Feature: Making the Rules

Customized Edits for the New World of Pharmacy


   
Tim White R.Ph.   

Tim White, R.Ph.

President

Hardy-White Pharmacies

Raleigh, N.C.

Four-location group of smaller, independent pharmacies ranging between 1,800 and 2,500 square feet. 

 

Pharmacy has moved rapidly to a point where software systems need to support a wide range of patient care and workflow scenarios, and even successful, profitable fill-and-bill has become a complex rules-based task. There are a number of technology solutions designed to organize workflow and track tasks, as well as long-standing edits to help ensure that only clean claims get transmitted. But it seems as if the clinical, claims, and business practice contingencies a pharmacy needs to address are ever increasing, with the rules varying by drug, payer, and patient.

Logic for Your Pharmacy

This is where Tim White, R.Ph., has seen great value in a feature he’s recently activated in the PioneerRx pharmacy management software that has powered Hardy-White Pharmacies for going on five years. This is something called manual edits, which White describes as customizable logic within the pharmacy software.

This brings a level of pharmacy-specific customization to the workflow logic that, according to White, in years past you’d have had to ask a developer to implement. “Now we have it in our own hands to be able to design the rules we need, which is wonderful,” he says. And even though manual edits are fairly new to Hardy-White Pharmacies, White’s already seeing a positive clinical, operational, and even financial impact.

Ever Do a Little Programming?

So what exactly are manual edits? As White describes them, they are logic-driven rules based on categories that he and his staff are able to develop themselves within the PioneerRx pharmacy system. There are then filters within the categories. An edit sets up a gate in the workflow that can work in several different ways. It can simply record that an action was taken, generate an alert and track an event, or put a stop on the flow, with an override required to ensure the correct action is taken. No matter how the manual edit is set, data goes into a postedit queue, which is the basis for reporting that lets the pharmacist manager review what’s been going on.

Proactive, Not Retroactive

Previously, Hardy-White Pharmacies had worked to track various clinical interventions and workflow tasks, but this was mostly done by using search-and-report features within PioneerRx. “This was a retroactive process,” says White, “versus being proactive with these manual edits. Now it’s ensuring we can take action in the workflow, rather than after the fact. I think it really helps you, particularly in the clinical environment, to see opportunities proactively.”

Right Questions, Right Time

One such clinical intervention is immunizations. For example, Hardy-White Pharmacies has deployed manual edits for identifying people who should be receiving Pneumovax or Prevnar, based on age. “The edit is set to collect everybody 65 and over in a category,” explains White. “We then filter for the people who don’t already have one of these vaccines recorded in their profiles. Note that we’re using both an inclusion and exclusion logic here.” The impact of this manual edit was immediate, notes White. “In just the first two days after we implemented the rule on Prevnar 13, we were alerted to 36 opportunities,” he says. The manual edit has brought a level of confidence to Hardy-White Pharmacies that the staff is consistently addressing opportunities for providing pneumonia shots, while the system-driven prompt means that the staff can keep the focus on the patient, where it belongs.

The manual edit has brought a level of confidence to Hardy-White Pharmacies that the staff is consistently addressing opportunities for providing pneumonia shots, while the system-driven prompt means that the staff can keep the focus on the patient, where it belongs.

Administering vaccinations is a good example of a key opportunity for pharmacies to expand their scope of practice, but one that brings with it rules and protocols that fall outside the typical prescription-dispensing flow. For example, Hardy-White Pharmacies need to populate the ethnicity field in the patient record when giving a vaccination. “What we did was set up this edit to create a work stop that requires us to be sure this field is populated,” says White. He notes that this is important for several reasons: Patient profiles are populated with the right data, while at the same time the staff is able to ask only the specific group of patients for which it’s needed. What could otherwise be a data collection task that’s burdensome for staff and possibly annoying for patients becomes a streamlined process that happens with the right patients at the right time.

New Approaches, New Rules

White offers another example of how Hardy-White Pharmacies are using manual edits to help address the needs of a cutting-edge field, pharmacogenetics. “We’re getting ready to enter a pilot trial,” says White, “and we need rules within PioneerRx that will help us consistently identify patients on medications with pharmacogenetic equations. For example, we are setting up categories for medications that are known to be metabolized with certain enzyme cascades.” Then, according to White, the edit applies logic that compares this drug category to a patient category to check if patients have actually had the pharmacogenetic test performed.

Solutions for the Most Current Problems

There is one more manual edit that Tim White has on his list, and it’s a major one that gives Hardy-White Pharmacies the ability to address the direct and indirect remuneration (DIR) fees that have been bedeviling pharmacy. “This is actually one of the first edits we put in,” says White. “We have basically been able to put in a block on specific medications for a certain payer that we had found were creating serious DIR fee situations and losing us a lot of money.”

The edit puts a hard stop on any order for one of these medications that will be adjudicated under this particular contract. The goal then becomes for staff to find the best way to get the patient access to the drug therapy, while also ensuring that the claim isn’t processed at a loss for Hardy-White Pharmacies. “What this does is give us the chance to address this before we submit a claim,” says White. “We should never be in a situation where we’re paying the PBM [pharmacy benefit manager] to fill a prescription, which is what these DIR fees can amount to.” And White has found that there can in fact be several options, once you understand a contract. For example, there are cases where the DIR fee only impacts the generic. In other cases, White finds that the pharmacy needs to recommend a therapeutic substitution. “It took us a few months to realize what was going on with this contract,” says White, “but we identified the problem and we have been able to use the manual edits in PioneerRx to set rules that mean we avoid taking unfair and avoidable losses on dispensing certain drugs.”

The end result is a practical set of tools for giving Hardy-White Pharmacies the means to efficiently and rapidly solve problems, without needing to have a programmer’s skills to do it.

Starting Simple

Hardy-White Pharmacies’ application of manual edits is a perfect example of letting software systems handle the kind of tasks they are ideally suited for: addressing logical processes the right way every time. But the key element here is that White and his staff get to build these themselves to suit Hardy-White Pharmacies’ particular and evolving needs, rather than having to put in a developer request.

The prospect of getting under the hood of the pharmacy system like this may be a little daunting, of course. We’re not all computer programmers, and how can we be sure the edits get the right results and not unanticipated outcomes? Tim White’s advice is not to worry too much. “The first point would be to identify things that you’re missing on a consistent basis, that you know you need to address,” he says. “Then think about what processes you need to involve to correct these issues. The nice thing on the PioneerRx system is it does allow you a little trial and error. We can create a particular rule and test it in small batches. Then we can go ahead and modify it, if needed. We do also ask questions of our PioneerRx rep if we’re building something complicated. She really knows the system and can point us in the right direction.” The end result is a practical set of tools for giving Hardy-White Pharmacies the means to efficiently and rapidly solve problems, without needing to have a programmer’s skills to do it. CT


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