Exploring the Role of Retail & Inpatient Pharmacies
Consider the systems needed to manage retail pharmacies vs. inpatient-oriented platforms. Inpatient processes can be scheduled to efficiently use staff and other resources. However, ambulatory patients dictate their schedule by deciding when, and if, to come to the pharmacy. Ambulatory patients must manage their own medication therapy, which requires education and active monitoring to ensure compliance. Inpatient processes operate within a local environment - the hospital. Outpatient medicine can cut across state lines as patients return to their homes and possibly order refills and additional medications from the hospital and clinics. Outpatient pharmacies can be subject to any number of regulatory and reporting requirements, such as the obligation to interact with state prescription drug monitoring programs. These are addressed on an exception basis by staff struggling to run the many ambulatory pharmacy functions that are not core to the EHR functionality.
POS (Point of Sale Systems)
When an inpatient EHR system is propagated to the outpatient pharmacy, there is the need to stand up or interface with, many applications not included in the EHR software architecture. For example, the ambulatory pharmacy cannot open the doors without a point of sale system (POS). Health systems have learned that the complexity of pharmacy POS extends far beyond POS services used at a gas station or restaurant. Pharmacy POS needs to be tightly integrated with the myriad of ways patients pay for prescriptions, including third-party plans, prescription benefit cards, payroll deductions, HSA/FSA programs, etc. The service line at the payment counter can be frozen when a patient produces a new payment card or decides to not accept a prescription that has an unaffordable copay. When POS functions are not integrated with pharmacy functions pharmacy staff may have to reprocess the order while patients are waiting.
Third Party Prescription Benefits
A complicating factor is the universe of third-party prescription benefit plans, which is mind-boggling and ever-changing. Adjudication rules are complex and some payments must be made through medical benefit plans. There may be special pricing to attract certain customer groups, such as the hospital's own employees. This functionality was not planned for in the EHR software architecture.
A major opportunity and complexity arises through class-of-trade rules applicable to drug acquisition. The most common case here is the 340B program. But there are other class-of-trade pricing opportunities involving GPO pricing and formulary/pricing programs targeted to specific patient groups. EHR pharmacy extensions typically do not address these issues and leave them to back-office processing functions that try to optimize financial performance after the prescriptions have been filled and the patient has left the pharmacy. Therein lies a serious problem: once the patient has left it is too late to optimize since the drug has already been dispensed. Many opportunities are lost in this shuffle, at great cost to the health system.
ScriptPro, a HIMSS Innovation Center Collaborator, offers a complete end-to-end solution for ambulatory pharmacy operations as depicted in the diagram below. On the left, we show interfaces with the health system EHR to receive patient, prescriber, and prescription information. The return arrow shows how dispensing history is sent back to the EHR so a central record is maintained for the patient.
Some health system IT groups have promoted the EHR-extension approach on the basis that it reduces the number of interfaces and applications they need to support. Invariably, this requires more interfaces than shown in this diagram, and many more applications than the single, unified ScriptPro operating platform. The IT group may end up supporting robots, point of sale, mobile and interactive voice response (IVR) applications, inventory management, 340B split billing, meds-to-beds, third-party claims reconciliation, revenue cycle management, and more. With ScriptPro, all applications are engineered to work within a comprehensive, unified system and the EHR only has to the support the four interfaces shown on the left side of the diagram.
Health systems are rapidly moving toward fully embracing ambulatory pharmacy programs. The benefits are huge - both for patients and for the financial well-being of the health system. As this shift in emphasis occurs, it is important that the systems deployed to run the ambulatory pharmacy are up to the job.