be “best of breed” systems for their individual areas and then tried to interface all of them. They never achieved that integration, and the team members who took this approach were recently replaced by new management looking for a new direction.

DSN: What are the challenges and opportunities between outsourcing vs. building your own?

OWENS: Ahh, the age-old question: buy vs. build. Having been on the pharmacy technology side of this equation for 30 years, I would have to lean toward outsourcing. What seems like a straight-forward, simple, inexpensive project nearly always turns out to be a slippery slope: more complex, inordinately more expensive and time-consuming. There are a number of excellent med sync programs already on the market. “Simplify My Meds” is a well-crafted National Community Pharmacists Association member program. And the Pharmacy Quality Alliance endorses the ABM model that Thrifty White created. In the first quarter of 2014, PDX is releasing med sync functionality called SyncScript. It will be available in both the Enterprise Pharmacy System and the PDX Classic Pharmacy System at no additional cost to our customers. We are making it available because we believe it is part of a critical platform for the outcomes-based reimbursement model required by the Centers for Medicare and Medicaid Services. To build SyncScript, we first recruited several of our chain customers to participate in a focus group for input and collaboration. Using a special development process, we can create functional screens in four-week cycles. This allows our focus group to really get hands-on with their review and input.

Some of the challenges and input we received along the way include the following:

  • The program requires a “touchpoint” prior to sync, usually 7 to 10 days prior, so notification to the pharmacist is necessary.
  • Appointment day offers such health-related opportunities as flu shots, medication therapy management consults and discharge counseling. We addressed this in our patient CARE module.
  • Heads-up compliance flags initiated through GAP reporting tell the pharmacy which patients are noncompliant with their maintenance medications. Those parameters will be pharmacy-driven, such as “script not picked-up within 10 days,” etc.
  • Filters were established using AutoFill logic: sync for one month at a time, days’ supply, or partial fill required. (Reimbursement for the billing for partial fill will be supported soon by Medicare.)
  • The entire process revolves around the sync date. It was suggested we use the most expensive drug as the base.
  • Enrollment uses various touchpoints, but patient opt-in is required. Mobile, IVR and email were all discussed.
  • Our soon-to-be released CARE module will contain all pertinent health data, including ICD-10s, lab values and health-related notes. This will weave in nicely with med sync.
  • When a patient opts-in for med sync, the system needs to remove them from the automatic fill (i.e., AutoFill) program for their meds. Otherwise the patient will receive confusing communication.

Above all else, data is king. Whatever med sync program you use, it must be able to access the data across the entire chain, and it must be able to transfer to other healthcare facilities easily. With full access to your patient’s health data, pharmacies will finally be able to move from just collecting the dots to connecting them.

SHEPPARD: The challenges with “build your own” versus working with a technology partner are primarily the high initial cost of developing a complex system, maintaining that system and developing the analytic capabilities to optimize a program like medication synchronization. From Ateb’s perspective, we are working to develop and adapt best practices, and we learn across a wide set of pharmacy operators so that each of our partner pharmacies benefits. Going it alone may give the pharmacy a feeling of more control, but it also means that they must have risk tolerance and the ability and willingness to engineer and manage an automated medication synchronization program. Moreover, Ateb has a dedicated analytics team using very sophisticated — and expensive — software and hardware to produce detailed analytics required to operate these programs efficiently. The cost of dedicating an analytics team during the start-up phase, when these capabilities are perhaps most important, would be prohibitive for all but the largest organizations. Hence, by partnering with technology companies like Ateb, the pharmacy can enter the space more quickly and more effectively without the burden of expensive start-up costs.

MULLEN: Building an adherence program is time consuming and resource intensive, not to mention difficult. Even if the resources are available, developing the right algorithm for your patients will take a lot of trial and error. The ROI is there, but it can be diminished if the cost of implementing the program outweighs the patient benefit. There are business partners out there today — like us —working on developing solutions or partnering with the right technology providers to make adherence programs a success for our customers.

NOFFSINGER: Speaking from the automation supplier perspective, we have seen benefits to both models. Outsourcing allows you to start faster and with few up-front dollars. Building your own allows you to control the content and quality of your program with more control. If you build your own, you must be committed to the business model and stick to it.

COUGHLIN: The challenges of building an integrated pharmacy system today are vast. Usually only the largest national chains undertake the challenge. The requirements evolve so rapidly that it becomes difficult to add them to existing platforms — imagine trying to start from scratch. That’s not to say some people will start from scratch and be successful. Those contemplating building an integrated pharmacy system need to carefully weigh the challenges involved, particularly if they are trying to run a pharmacy practice while building the systems.

DSN: How does consumer-facing technology play a role in the delivery of medication synchronization outcomes?

NOFFSINGER: Med synchronization is all about the consumer’s ability to take the right medications at the right time. Whether its technology, packaging or processes, everything must be geared to reach that end. I personally feel that simple, easy-to-use tools are the best way to interact with the consumer using med synchronization. More specifically, packaging that is easy to understand and use, and very simple educational tools, are our best bets to keep these patients out of the hospital and living independently for longer periods of times.

SHEPPARD: The appointment-based model works because the pharmacy and the patient work together to help the patient achieve a desired outcome. This includes pharmacy outreach to the patient multiple times per month. Ateb has found that many of the routine interactions between the pharmacy and the patient lend themselves to automated communications, whether via an automated phone call, a text message or a notification through a mobile app. Ateb offers pharmacy options to automate each of the communications as they see fit. Regardless of how the communication is made, each is tracked and monitored to determine if a follow-up intervention is needed. Ateb also has built modules that help the pharmacy direct specific interventions or points of education to the patient that are essential to improving health outcomes. As the annual WilsonRx pharmacy surveys have shown, the level of patients’ engagement with their pharmacy directly correlates with their pharmacy satisfaction. Time My Meds creates a high level of engagement that increases the level of patient satisfaction, improves adherence, drives revenue into the pharmacy and, most importantly, encourages better health outcomes for patients.

MULLEN: Consumer technology adds convenience and flexible communication options. This may seem basic, but an adherence study from November 2010 to December 2011 involving 735 patients found that 39% of patients didn’t pick up their prescriptions because they simply forgot or didn’t know there was a prescription at the pharmacy for them. This shows that communicating with patients to remind them of their medication is very important. Much of the consumer technology that supports communication for adherence programs is already in the hands of patients. Our systems already include text messaging, automated prescription fill reminders and pick-up calls, as well as mobile applications that include anytime-anywhere refills, alerts, medication history information and two-way communications between the patient and the pharmacist all within the app.

COUGHLIN: Web-based mobile technologies make it easy for patients and doctors to communicate with pharmacies and vice-versa. Supporting and expanding on these technologies is key to keeping up with the expectations of consumers, thereby promoting desirable consumer behavior. Medication synchronization certainly simplifies the ability to use mobile devices as adherence tools effectively.

OWENS: I believe kiosks will play an increasing role as a touchpoint for consumers over the next two to three years. There are so many areas where a remotely monitored kiosk makes sense. For example, a very rural area where the patient must drive 70 or 80 miles to reach a pharmacy, but the factory where the person is working has a pharmacy kiosk right in the entry. We can all remember how ATMs transformed retail banking. Similarly, kiosks also will fill a void, especially in rural areas and large factories. The idea is for the kiosk to be an extended reach of your pharmacy — a component of your connected care strategy. Your pharmacist handles the patient remotely through two-way video, voice and image. It’s pretty slick. You can see how convenient it can be for your customer to drop off their script to the “factory pharmacy” in the morning and pick it up as they leave work. Technology will continue to find new ways to improve convenience and safety for the customer, and we all know that is a winning formula.

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