Start asking questions about workflow technology, and you're certain to get a range of answers. For instance, you might hear that you don't need technology to have workflow. Or you might hear a list of all the great technology available to structure and track what happens in the pharmacy. In the spirit of discovering all the possibilities of workflow technology, ComputerTalk surveyed a number of pharmacy technology companies to hear how they approach the subject and what they've found when talking with pharmacists about it. It turns out that there really are a number of different ways to manage workflow, but in all the variety, there are some very basic goals that the technology can help pharmacy reach - namely, improved accuracy, efficiency, and patient safety.

Any conversation among pharmacists about a new piece of technology is certain to touch on the financial rationale, often spoken of in terms of the number of prescriptions per day that justifies an investment. Workflow technology is no different, and you'll hear a range of anywhere from less than 100 prescriptions a day up to 300 as the threshold number. You might wonder about a number under 100, but it's a reflection of the flexibility of the elements of workflow. However, while looking for a volume threshold has a certain practicality to it, it may not be the only way to assess your suitability for the more sophisticated aspects of workflow.

In fact, according to a number of respondents to our survey, you might not want to spend a lot of time thinking about prescription volume at all. Prescription number one may well be the right point to start thinking about workflow solutions. "We are not sure this is a volume issue," says Tom Michalski, director of product management for McKesson Pharmacy Systems. "It may be a patient safety issue that must be answered by a careful risk analysis within the pharmacy." In Innovation CEO Mary Reno's opinion, focusing mainly on a number is like asking: What prescription volume justifies a pharmacy management system? "For years, DUR and third-party work was done manually. Now, even the smallest pharmacy has a pharmacy management system and would not even think about operating without it," says Reno. "We believe workflow is on the same path." Debbie Sheppard, VP of sales and marketing for Ateb, is another who believes that all pharmacies can benefit from workflow, with lower-volume pharmacies gaining the ability to more effectively leverage their limited resources and then improving task efficiency and accountability as volume grows. "Advantages exist at any prescription volume," says Sheppard, "because workflow provides tools that improve prescription tracking and filling accuracy, which are not volume related." Jeremy Hume, VP of sales for KeyCentrix, also feels that volume shouldn't be the main consideration, instead suggesting a focus on the prescription-handling process. "The more people who are involved in the processing of a single prescription," he says, "the more of a need the pharmacy has for workflow." Taking this view into account, widespread implementation of workflow may simply be a matter of time. "Affordable and fully functional automated workflow systems will be in more than 90% of retail pharmacies by 2010," predicts Christopher Thomsen, VP of business development for Kirby Lester.

Starting out talking about which pharmacies can reasonably think about workflow technology means that we've skipped a very important point: What exactly is "workflow?" Surely, even if it is a solution that can be good for everyone, not everyone is going to want or be able to implement the same
version. "Not every pharmacy will use every feature in a high-end workflow system," says Reno. "Pharmacies with very low volume or dedicated owners and staff can, and do, get by with basic functionality such as capturing a script image and scanning a stock bottle NDC. But in our view, calling software like this ‘workflow' overstates what it does. Most pharmacies will need more than this." Let's get to the meat, then, and find out just what vendors mean when they talk about workflow.

A list of the pieces of technology and the steps that can make up workflow can offer a good start for thinking about how this concept fits into a given pharmacy. But it may be better to consider more generally what areas workflow systems are designed to address, and leave the specific choices of features to each pharmacist. Ketan Mehta, CEO of Micro Merchant Systems, offers this very simple definition. "You get an electronic map of where the prescription has been," he says. "You can look at a record and see all the routes that a prescription has taken and what its current status is." According to Michalski, this ability to monitor the flow of the prescription at each stage of fulfillment is at the very center of the control that workflow offers. "You gain the ability to prioritize work in order to meet patient expectations," he says. "And store managers can monitor the ‘big picture' in the pharmacy and adjust resources as needed."

Compared to a standard pharmacy management system, workflow targets a much wider set of responsibilities, points out Larry Stephenson, HCC's VP of pharmacy system sales. "The pharmacy management system is designed principally for managing the financial aspects of the pharmacy, from transaction processing and perpetual inventory to sophisticated analytical reports," Stephenson says. "A workflow system is designed to manage efficiency and provide safety mechanisms for the mechanical process of filling the prescription." Speed Script's director of business development, Heath Reynolds, looks at workflow and also sees a contrast between it and the traditional pharmacy filling process. "Typically, prescription dispensing has been given more of a craftsman's approach, in which one person works on a product from beginning to end, with prescriptions generally being filled in the order they were received," he says. On the other hand, a workflow system is more like an assembly line, according to Reynolds, from which prescriptions are selected according to a priority scheme and flagged with the appropriate status as they go through the data entry, fill, verification, and pickup stages.
What Reynolds is describing is the queue-based approach that creates the division of labor that is typical of workflow. "With workflow, the prescription-filling process can be split among staff who use queues and pass the information among themselves while processing the prescription," explains HBS's VP of pharmacy systems, Steve Hess. Queues mean that the right staff members end up working on the prescriptions that are the highest priority to them, whatever their role may be. And though this offers an obvious structure to the dispensing process, Hess emphasizes that workflow needs to be customizable, since one set of queues and workstations will not suit every pharmacy.

Tom Rhoads, executive VP of sales and marketing at Parata, expands on the idea that a variety of strategies exist to resolve workflow issues. He views dispensing automation as a surgical approach that targets the manual counting and filling process so that the rest of the dispensing flow can run more smoothly. "If the pharmacy operates well aside from crunch times, implementing dispensing automation to handle 50% to 65% of the volume relieves the primary bottleneck, allowing staff to handle the other aspects of the pharmacy's workflow more efficiently and accurately," he says. "Where
software solutions may provide a turnkey process to manage every aspect of the pharmacy's workflow, automation relieves the counting and vial-filling pressure points without affecting the rest of the process, which may be working well."

If you are looking to implement workflow technology across your dispensing process, though, there should be opportunities to increase efficiency, notes SoftWriters VP Tim Hutchison. "Workflow lets you use your resources better by off-loading the more mundane tracking and monitoring tasks to the computer," he says. And true workflow should offer these benefits with end-to-end coverage. "Workflow systems handle prescriptions before they are placed into the pharmacy system, as well as post-pharmacy-system workflows and exceptions," says Louie Foster, director of product management for Integra. As an example, he points out that many pharmacies will park items to work on until a specific delivery run or set aside items that need clarification, putting them outside of the scope of the pharmacy system. Innovation's Reno concurs. "Pharmacy management systems make sure that the prescription should be filled," she says. "Workflow systems pick up where pharmacy systems leave off." In Reno's mind, workflow "wraps around" the pharmacy system by tracking prescriptions before they actually flow through the pharmacy system and, crucially, also tracks prescriptions that should not be filled. "For prescriptions that the pharmacy systems says should be filled, workflow then provides tracking through the entire process and many hands - in and out of automation, in and out of will-call, all the way through pickup or delivery to the patient," she says. When mistakes are tracked as well, managers can run reports that offer a complete picture of what's happening in a pharmacy.

For ScriptPro CEO Mike Coughlin, this complete tracking capability is at the heart of workflow. "Our workflow consolidates and tracks a patient's entire order, from the time the prescription is filled to when the medication is dispensed," he says. Coughlin also points to the need to know more than just where a prescription is and where it's been. There's a range of other information to glean, he says, such as staff utilization; fill-time averages; wrong bar-code scans, which he calls "near misses;" lot numbers; and much more. What Coughlin touches on gets at something relatively new to workflow, and something that should mark a big step forward in defining what this technology is all about.

Systems are now being designed to take advantage of the data collection inherent in the workflow concept and leverage it to provide real-time information that can be applied immediately to improve a pharmacy's efficiency. "Other than accuracy in the fulfillment process," says SoftWriters' Hutchison, "one of the biggest reasons to implement workflow is the ability to view and resolve bottlenecks in the pharmacy and generate performance metrics on employees to identify problem areas." Performance tracking features are an important part of McKesson Pharmacy Systems' new product, according to Tom Michalski. "We designed Pharmacy Navigator to bring together key metrics - such as prescription volume in each workflow queue, cycle times or throughput of each delivery method, employee productivity, and prescription profitability - and put them in a dashboard viewed on a single screen," he says. RNA Health Information Systems has also moved to provide this kind of insight into pharmacy operations, according to the company's president, Gary Schoettmer. "The pharmacy operations manager can use our TrackPoint dashboard feature to expedite order fulfillment by using a bar-graph feature to see at a glance where prescriptions are in the workflow process," he says. "These graphs also indicate the level of productivity in each area of workflow and offer the ability to click on the event data line to view and/or print a list of prescriptions associated with each area of the workflow process and re-allocate resources appropriately."

Whether action and change come from such an on-demand analysis of workflow or from a careful review of reports and logs, it's clear that this is a technology that's driving at a standardization of the prescription-filling process. "When you are tracking every prescription," says Kirby Lester's Thomsen, "you have the information you need to establish efficient and accurate dispensing protocols." For example, says HBS's Steve Hess, not only can you institute such procedures as having several people check the written prescription against the actual drug being dispensed, using such tools as bar-code scanning and final pharmacist verification from a scanned prescription image and a pill image, but you'll also have the information available to verify that these procedures are followed. This attention to detail can offer significant results, notes Dick Bradley, a pharmacist with QS/1's consulting service. "What often surprises pharmacists most is how many errors they catch, and the ease of integration of these verification steps into the prescription-filling process," he says.

Verification is a task that bears a little more discussion. Of course, you don't need anything fancy to make sure that a dispensed prescription is correct and to do so at several points in the filling process. This is a core activity in any pharmacy, without exception. But workflow can offer a new level of certainty and a better flow of information. A strong workflow model makes sure that the highest level of attention is applied to every prescription and backstopped with tools such as bar-code scanning, as well as prescription and pill images. "Our bar-code scanning technology ensures that 100% of your prescriptions are checked for accuracy, not just the fast-moving prescriptions," says ScriptPro's Coughlin. Drug-pick verification also helps to ensure that the drug billed to insurance is the drug dispensed to the patient, notes Micro Merchant's Mehta. This serves the double purpose of reducing exposure in case of an audit and confirming that the patient is getting the right medication with the right strength. More precision in getting the right medicine to the right patient isn't the end of it, according to RNA's Schoettmer. "Beyond the detailed review of the prescription record, drug interactions, allergies, and pill images with both side imprints and description, we let you review and verify the profit margin on a prescription," he says. Ultimately, each point of documented review added through workflow technology will offer the opportunity to determine whether or not to continue with a prescription fill.

If there is an issue at any stage, HBS's Hess notes, workflow also offers structured problem tracking and resolution. "Properly used, this allows the pharmacy to make sure that clean scripts keep moving forward," Hess says, "while also creating a standardized process that allows for the analysis and proactive resolution of problems." The exception process needs to offer just as high a degree of customization as the various filling and dispensing queues. Micro Merchant's Mehta understands this and describes how his users respond to exceptions. "Because of the fluid nature of rejections and the complexities in filling a prescription, we offer pharmacists the ability to dynamically create tags for prescriptions," he says. "This means they can create as many types of tags as they like, and then run reports to view all prescriptions tagged for specific reasons."

This standardization of process can reach far beyond the actual medications a pharmacy dispenses, and can apply to the flow of information about a medication and the patient taking it - ideally, through the digitization of documents by scanning or by receiving them electronically to begin with. "Workflow should offer a bird's-eye view of all information associated with a prescription and patient," says Integra's Foster. The prescription order itself is a basic piece of this information, but not the only one. Foster offers several examples of situations when documents need to be rapidly and easily retrieved by staff, whether they worked on the order originally or not. For instance, a doctor may call to discuss clinical areas, or the pharmacy may want to make information available to pharmacists to view remotely during on-call times. Then there's the enhanced triage and automated routing available when an emphasis is placed on document management. "Pharmacies can pre-prioritize incoming orders based on long-term care facility, date, time, and day of week," says Foster. "And we also offer the ability to apply static bar codes to pre-identify forms and dynamic bar codes that tag outgoing documents so that they are automatically routed through the workflow on reentry to the system."

It isn't surprising that a solid, standardized dispensing and information- handling process with multiple verification points increases safety, which in the view of HCC's Stephenson is the critical take-away when considering workflow systems. "By providing checks like visual verification for technicians during counting and pharmacists at the final check, as well as through bar-code verification of product selection, error rates decrease dramatically," he says. The role of bar-code scanning can't be underestimated. Ensuring that the correct drug has been selected from the shelf by comparing NDC numbers during the drug-pick operation is critical. In fact, says Mike Coughlin, ScriptPro's bar-code technology does not even allow the prescription label to be printed until the correct product code is scanned. "This requirement is a key safety feature, which our system restricts users from bypassing," he explains.

Another important outcome from instituting workflow is the chance it provides to take a fresh look at the role each staff member plays in the pharmacy. Talking about "changing roles" can often be misinterpreted as a polite way to discuss staff reductions, notes HCC's Stephenson. But the many efficiencies that workflow systems provide are better realized when existing staff work more effectively. "Our current customers tell us that our tracking system has allowed them to double their walk-in business without increasing staff," says ScriptPro's Coughlin. And these improvements result from changes that can make a lot of sense. For example, consider the benefits of a process that allows pharmacist support personnel, such as technicians, to channel prescriptions in an orderly, efficient, and fully documented fashion to the pharmacist for review and approval. This can signal an important shift in roles in a pharmacy.

QS/1 pharmacist Dick Bradley offers an example of just such a shift, which helps to position pharmacists where they can best interact with their patients — in this case at the point-of-sale (POS) system. It's relatively easy to understand how POS can be a key piece of a workflow technology suite, since it closes the loop on prescriptions dispensed in the pharmacy by providing for a final bar-code tracking point and for the collection of signature and payment information. But it may not be clear why a pharmacist should work at a post that is more traditionally staffed by a clerk. "At POS, I am facing the patient or caregiver," points out Bradley. "If workflow has been deployed effectively and fully integrated with the POS, then I, as the pharmacist, will have a final chance to review any pertinent details - such as pill image, instructions, and notes on the file — and associate all of this key information with an actual human being," he continues. "This is not only a prime counseling opportunity, but an important time to build relationships with patients. It's a chance for the pharmacist to impress on the patient how much care and attention have been given to filling the prescription." This ability to have pharmacists available to take on this role at such an unorthodox location as the POS system rests firmly on a solid workflow process and well-integrated technology.
Putting staffing levels and roles aside, another key question is whether a new workflow system will gain rapid acceptance by a pharmacy staff. On this count, Larry Stephenson reports that employees at many of HCC's customers end up being excited about the installation. "As with any system, getting the staff to buy in certainly helps pharmacy owners with building acceptance for new policies and procedures that will drive performance and safety," says Stephenson.

There's yet another benefit that can derive from increasing safety and efficiency, major objectives unto themselves. This, according to ScriptPro's Coughlin, is a less stressful work environment. "After workflow goes in, we frequently hear that ‘there is no more chaos' in the pharmacy," he says. A lower level of stress can create a virtuous circle as it translates into fewer mistakes and lower turnover, notes Innovation's Reno, which then translates into real money. "There is substantial value in the peace of mind that workflow brings to the pharmacy," she says. "You don't have to remember things that are tracked automatically as part of a computer record." This is peace of mind not only for the staff engaged in minute-by-minute dispensing operations, but managers and owners as well. Key-Centrix's Hume tells the following story to illustrate this point. "When the whole concept was relatively new, a client of ours made a big investment in a workflow system," he says. "When we got to know him well enough, we asked him, ‘How did you justify the cost?' He half-laughed and said, ‘One lawsuit. I have two kids in college, I just built a new house, and I have a good pharmacy practice. One missed fill, and all of it can go away.'"

What does it all boil down to, then? There's a lot about workflow that's perfectly intuitive. If you've been practicing pharmacy for a while, you probably understand the concept pretty well. But you may not realize how much technology can do to improve the process that exists in your pharmacy, how customizable these tools are, and the range of prices at which solutions are available. "Pharmacists don't always expect the software to be so comprehensive," says Micro Merchant's Mehta. "Also, the ways in which we can use technology to improve workflow are constantly changing," he continues, "so we have seen that every time we show pharmacists a new option, they are pleasantly surprised." Perhaps it comes down to the fact, then, that it pays to keep an eye out for ways to improve how things are done in the pharmacy. Keeping an open mind can lead to good things, says Innovation's Reno. "When pharmacists step back to look at all of the strange things that eat up time and cause headaches and customer inconvenience, and then realize that tools are available to assist with these types of issues, it's an awakening," she says. "We enjoy broadening their ideas and perceptions." An open mind is also necessary when approaching workflow as an investment. "There's a range of costs and variety of automated workflow systems that are available from both pharmacy automation and pharmacy management system vendors," points out Kirby Lester's Thomsen. As a result, pharmacists who look diligently will likely find the right tools at the right price. And finally, points out McKesson Pharmacy Systems' Michalski, "Workflow has that key characteristic that's part of every piece of technology that ultimately proves its worth. It means the pharmacists can spend less of their day working in front of a computer screen and more time actually talking to their patients." CT

Will Lockwood is a staff writer and senior editor for ComputerTalk. He can be reached at will@computertalk.com.