Leveraging Technology

to Improve Adherence

Meaningful patient interventions don’t have to be time-consuming with the right tools

By Jennifer Bruckart

programs need to be seamless, easy to implement, and integrated into the pharmacy management system.

Finding Solutions Information is at the heart of patient care, and it’s especially true when it comes to adherence. Whether it’s helping to identify a non-adherent patient or facilitating a fully integrated patient care program, information is at the center of any patient-centered pharmacy practice. And, in the pharmacy, most of that information flows through the pharmacy management system.

Information Overload In 2011, NCPA conducted a focus group to identify the barriers to pharmacist-delivered adherence services. At the time, technology was identified as one of the biggest challenges. Several participants commented that although pharmacy management systems contain infinite amounts of information about a patient’s medication history, deciphering the information into meaningful patient interventions can be time-consuming. “I could hire a full-time staff person just to analyze and dissect our patient data, but I don’t have that luxury,” one participant commented. Others pointed out that although these systems contain extensive refill histories for each patient, most systems do not have an easy way to parcel out late refills on chronic medications from acute medications. And while a system may flag late refills for a single medication, it ultimately falls on the pharmacy staff to interpret that information to determine if a late refill is of concern. By the end of the focus group session, almost all of the participants agreed that to be successful, adherence

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Fortunately, pharmacists are finding new and creative ways to use their pharmacy management systems to help with their adherence programs. System capabilities also have increased in recent years, helping pharmacies to do activities such as flagging non-adherence, sending reminder texts when a patient’s prescriptions are ready, and calling the patient if a prescription is not picked up. “Adherence is the buzz word at Eden Drug,” says Pete Crouch, RPh, owner of Eden Drug in Eden, N.C. “We use our Computer-Rx software to text patients when their prescriptions are ready, we use smart phone apps to give easy access to their prescription refills and prescription records, and we use our system to monitor adherence rates and look for opportunities to counsel patients at the pharmacist check terminal.” Crouch’s system features an adherence thermometer that appears in several places in the patient’s record and allows the pharmacy staff to quickly know if there are any adherence issues that they need to address with the patient. Medication possession ratio (MPR) and proportion of days covered (PDC) are two common methods used to quickly calculate a patient’s adherence. PDC is the newer and more comprehensive measure used in the Medicare Part D program as part of the plan ratings system that uses 1–5 stars to rate plans based on their performance. Joe Moose, PharmD, co-owner of six pharmacies in North Carolina, said his system displays an MPR for each medication a patient is taking. He agrees that MPR is an important measurement when it comes to monitoring

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adherence, but he also emphasizes the importance of identifying gaps in therapy, which his system helps him find. “What happens to a patient who's been taking Advair for three years like clockwork and then just decides to stop taking it?” he asks. “What's important to us are the drugs that aren't getting picked up. That's a sale that you're not going to have, but it's also a drug that the patient probably needs.” Moose’s Pioneer Rx system allows him to see several different adherence measures at one time, making it easy for his staff to know if there’s a potential adherence issue. “Instead of looking at one screen to find the patient's MPR and another screen to calculate the gap in fill history for the patient, we are able to see all of the data on one dashboard screen at the same time,” Moose says. “The dashboard is also color-coded to alert us to medications that are due to be filled for our patients. Having all of this information with the click of one button allows us to be more effective practitioners, more efficient, and to give more well-rounded care to our patients on a daily basis.” After all, Moose says, “We don't just treat patients one day a year [such as during a CMR or MTM session]. We treat them all year long, and identifying those gaps and having those 1–2 minute touch points should be done every time the patient walks in the door,” Moose says.

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Crouch’s pharmacy is also interested in preventing gaps in therapy by using a service provided by Prescribe Wellness that places automated phone calls to patients on maintenance medications that are seven days past due. The program is already showing impressive results and helping to close these concerning gaps in therapy. Research shows that non-adherence also results from patients not understanding how or why to take their medications. That’s one reason why Crouch signed up for a program that automatically emails a video to patients when they first fill a prescription for a new medication. There are more than 100 videos to choose from, and they help to explain the medication, how to take it, and what they should expect as a result of taking it. Videos like this help patients recall Crouch’s counseling and dosing instructions after they get home. Medicare beneficiaries, especially those with complex medication regimens, represent a huge opportunity for patient outreach and education, which is why Steve Adkins, PharmD, owner of Health Park Pharmacy in Raleigh, N.C., was grateful for the assistance of a new tool to help in his patient outreach efforts this year. “Prior to [Medicare] open enrollment, we did educational seminars at senior facilities about Medicare and the major changes coming in 2013,” Adkins explained.

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“During those events, we conducted medication checkups, where we screened patients for adherence, checked blood pressures when applicable, and made clinical recommendations to prescribers.” Adkins’ team also used the iMedicare App to show patients how much their medication costs would be, when they could expect to go into the donut hole, how much money they could save by switching 1–2 medications to lower-cost alternatives, and how getting added to the pharmacy’s synchronization program could help them with their personal budget and overall health. “As a result, we did close to 200 MTMs and saved our patients more than $200,000 this year,” he says. “We also caught two patients during their medication check-ups who were in hypertensive emergency and were able to get them in with their primary care physician and make clinical recommendations to more efficacious antihypertensive regimens.” Increasingly, vendors are responding to their customers’ needs for better, more integrated adherence tools. Some software systems have interfaced with outside systems to make the dispensing process easier, specifically with regard to prior authorizations (PA). Obtain-

ing PAs can introduce unnecessary disruptions in the dispensing process and potentially delay the patient from receiving a medication. “Our HCC software automatically generates a form that the technician will use to enter the information into a free online program called Cover My Meds,” says Jason Wallace, PharmD, owner of Grant County Drugs in Dry Ridge, Ky. “The pre-authorization is loaded into the Cover My Meds database, and the correct form for the patient's insurance company is populated and sent to the physician for signature or medication interchange. This streamlines the process and increases adherence by reducing the amount of time that lapses between the prescription being written and the patient receiving the medication.”

Synchronization Solutions Wallace’s pharmacy is one of more than 1,000 community pharmacies that are providing medication synchronization services (consolidating and coordinating a patient’s prescriptions to refill on a single day of the month) to their patients. “We have about 90 percent of our patients streamlined to refill their medications on the same day each

How Can Technology Work for You? Technology is a critical element to providing medication synchronization services, which have been proven to improve medication adherence. Find out from your vendor(s) if they offer these types of system features to help streamline your synchronization program:

list, detect the maintenance medications that are best for synchronization, identify the recommended anchor medication and refill date, and calculate the shortened days’ supplies needed to coordinate with the anchor medication.

Identification of Eligible Patients Back-end logic that you can modify and use to identify patients who could benefit most from medication synchronization services.

Outbound Calls Scheduling tools to remind your staff to call the patient one week prior to his/her pickup date to review their medications in advance of filling them; additionally, capabilities to track successful completion of these calls.

Identification of Enrolled Patients Icons or other indicators that can help you identify patients who are enrolled in the synchronization program so that when a new prescription comes into the pharmacy, your staff can quickly determine if the prescription is for one of these patients; also, patient identifiers and/or group numbers to help organize patients based on their anchor date. Patient Enrollment/Initial Synchronization Automated tools that display a patient’s medication

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Patient Notifications Capability to send an automated message (via phone, email, or text) to a patient to remind him/her that the medications are ready to be picked up at your pharmacy. Additional details about the medication synchronization process can be found in the Simplify My Meds Pharmacy Operations Manual. To learn more, please visit www.ncpanet.org/smm or send an email to [email protected].

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Tech Notes: NCPA members share ways they use technology to help improve patient adherence “Our pharmacy software [Speed Script] allows us to easily keep track of patients in our Simplify My Meds program, and it helps identify potential patients. We set an anchor date for each patient, which can be easily moved, if needed, in our software. The system has a list of prescriptions printed out automatically after our nightly backup, so it is available in the morning for filling. The process is simple. You can use it for a patient that can’t remember to call for their one prescription each month or for a patient with 15 prescriptions.” Marty Michel, RPh Key Drugs | Poplar Bluff, Mo. "As a closed-door LTC pharmacy, we are constantly moving patients and adding or discontinuing medications into cycles. Our operating system—Framework by SoftWriters—allows us to confidently assign hours of administration codes (HOAs) and cycle fill indicators for patients who may have complex medication regimens. Framework links to our automation and organizes the med pass into whatever packaging format our customers want. All these features contribute to improved adherence and patient outcomes."

“Our pharmacies run two adherence programs. We use MedicineOn-Time for our patients in assisted living and independent living settings. Our HBS system includes an interface with the Medicine-OnTime system, which helps by eliminating some of the duplicate work that would be necessary if the two systems did not communicate. We also have a program in our retail pharmacies where identified patients are assigned to a technician who works with the patient, contacting them at least twice a month and working as much as possible to synchronize refills and encourage adherence.” Phil LaFoy, RPh Blount Discount Pharmacy | Maryville, Tenn.

"Our system [QS/1] has a program called Health-Minder which helps pharmacies manage med sync and compliance. For those who opt in, we can then run Health-Minder to identify when their refills are due." Jeff Harrell, PharmD Peninsula Pharmacies | Ilwaco, Wash.

Rick Steinhauser Merwin LTC Pharmacy | New Brighton, Minn.

month and have many of them arranged for free home delivery,” Wallace says. “Our system has a feature that allows us to queue these medications to be refilled at the press of a button.” With more pharmacies adopting medication synchronization as a standard of care, pharmacy owners are looking for more tools to help with the synchronization process and ongoing program operations. Once a patient is enrolled in a synchronization program, it’s important to know this so that prescriptions for these patients can be automatically flagged for special treatment. “We have one technician who runs our Simplify My

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Meds program,” says Justin Wilson, PharmD, co-owner of Valu-Med Pharmacy in Midwest City, Okla. “Sometimes that technician isn't in the pharmacy. If one of the patients on the program comes in with a new prescription, our Computer-Rx system displays the patient’s adherence date, so our staff can quickly check and see what date the patient is anchored to. If today's the seventh, and the patient’s anchor date is the 22nd, we know we should short fill a 15-day supply to get him to his next synchronization date.” Other vendors have created special alerts to notify them that a patient is enrolled in the synchronization program so that these prescriptions can be flagged and

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passed along to the staff member who oversees the synchronization program. “We asked our vendor (Rx30) to make the patient memo box pop up every time we access the patient profiles,” says Jessica Beal, PharmD, of Hobbs Pharmacy in Merritt Island, Fla., who has more than 130 patients enrolled in the pharmacy’s Meds Made Easy synchronization program. “We put a note in the memo field to designate that it’s a synchronization patient. At this point, if it is not an antibiotic or pain medication, our techs just put it on hold and give the prescription to our synchronization program manager to review.” (Editor’s note: Hobbs Pharmacy’s adherence efforts will be profiled in more detail in the July 2013 issue of America’s Pharmacist.) Some systems alert the pharmacy staff to a patient’s synchronization status and automatically calculate the short fills needed to coordinate with the patient’s remaining prescriptions. “When one of our cycle fill patients shows up with a new prescription, the system knows the patient's cycle fill date, and it automatically has a pop-up screen that alerts us that the patient is on cycle fill and that a short fill of a 12-day supply is needed to synchronize this prescription with the patient's fill cycle,” Moose said. Others are looking to outside vendors who are helping to automate the synchronization process. Ateb, a pharmacy technology company based in Raleigh, N.C., has developed a software program that automates many of the routine tasks associated with synchronization. Jerry Leonard, RPh, director of pharmacy for four Drug Emporium-owned pharmacies in the Charleston, W.Va., area, launched NCPA’s Simplify My Meds program (free to NCPA members) in his pharmacies in February using Ateb’s platform and so far, his staff members have enrolled more than 60 patients in the program. “The software is helping immensely with the synchronization calculations and scheduling, and it’s much easier to use than I thought it would be,” Leonard says. “I like that they have built in tools to do our own MTM and schedule immunizations too.”

Future Capabilities Justin May, PharmD, director of pharmacy for Red Cross Pharmacy in Marshall, Mo., currently oversees the 12-store regional chain’s medication synchronization program. After learning about medication synchroniza-

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tion at an NCPA convention two years ago, Red Cross launched its Elite Care program with only a handful of patients using a combination of Microsoft Excel and Outlook to organize and schedule the patients. The program has outgrown this low-tech system with more than 2,200 patients enrolled so far, and May looks forward to integrating the program into the pharmacy’s Computer-Rx system. (See sidebar for ideas on how your pharmacy management system can help you streamline your synchronization program.) Additionally, he would like to see more tools that allow pharmacy staff to better serve the needs of their patients. “We need more tools that help us focus on the patient and anticipate their needs,” he says, pointing to companies such as Amazon that use logic and purchasing behavior to make recommendations for additional products and services. When the patient is filling a prescription for an antibiotic, he explained, the system might recommend a probiotic. Or, a patient filling a prescription for metformin might be asked if he/she needs any diabetes strips or would like to sign up for the pharmacy’s upcoming diabetes education program, he explains. May has done some patient-level analysis of his store’s synchronization program, and he discovered just how valuable these patients are from a business standpoint. His analysis showed a 28 percent increase in gross revenues for the patients enrolled in the synchronization program. He also discovered how many patients are spending more than $10,000 (with some even accounting for more than $30,000 of revenue) in the pharmacy. “Those are extremely valuable patients when you look at it in those terms,” May says. “We want to make sure we’re taking care of them and anticipating their needs.” Moose agrees that these patients represent opportunities for the pharmacy, and he sees synchronization as just a first step to more integrated patient-centered care. “There are synchronization programs, and there are integrated programs,” he says. “The end goal is an integrated program. We should all be thinking along those lines. How can we work with doctors, nurses, dieticians, and others in order to get the best outcome for our patients? That's where the real value is.”

Jennifer Bruckart is NCPA director for program outreach and special projects.

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