COVER STORY: September/October 2014

The Evolution of Central Fill

Central fill has held out a lot of promise over the years as a way to concentrate the prescription-filling effort through an investment that better leverages the capabilities of workflow and dispensing automation. The goals? Standardize processes, reduce costs, improve efficiency, and most importantly, afford pharmacy staff the chance to step away from certain repetitive tasks and focus on the bigger picture. The concept has certainly evolved and gained a lot of traction at a number of pharmacies — whether with 100 locations or 10. And when you set aside the notion that you need to meet certain criteria of size, geographic spread, or technology investment to make central fill viable, it turns out that more pharmacies than you might think can benefit from central fill.

Why Central Fill

Central fill can advance different kinds of strategic goals, including supporting growth, deploying labor and capital efficiently, and expanding patient services. For example, when central fill takes over repetitive dispensing tasks, you are saving pharmacists time in the pharmacy. At Kinney Drugs this has allowed pharmacy staff more time to focus on providing patient care and professional services, according to Dave Adsit. “Our retail locations are still very busy and are still filling prescriptions,” he says. “But when we implemented central fill, we were looking for ways to meet our long-term goal of freeing up pharmacists’ valuable time for services such as immunizations and MTM.” If there’s one area that’s growing in pharmacy, it’s these services, notes Adsit, and immunizations offer one really great example. “That grows year after year,” he says.

Thrifty White had a similar goal when it began running central fill in 2004, according to Tanya Schmidt. “Central fill means that we can streamline our workflow and create efficiencies so that our local pharmacists are able to use their clinical skills with their patients,” says Schmidt. “This has really enhanced the pharmacist-patient relationship.” Among the services supported by central fill at Thrifty White, Schmidt lists immunizations, counseling, and comprehensive medication reviews.

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Dave Adsit, R.Ph., Director of Pharmacy Operations, Kinney Drugs

Regional chain with 101 locations in New York and Vermont, 100 of which are served by central fill.

Then there’s the ability to grow your location count and patient base, something that both The Pharmacy Counter and United Rx have been able to do, thanks to central fill. 

United Rx expanded within the last four years by opening three satellite pharmacies, notes Ami Patel, and made the decision at that time to create a centralized prepackaging operation at the original Chicago-area location. “We looked at it,” says Patel “and thought, instead of having to install dispensing machines at each location, having to manage inventory at each, and needing a tech trained and devoted to packaging at each as well, why not be more cost-efficient and less labor-intensive by centralizing all this in our Hillside location?” 

The Pharmacy Counter was already a multilocation operation when it decided on central fill. In this case, there was a need to handle growth that came in the form of new patient populations that the pharmacy wanted to serve, according to Bryan Coehrs. “We became part of Pro- Medica,” he says, “and we had the specific goal of expanding our services to reach more members of the community and also bringing the healthsystem employee prescription plan in-house.” Growth in the community alone would have taxed The Pharmacy Counter’s capacity, but by far the bigger factor was serving all 15,000 ProMedica employees and their dependents. “We knew that there was no way we could staff up our pharmacies to handle all these prescriptions,” says Coehrs, “So central fill was the answer to serve the new patients we were bringing in, while controlling costs and inventory and rationalizing operations.”

Rationalizing operations can mean putting existing capacity to better use and can be an important motivation, as we can see in examples offered by both Medical Center Pharmacy and Fairview Pharmacy Services.

Fairview Pharmacy Services developed its central-fill operations close to eight years ago on the back of existing automation located at its headquarters facility used to fulfill mail-order and specialty orders. “We’d found that we had quite a bit of capacity at that facility,” explains Kyle Skiermont. “So for us it was a way to create multiple wins out of the technology that we had.” This realization aligned with an ongoing need to manage pharmacy staffing levels effectively. “We often find that we need to add staff at a location,” says Skiermont, “but what we need isn’t always a full-time pharmacist or full-time technician. So central fill has helped us address these incremental staffing needs.”

For George Awad, the “aha” moment that Medical Center Pharmacy could be better using its capacity came when he drove by and saw three of his delivery vehicles on the same street at the same time. “I said to myself, this is not efficient,” he explains. “I decided to collect all the delivery packages in one spot and reroute them. We went from 28 delivery cars down to 17. This led me to start thinking about PAs [prior authorizations], about billing, and about other jobs we could do at a central location.” And so Awad leveraged the pharmacy’s workflow software and moved existing dispensing cabinets to one location to create a central-fill site. Central fill has also helped Awad be efficient with staffing, while following California’s regulations governing the pharmacist-technician ratio.

« Tanya Schmidt, Pharm.D., Central Sites Operation Manager, Thrifty White Pharmacy

Employee-owned regional chain with 91 locations serving the Dakotas, Minnesota, Montana, Wisconsin, and Iowa via a central-fill site in Fargo, N.D.

Central-Fill Eligible Prescriptions

Routing prescriptions into central fill creates a range of benefits. But in order to make the most of the process, you have to be sure the right orders are being filled there. So which ones are the right ones? In general, it’s all about assessing orders for urgency and availability of stock.

At Thrifty White the decision is based on several factors, according to Tanya Schmidt. First, the order has to be fillable from a formulary list of what are typically maintenance medications. Next, a patient should be signed up for the pharmacy’s Ready refill program or for Med Sync. Finally, the patient has to give consent for central fill.

Similarly, at Kinney Drugs, any routine prescription that meets the correct promise time is a candidate for central fill, according to Dave Adsit. For example, a routine medication that a patient doesn’t need until the following afternoon will ideally be filled centrally.

The Pharmacy Counter has a centralized order-processing location where the staff triages prescriptions that come in via phone, the Web, or IVR, or that are generated by autofill. Technicians batch the prescriptions within the workflow, which means that they assign them to a location for filling based on several criteria. Then, according to Bryan Coehrs, if it is a viable central-fill prescription, the staff puts notes in the Rx notes field that tell central how to route the filled prescription: to a store, mailed, or delivered to a patient’s home. If it is needed right away, it gets routed directly to a store for filling.

United Rx is a little different, since it’s serving primarily skilled-nursing facilities, with its central site providing prepacks to its satellite locations. In this case, it’s all about using pharmacy system reporting features to keep track of the most frequently dispensed medications for each location. According to Ami Patel, United Rx’s goal is to prepack the top 200 most-used medications, with consideration given to differing facility formularies.

« Ami Patel, Pharm.D. , Director of Pharmacy United Rx, Hillside, Ill. 

Closed-door pharmacies serving primarily skilled-nursing facilities and institutional clients, with main location in the Chicago area that provides central compliance prepack for satellite locations in southern Illinois and Indiana.

The Technology: Software

While some might immediately envision conveyor belts and robots when they hear central fill, there’s actually no single technology that makes these sites tick. Just as in other dispensing environments, it’s about putting together the right elements to meet the specific demands of a given pharmacy operation. As such, software, dispensing automation, communications services, and logistics all play roles.

Software from QS/1 is central to The Pharmacy Counter’s process, as Bryan Coehrs explains it. “We’ve used a call center for prescription intake for a long time now,” says Coehrs. “Originally, this is where we took prescription numbers and then passed them along to the local pharmacy for fulfillment.” This call center has now evolved into what The Pharmacy Counter calls its Pharmacy Customer Service/Triage center. It is staffed by seven certified technicians, who take orders and batch them in the QS/1 NRx pharmacy management system for routing either to a store or to central fill, where they enter a filling process driven by AmerisourceBergen Technology Group’s OptiFill automation, which combines FastFill 220 robotics and a conveyor system.

Even IVR can come into this mix, since the standard system parameters for distributed fill don’t necessarily make sense when applied to central fill. This is what one chain found, according to Duane Smith, director of technical services for voiceTech. For example, the pickup time for prescriptions centrally filled may not be the same as for those filled in the pharmacy itself. So the IVR system needs to automatically assign a pickup time for the next business day, but add additional time if an extra step is needed, such as when a prescriber authorization is necessary. 

You also need flexibility in determining the cutoff time when the prescription is not going to be available to be
picked up on the next business day. This gets complicated when the cutoff time isn’t necessarily the same as when the pharmacy closes. Other factors that IVR needs to consider when assigning a promise time are proximity of the pharmacy to the central-fill location, the delivery method used, and whether or not a delivery is possible on a particular day for a particular location (i.e., if the local pharmacy is not open seven days a week or there’s a holiday). 

George Awad, for example, subscribes to this idea of centralizing other processes and technologies, including IVR and functions within the dispensing flow, which at Medical Center Pharmacy is driven by HBS software. 

The Technology: Hardware 

Of course hardware that automates the fulfillment process plays a major role in central fill as well. This ranges from countertop counting to counting cabinets, robotics, and conveyor systems. Thrifty White uses a sophisticated array of hardware to fill prescriptions at central fill, according to Tanya Schmidt. There are ScriptPro robots being fed vials by a puck-based conveyor system used to carry orders, as well as an autobagger and autocappers. In the manual-fill area, Thrifty White is using Kirby Lester counters. “So there are quite a few systems working together at one time,” says Schmidt.

The pucks are an interesting and advanced feature. They use RFID tags to transmit details to the conveyor and robotics about just where they are going and what needs to go in the vials. Schmidt is also quick to note that the ScriptPro robots are not what you’d find in a typical retail location. “They’ve been customized and configured so that a conveyor belt brings the vials in the pucks directly into the base of the robot, and then an arm picks up the bottle for filling,” she explains.

« Bryan Coehrs, Pharm.D., Director of Pharmacy Operations The Pharmacy Counter, Toledo, Ohio

Nine-location pharmacy subsidiary of ProMedica, a health system in northwestern Ohio and southeastern Michigan. Four standard community retail locations are the primary locations served by central fill.

At Fairview Pharmacy Services, refill prescriptions coming into its McKesson EnterpriseRx pharmacy management software are routed to central fill based on preset parameters, according to Kyle Skiermont, and then passed into a central dispensing workflow driven by OptiFill II from AmerisourceBergen Technology Group. Fairview’s OptiFill system combines a barcode- managed conveyor-driven workflow to route totes through the filling process, including to AmerisourceBergen’s FastFill 54 robotics or manual dispensing stations, pharmacist verification, and packing for delivery to local sites. “It’s a heavily automated process,” notes Skiermont. “One key aspect is the barcode readers that track the totes and route them to the right stops in the workflow.” This is critical for allowing Fairview to efficiently manage and track all the many prescriptions run through the OptiFill technology, which includes not just refills for delivery to local pharmacies, but specialty and mail-order prescriptions as well.
But you don’t necessarily have to commit to this level of automation to run a central site successfully. For example, United Rx decided to install packaging automation when it made the move to central prepack, and the solution turned out to be as simple as four DOSIS compliance packagers from Manchac. “DOSIS allows us to prepack for different days’ supply: seven, 14, 28, or 30,” says Ami Patel. “We can have it programmed for this and keep things sorted by each pharmacy location’s needs.”

The situation is similar at Kinney Drugs and Medical Center Pharmacy. Kinney Drugs’ central site currently relies on a mix of Parata Max, ScriptPro robotics, and Kirby Lester KL1 tabletop units to provide a level of automation, according to Dave Adsit. This allows Kinney to maximize efficiency, while minimizing expense.


« Kyle Skiermont, Pharm.D., Vice President of Operations, Fairview Pharmacy Services

Minneapolis-based health-system pharmacy owned by Fairview Health Services. Outpatient pharmacy operations include more than 35 retail sites, specialty, mail-order, compounding, long-term care, and home- infusion pharmacies, as well as a small pharmacy benefit manager (PBM).


Medical Center Pharmacy was already using the Innovation PharmASSIST Symphony workflow system and SmartCabinets. The counting cabinets in particular were all moved to one pharmacy, and this has formed the core of a successful central-site operation for the last four years, according to George Awad. Notably, Awad now feels that he’s reached a point at which he can take the next step. He’s come to see that the pharmacy can’t continue to grow with what is essentially a manual system, even taking into consideration the counting cabinets. “We don’t have the space for additional automation or people,” he says. “The only way to expand is by restructuring to complete automation, which is why we are in the process of a central-site redesign that will include two dispensing pods with Innovation’s RDS ROBOTx machines, a conveyor system, a sorter, and a capper.”

What Changes In-store

With all the automation at central sites, what’s happening with in-store technology? Well, it depends on the pharmacy, of course, but in general the drive to rationalize and concentrate automation investment, particularly in higher-cost robotics and counting automation, means that there’s likely to be less out in the field. In part this is because central fill can be based on bringing together existing automation in one place, as we saw with George Awad. This was also the case for Kinney Drugs when it was ramping up its central site. “When we started, we actually pulled some ScriptPro technology from a moderate-volume retail location and moved it into the central site,” says Dave Adsit. Kinney Drugs does, however, still use robotics in its high-volume locations, specifically the KL60 from Kirby Lester and the SP200 from ScriptPro. “We still have locations that require robotics in order to maximize customer service for prescriptions that aren’t viable for central fill because of the promise time,” notes Adsit.

Dispensing automation is concentrated at central fill at Thrifty White, too, and in the end this is part of the benefit of the strategy. “We’ve been able to use the space where we used to have dispensing automation as areas to better serve our patients,” says Tanya Schmidt. “For example, we have consulting rooms that put the pharmacists and the patients right across from each other for counseling.” 

Outcomes 

Just as there are a variety of reasons why a pharmacy will run a central-fill site, there are also many different benefits that they can derive. George Awad has a good-sized list, starting with how central fill streamlines the work at Medical Center Pharmacy. “We control the majority of the work in one place,” he says. “There’s better quality control, and when we make any changes, we implement them all at once and can keep a close eye on everything much more easily.”

Tanya Schmidt also points specifically to streamlining workflow as a hugely positive outcome at Thrifty White. “There are definitely benefits for ensuring quality and accuracy, too,” she says.

For Dave Adsit, the key benefit of running a central site is that many of the operational and professional activities that happen in a retail location do not occur in central fill. “This allows us to stay focused on the task at hand and fill high volumes accurately and efficiently,” he says.

United Rx’s central prepack has a big impact, too, according to Ami Patel — both controlling labor costs and increasing productivity at all locations. “At our Hillside location, we have just one technician who manages all four DOSIS machines,” says Patel. “He knows the ins and outs of maintaining the inventory and the automation, and he makes sure they are set to run overnight.” That right there is a lot of filling capacity from one staff member. But this productivity also frees up other staff members, both pharmacists and technicians. “This is a big contributor to cost-efficiency,” says Patel. “For example, central prepack allows us to get more work done at our satellite pharmacies during shorter hours, say 9 to 6.”


« George Awad, R.Ph., Director of Pharmacy, Medical Center Pharmacy, San Diego, Calif.

Thirteen-location pharmacy filling around 1.3 million prescriptions a year overall. One location provides central-fill services for all locations.

 
Central fill also helps rationalize inventory. United Rx once again offers an example of how this works. “Having our high-volume prepack delivery centralized in Chicago means that we get to select and fill the most cost-efficient NDCs,” she says, “and we can order larger bottle sizes to reduce costs when it is a drug we are using a lot of across all our locations.”

Overcoming Barriers

There are also concerns, real or perceived, that you may have to address about central fill. For example, Bryan Coehrs sees the biggest challenges, without anything being a close second, as logistics and communication. “You have to be careful there,” he says, “since you can kill the efficiency if your process means that communications don’t make sense downstream.” For example, notes Coehrs, you want to be sure that the staff doesn’t select the wrong NDC for filling at central, or the fill will be rejected. “We’ve been working hard to develop consistent communication methods to ensure there is no ambiguity regarding the order. We hold regular meetings and try to resolve issues before they become big,” he says.

Another issue that people perceive is the need for the right geographic distribution of locations to have central fill work. However, both Kinney Drugs and Thrifty White are able to serve locations across a wide area from a single central site. Kinney has its own distribution center, notes Dave Adsit, with in-house trucking routes for delivery. But Kinney also works with UPS to support the central-fill strategy. “We’ve found that we have been able to move prescriptions to distant stores very quickly,” says Adsit.

Central fill might also be perceived as outsourcing prescriptions, which is categorically not the case. Both Dave Adsit and Tanya Schmidt emphasize how important it is to be sure people understand that these are prescriptions being filled by the pharmacies’ own staff to the highest standards of quality and precision. “Some people may not realize that there’s probably even greater consistency of quality in a central site than we can achieve in-store,” says Schmidt, “because of the automation applied to filling and routing and the RFID-driven management of orders.” 

And of course, one real consideration is that getting central fill going requires a lot of time and planning. “You have to be sure you are selecting the right drugs for your central fill and understand how your process is going to handle variations in the needs of the patient populations your locations serve,” notes Ami Patel. “For example, we have a top 200 list for each pharmacy that we are tracking in our SoftWriters FrameworkLTC software, and we made sure that it was going to be easy to swap out canisters in the DOSIS packagers to meet the needs of each location. There is time involved in getting all this right at the beginning.”

Even though Fairview Pharmacy Services was already running the AmerisourceBergen OptiFill technology platform it would end up leveraging for central fill, it still took some time to ramp up this part of its operations. “We found that it’s a little bit of an art to decide which stores to turn central fill on for,” says Kyle Skiermont. As he explains it, you need to understand the effective filling and patient care capacities of a local site in order to know if there’s a need for support from central fill in a given case. “We want to make sure that we were both capitalizing on our automation’s capacity and still using the capacity at our sites fully,” says Skiermont. “This is an ongoing process for us.”

Finally, you and all your staff need to have confidence in the consistency of your central process. “We run our prepack operation 24/7,” says Patel, “and we had to be sure that everything was going to run smoothly overnight. Our experience with the automation and our attention to process has given us this confidence.”

Metrics 

But even with all the promise that central fill offers, how do you really know that it’s meeting strategic goals? What measures should you look to, to judge success? Bryan Coehrs believes this means thinking hard about what your end game is. “Some pharmacies might have the sole goal of reducing in-store staffing or downsizing expenses,” he says. “While we have been able to accomplish this, we also focus on how central fill creates efficiency and capacity, and supports patient care capabilities.” Coehrs is confident that central fill is reducing the filing burden for The Pharmacy Counter locations. “At our busiest store, which produces the largest share of our central volume, we’re seeing just over 50% of our prescriptions going into central,” he says.

Metrics that show prescription throughput to central fill are indeed important, according to Dave Adsit. Kinney Drugs keeps a constant eye on prescriptions filled at central each day and the overall percentage of volume handled there. “These numbers determine just how powerful your central fill is,” he says. “These are measures that we continue to look at and that we want to improve on annually.”

There’s an equal emphasis on continual assessment of the impact on efficiency and labor costs at Thrifty White, too. “We are a 100% employee-owned company,” says Tanya Schmidt, “and so everyone understands the value of making both the central-site labor and local pharmacy labor as productive as possible. For the one it is filling scripts as efficiently as possible. For the other it is doing the most you can to build patient relationships.”

It’s also important to look at return on investment, which can be a little tricky considering all the different factors involved. “We haven’t quite got our head around how to judge the value yet,” admits Bryan Coehrs. “There are different metrics, such as workload units or number of prescriptions filled per technician, that we are looking at, and we’re operating on the assumption that central is a less-expensive way to fill prescriptions. But we haven’t found the exact right measure of this yet.”

And while lower costs are without a doubt a good thing, it is important to reiterate that they shouldn’t necessarily be your main focus, according to Kyle Skiermont. “We know that whatever the variables are, it is appreciably less expensive to fill prescriptions at our central site,” Skiermont says. “But while saving money on the fill is certainly important, the primary motivation for us is that we can free up staff for patient service and create a better patient-centric environment for our staff.”

Establishing a specific ROI isn’t impossible, of course, as George Awad demonstrates. He has run the numbers to figure out what it costs him to fill a prescription at local stores and to fill one manually at the central location, and he’s estimated what it will cost once he has his robotic solution installed at central. “I will tell you very simply, the cost is less than half at our central location filled manually,” he says, “and I should get that down to less than a sixth of the cost once we’re filling with a robot.”

Creating Winners

Central fill has certainly come into its own, and there remains a lot of promise in it for a lot of different kinds of pharmacies. “Central fill fits into what we are trying to do,” says Kyle Skiermont. “It’s positioned right in that wheelhouse of better outcomes and lower costs.” Central fill has evolved into one of those situations where there can be winners all around — in this case, pharmacy, staff, and patients. The pharmacy wins when central fill increases efficiency and reduces costs. “As reimbursements keep going south all the time, the only way we can survive is by filling high volumes efficiently,” says George Awad. “Rather than work three times as hard for less money, we decided to look to central fill and automation to help us.”

A better pharmacy business certainly benefits pharmacy staff, too, but the impact on staff is also seen in other ways, according to Tanya Schmidt. “We have had very positive reactions to central fill from staff, and particularly from pharmacists coming to work for us,” she says. “You go to school to help patients, and some pharmacists can be reluctant to take a retail job because they are afraid they won’t be able to use their clinical training. When they are able to do that in our pharmacies, it makes it very easy for them to see the advantages of a central-fill site.”

And finally, there are the patients, who win when pharmacists and technicians find they have the time to focus on people rather than pills. “We’re definitely seeing that central fill is taking The Pharmacy Counter where we want it to go,” says Bryan Coehrs. As the volume going into central fill has increased, The Pharmacy Counter’s pharmacists have more time for clinical activities, according to Coehrs. Immunization numbers have gone up, the ability to evaluate adherence has gone up, and the pharmacy is able to look at getting more into the specialty market. “I’m a pharmacist myself,” says Coehrs, “and I firmly believe that our most important role is with the patient.” Certainly Coehrs is right about this, and as the practice of pharmacy continues to tighten its focus, central fill should continue to evolve to support it. CT

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


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