As in past years, we continue to see systems upgraded in order to benefit from the latest features. And as you will gather, technology continues to factor in - in a big way - to help offset margin pressures and cope with rising prescription volume.

That said, we found that more than a third of the chains had upgraded pharmacy management systems in the past year, with a few switching vendors in the process. System upgrades are also on this year's agenda for several chains, and a few will be looking at new systems. What's interesting is that 60% of the upgrades were to workflow systems, but not in every store, since the feeling is that it takes 200 to 300, and perhaps even 400, prescriptions a day to justify these systems. The biggest advantage, as one person explained, is that workflow systems mean "no missing prescriptions, no amber alerts, and better control." Another benefit voiced was that these systems identify where each prescription is in the fill process, with better quality control. This explains why, in a high-volume pharmacy where things can get hectic at times, a system that can help smooth out the workload is worth the investment. The idea behind a workflow system is to distribute the work by workstation and track prescriptions in the filling queue. "These systems drive people to focus on their function in the pharmacy" is the way one respondent put it, and they reduce the risk of prescription errors.

Bar-Code Scanning

Bar-code scanning is another way to reduce errors. No surprise then that this technology has really caught on of late. More than 80% of the chains use scanners in the prescription process, and two-thirds of these chains are scanning in every store. These are much higher levels than found in last year's survey. Evidence that scanning is becoming the standard of practice is that in those chains not scanning in every pharmacy, most plan to increase usage. For the few chains not scanning, all but one plan to implement this technology.

We also found an increase in the use of pill imaging in the prescription process. Compared with 30% last year, this year 35% of the chains allow pharmacists and technicians to see an actual photo on the computer screen of the drug being dispensed.

And there was an increase in document imaging at intake this year, with 30% scanning the written prescription, compared with 20% last year. One chain reported that while it wasn't using document imaging at the moment, it soon will be.

Printers

We found a modest increase in the use of thermal printers; 20% of the chains use these printers, compared with 15% last year. Close to a third of the chains plan to install these printers. Advantages cited were less paper waste, small size, clearer printing, no toner cost, and speed.

With laser printers, the preference is the double-drawer model, with duplex printers a distant second.

IVR

Next to pharmacy management systems, IVR is the second most popular piece of technology used - more than 80% of the chains use IVR systems. And we found once again that 70% of the chains used these interactive voice response systems, if not in every store, in nearly every store. Only three chains have no plans to use this technology.

Owning the equipment, with each store having its own IVR system, is the popular choice, rather than outsourcing. Where the

system is outsourced, it is used by two chains to avoid busy signals. Only one chain reported using a centralized system for its stores.

Use of the system to remind people that their prescriptions are ready hasn't gained traction, with just 20% using this feature. Among those chains not yet using IVR for these outbound reminders, there was an even division between those that plan to and those that do not.

Front-Store POS Integration

Here we see another trend. A higher percentage of chains reported having the pharmacy management system fully integrated with the front-store point-of-sale (POS) checkout system - 40% this year, compared with 30% last year. Moreover, a few chains have plans for this or already have it in development.

What's holding some back is a lack of resources to handle the project, or the point-of-sale system and pharmacy management systems are older versions, with limitations on integration. In one case, the reason given was "there are too many different types of POS systems in our business."

Noted benefits of integration include better control over the will-call bin, accountability of prescriptions picked up through signature capture at the point of sale, and accurate prescription pricing at checkout.

E-Signature Capture

Even without POS integration, electronic signature capture devices are gaining in popularity. We found that 65% of the chains are capturing signatures electronically for third-party logs, the HIPAA privacy notice, counseling, and the like. We also found that for chains not yet using e-signature capture, 60% plan to install this technology.

Automated Counting and Robotics

The findings this year pretty much mirror what we found last year. Automated counting can be more easily justified in stores with lower prescription volume than robotics can. With counting, the popular perception is that justification can be made if the volume is in the 200-to-300 range per day. With robotics, the range is 300 to 400. However, in both cases there are those who feel that lower volumes can warrant use of these systems.

Automated counting systems have been around longer than robotics and therefore will be found in more pharmacies fitting the lower volume profile. Once again we found several chains using a mix of these systems, depending on store volume. In the aggregate, 65% of the chains use counting systems, and 55% use robotics in at least one store. When measured on the total store population for this year's survey, robotic systems are used in close to 15% of the pharmacies, and counting systems in 10%. One chain reported that it is pulling all of its counting systems and replacing these with robotic dispensing systems.

Are there plans to use more automation? What we found was that 25% of the chains were planning  either to install more automated counting systems or to install the first system. For robotics, the reading was 35%.

When asked to comment on the decision to install robotics over counting, one person explained, "Robotics is more efficient. Counting systems require too much manual assistance to allow you to reduce labor." Another comment was that "the robot labels and caps, in addition to counting, and then alphabetizes [the prescriptions] in a pick bin." One person liked the reports generated from the robot that help manage the pharmacy department.

Countertop counting systems, in contrast, are used in 65% of the chains, often in tandem with high-capacity automated counting and robotic systems. Not every pharmacy within a chain is using these counters, however. We found use in only 15% of the total pharmacy locations.

Other findings included bidirectional interfaces with the pharmacy management system, which are likely to be more common with robotic systems than with counting systems. And there is a high level of counting accuracy with these systems. Reliability is also high, with minimal system downtime being experienced.

With robotic systems, a few respondents mentioned the vendor's reputation for customer support as an important consideration in vendor selection. With so much of the prescription volume riding on these systems, quick response to system malfunctions is essential. Everyone was pleased with vendor support when problems surfaced.

In-Store Clinics and MTM

In-store clinics have certainly caught on - close to 60% of the chains have these clinics. With these, separate systems are generally used to document the encounters and bill for the service. When these claims are billed electronically to the insurance company, it is usually via the X12 837 transaction.

With Part D medication therapy management (MTM) programs, we found that 60% of chains are participating in these programs. However, the average number of patients per store singled out as candidates for MTM by the Part D plans is not significant. One person simply said "too few to be meaningful," and another said that just a "small number" are being referred. The expectations that pharmacy would be mainstream to this component of the Part D prescription program has yet to materialize, based on survey findings.

In addition, we learned that 85% of the chains actively involved with Part D MTM are documenting these encounters through a web portal.

The MTM program most frequently mentioned was Community MTM Services, now known as Mirixa, which uses a web-based interface.

What makes the web a good option for Part D MTM is that 95% of the chains provide pharmacists with web access - 70% of the chains control the sites that can be accessed; 30% do not.

Electronic Prescriptions

Close to 60% of the chains reported seeing an increase in electronic prescription activity in the past year. This is a dramatic increase from 25% last year. However, the number of prescriptions coming in from physicians, while growing, is still low - less than 3% on average. As one person commented, "It's still minimal." In fact, several chains have yet to see any electronic prescriptions.

But as physicians ramp up with the technology, electronic prescriptions will become more commonplace. One example is a chain that has a store seeing 25% of prescriptions arriving this way. Another reported that it has a store in a pilot with physicians, and they are experiencing "many," particularly for refill authorizations. One can infer from this that there are pockets where physicians have embraced e-prescribing.

NPI

The national provider identifier (NPI), now required by the HIPAA legislation, is a trouble spot for pharmacies. Roughly 70% of the chains reported difficulty in getting physicians' NPIs. The problem is that many doctors still do not have a number - more than 90% gave this as the reason.

Responsibility for getting this identifier rests with the pharmacists and technicians. This is the case with 50% of the chains, with 25% handling the task at headquarters and 25% using a combination of headquarters and store personnel.

Only three chains have had experiences with bad NPIs. One person explained that they were given the wrong number by the office staff, i.e., the entity's number rather than the prescriber's.

With the high number of third-party plans that are still not ready to accept prescriber NPIs and are working under the CMS contingency plan to buy more time, this is not causing a problem with pharmacy billing. However, it has caused some inconvenience, because pharmacies have to make sure to send the number that the plan is set up to accept, which means maintaining the plan's parameters in the pharmacy computer to ensure that the correct number is being sent.

CMI and MedGuides

With the deadline drawing near for the FDA's second shopper survey, we found that two-thirds of the chains have done nothing to bring consumer medication information or monographs being handed out into compliance with the Keystone Guidelines - not much different from last year. With those that have stepped up to correct the deficiencies, the area most frequently addressed was larger point size for better readability; a few also shortened line length.

The medication guides, or MedGuides, that manufacturers are required to distribute to pharmacies for drugs that the FDA has singled out as having high risks are proving difficult to obtain; close to 40% of the chains are having a problem getting them.

Measures taken by the chains to ensure a ready supply of MedGuides include placing the guides on their intranet for downloading or providing access through the Internet. In other words, in a few cases chains have undertaken to produce these documents on their own for the prescriptions involved.

CSOS

This DEA-approved electronic method of ordering controlled substances is seeing increased usage. This year 30% of the chains are using CSOS, compared with 15% last year. Where CSOS has not been implemented, close to 60% reported plans to use this ordering system. One chain was in the process of testing at the time of the survey. Another has it on its to-do list.

Benefits being realized include getting next-day delivery, easier check-in, and the time savings and convenience of this digital-certificate-based, electronic ordering system.

Preedits

This service, which network switches began offering several years ago to catch claims that would result in lower reimbursement, now enjoys widespread adoption. The response to this service has been nothing less than spectacular, with 90% of the chains using a preedit service, up from 80% last year. There were only three chains not using this service, with one of the three reporting plans to use it. And once again, there was no question that preedits can improve reimbursement.

The edit that provides the most value is checking that the correct dispense-as-written (DAW) code is being used for multi-source drugs. This was followed by the edit on average wholesale price (AWP) and usual-and-customary pricing. The value of an edit on the prescriber's DEA number got mentioned as well as the "resubmit" feature of these editing services.

ROI

Using a rating scale of 1 to 5, lowest to highest, we asked survey participants to rate various technologies for return on investment (ROI).

IVR was the clear winner this year, as in years past, with a weighted average rating of 4.2. Tied for second were e-signature capture and workflow systems, each with a 3.7 rating. This was followed closely by robotics, with a 3.4 rating. The lowest ROI, as was the case last year, went to automated counting systems, with a 2.9 rating.

On balance, the ROI for these investments is quite favorable, giving confidence to the decision that it is money well spent, particularly when factoring in considerations such as impact on staff productivity, improving quality of life, and contributing to patient safety. These are intangibles that also help justify the investment.

For improving staff productivity, IVR, robotics, and workflow systems were at the top of the list. Doing the most to improve the quality of life for the staff

was IVR, by far the largest vote getter, followed by workflow and counting/dispensing automation. When it comes to patient safety, workflow and robotics took the honors. IVR showed up on the list as well, because of the doctor-messaging feature of these systems that avoids handwriting misreads. Also getting mention for its patient safety factor were bar-code scanning and pill imaging.

But as a VP for one pharmacy chain noted, "elimination of PBMs and Medicare Part D" would have the greatest impact in all three areas.

What's Needed

While conducting the survey, we used the opportunity to poll respondents on new computer applications or improvements to existing technology that they would like to see. There were two mentions of biometrics, which the survey found are seldom used for access control to patient-sensitive information. One comment noted a need for "affordable biometrics." The cost could very well be the reason we did not find more use of biometrics in the survey. Another thought offered was that RFID would be a better alternative to biometrics.

Electronic prescribing made the list. One person mentioned the need to "improve electronic prescription translation into the pharmacy management system."

One improvement suggested for IVR systems would be to have these systems handle voice recognition for ease of use.

Then there was the cry by the owner of one chain for software to better manage inventory: "Somebody please write a program to forecast inventory usage to tell me when to order something based on historical usage, to keep inventory dollars off the shelves. Let's say we dispense a drug three times in 30 days, like the 5th, 10th, and the 20th. If we can generate a refill-due report, why not an inventory-due report, which is the same type of report? Something in the system could flag the drug as being due for a fill in the next three, five, or seven days, for example."

Where We're Headed

The technology used in pharmacy is providing a fairly quick payback, and we continue to see more integration of the various systems. Much of what's used not only helps increase the number of prescriptions that can be filled in a day, but also contributes to safety and a higher quality of life for pharmacists and technicians. The trend line for e-prescribing is positive, more attention is being paid to edits on third-party claims to increase reimbursement, bar-code scanning is becoming an important quality control measure, and more chains are turning to pill imaging and scanning of the paper prescription at intake to reduce prescription errors.

This all adds up to a lot of value being added in the prescription-filling process that benefits both pharmacy operations and the patient. CT

Bill Lockwood is the founder and publisher of ComputerTalk.