There are many ways in which pharmacies can move beyond traditional medication-dispensing activities and the standard retail model. The right way to do this and be successful is clearly going to vary from pharmacy to pharmacy. Here, we focus on just two examples of pharmacies that have built their businesses around providing cutting-edge services. At Madison Avenue Pharmacy, this has meant leveraging skill in running a retail pharmacy into offering not only valuable long-term care services, but administering a pharmacy benefit for World Trade Center first responders as well. In the case of Village Fertility Pharmacy, the focus is on providing fertility medications, a practice with some unique demands even for specialty pharmacy. In both cases, there's technology that supports these efforts by providing the time and tools needed to carve out a niche.

Madison Avenue Pharmacy

Your first impression upon walking into Madison Avenue Pharmacy in New York City will be of a thriving retail operation. And you certainly won't be wrong. But while this 1,400-square-foot store has always had a steady business from clinics at Mount Sinai Hospital, which is across the street, as well as from the surrounding Upper East Side neighborhood, a lot has changed in the last seven years. That's when Marc Brandell came in as chief operating officer and supervising pharmacist. "When I came in, there was another pharmacist   and myself. We serviced the clinics in Mount Sinai Hospital, including pain management, palliative care, and internal medical associates," Brandell explains. "It was a straight forward pharmacy business filling between 300 and 350 prescriptions on a good day." The technology and workflow were pretty standard for the time as well. As Brandell describes it, a pharmacist did data entry, the technicians filled, and another pharmacist helped with filling and did the final verification checks. This was a completely manual process.

Then some changes in personnel offered an opportunity for Brandell. "First, I had a person whom I trained to do the data entry, which freed up one of the pharmacists," he says. While this meant the workflow didn't have to stop for every call that came in, there were still work-stopping events such as when someone called in asking about a prescription or raising a question about a dispensed prescription. "Everybody stopped and looked, or someone had to go to the file to look up a dispensed prescription to verify it was correct," says Brandell. By his own admission, wait times at Madison Avenue Pharmacy were pretty long, and he didn't really know what to do about it. "Were we going to hire more people?" he asks. Then, there was another event that started the pharmacy down the path to installing technologies that fundamentally changed the kind of services that Brandell and his staff can offer.

Change Arrives

What happened was that Madison Avenue Pharmacy's regional wholesaler went out of business and McKesson entered the picture. Brandell was apprehensive. "I'm a local New York guy. I like local business," he says. On top of this, Madison Avenue's owner, Rich Schirripa, wanted Brandell to take a look at what McKesson's automation division - called McKesson APS at that time - could offer. "They said that they could help with our wait times. But I was dead set against automation and I told them so," says Brandell. "I told them ‘Every time you automate someone loses a job. These people are family to me. We are not losing anyone, and I will not jeopardize anyone's job.'" Despite his misgivings, Brandell filled out a questionnaire describing the pharmacy's operations and then flew out to a trade show to look at the automation in person. "It looked fine," he says. "Then we went out to dinner and the people from McKesson APS say, ‘Based on your data, we can decrease your wait times by X amount and increase your volume by X amount without firing or hiring anyone.' I said: ‘I'll believe it when I see it.'" Schirripa, however, was sold and told Brandell to move ahead. The three components were workflow, automated will-call cabinets, and four AccuMed cabinets that could hold up to 72 drugs. Brandell, in his capacity as managing pharmacist, did set some ground rules for the installation. "I told them that if we were going to do this, we were going to have to stagger the installations," he says. Brandell worked to set up a plan with three steps in the installation: the workflow, then the AccuMed cabinets, and then the will-call, each 30 days apart.

The New Technology

"The day comes when the guy arrives to drill the counters for workflow stations and we were all hit by the fact that this was a reality," says Brandell. "And we still weren't sure what to expect." As it turned out, Brandell reports, his people loved the new workflow technology within 30 minutes of getting it running. "The biggest mistake we made at that time was that within three days we were saying to ourselves ‘Where are the AccuMed cabinets?'" he says. Brandell and his staff were thrilled with the bar-coding, the scanning, and the other workflow features. "All of our major problems with keeping patients informed and finding prescriptions and making sure the right drug went out were gone," he says. Case in point: Before Brandell joined Madison Avenue Pharmacy, there was an issue with the DEA over controlled substances. "There was no ownership in the filling process," he explains. "If   there were a mistake with a Class II, the DEA wouldn't know who to fine, so they'd fine everyone." After the pharmacy installed workflow, the DEA revisited this issue and asked Brandell, as the managing pharmacist, what he was doing to prevent any future occurrences. "I told them that we'd just put in McKesson's P2000 workflow, which has bar-code tracking," he says. "The DEA said ‘Thank you very much. That covers it.' And we haven't heard from them since, because the bar codes mean that everyone has ownership of the steps in the process they handle."

Next came the AccuMed cabinets, followed by the will-call cabinets. Brandell installed the AccuMeds against a wall in a location that made them visible to the pharmacy's patients. "It looked pretty cool," he says. More importantly, this counting technology had a major impact on the pharmacy's efficiency. "Now we didn't have to run to the shelf for our top 72 drugs," Brandell explains. "And we found out that, you know what? When it is easier to fill prescriptions and solve problems, our pharmacists can fill more efficiently and pay more attention to the doctors, to the phone calls, and to our patients." This could not have been more important, since Madison Avenue Pharmacy was built on a service-oriented model. "We added this technology, and even as we started filling more prescriptions the service level went up, not down," he continues. "My pharmacists had clear heads."

Always ready with a good example, Brandell offers this story about the impact of workflow, counting, and will-call automation. "Rich, the owner, comes in one day for a meeting we had scheduled. He looks at the line and he's a little upset and he comes to me and he says, ‘What are you doing? You are the only person with free hands and you've got 15 people in line.' I say, ‘Really? Come into the office.' When we got there I showed him the security cameras, and in the time it took to walk a few steps back to the office, the line was gone." Brandell offers an important observation based on such experiences: People don't mind standing in a line they know is going to move.

Change, Again

Volumes increased at Madison Avenue Pharmacy, and Brandell was extremely pleased with the fill-through-automation rate. "Between the AccuMed and unit-of-use, we covered 45% to 50% of our dispensing," he says. And then, naturally, new challenges arose. "We closed one of our stores a couple of blocks away," Brandell says. "Rich didn't want to sell to a chain.  He wanted to bring as much of that business here as possible and he didn't want any of that store's staff out of work. In addition to that, we had the opportunity to begin serving an LTC facility," he says. This was all on top of the obvious need to continue serving the pharmacy's existing patient base. "It was a triple threat, and we had it happen all in one shot," remarks Brandell. Volumes shot up to 650 or 750 overnight. "AccuMeds just weren't doing it anymore," says Brandell. "I'm saying: ‘What am I going to do?'" Brandell sat down with Schirripa and put it this way:  "We can't handle this. First, it's not safe. Second, we have hour wait times. We're losing our core patients and we can't satisfy the accounts we signed on because of the service we provide." Within a month, Madison Avenue Pharmacy had replaced its counting cabinets with Parata RDS robotic dispensing. The irony in this story doesn't escape Brandell. He went from being the guy whose first reaction to automation was "no way, no how," to not being able to live without it.

Now when Madison Avenue has a busy day, filling say 550 prescriptions, Brandell is happy to find that his people are able to take a break. "I'd rather they have a little down time and be able to emphasize safety and be able to give the customized service we're known for," he says. "And if someone is on the phone talking with a doctor or a patient, I don't want them   to feel pressure as baskets of prescriptions  pile up."

The New Services

Of course, this arc away from being a manual-fill, manual-process pharmacy is something increasingly common. What's important is that Brandell has seen opportunities to build on the service levels Madison Avenue can now provide and the volume it can now handle to develop services that make the pharmacy stand out. "The technology helped us to think outside of the box to create new revenue streams," he says.

For one example, Brandell points to his ability to set up an LTC facility so that doctors can see patient profiles using nursing home software from Opus-ISM, the same company that provides the pharmacy's software for processing its retail prescriptions. "These profiles offer facility-specific, doctor-specific, and real-time information that I can make available to any doctor who requests it," Brandell explains. "If there's a question about exactly what meds a patient's taking, the doctor can access the profile in real-time to answer any questions. This saves the doctor the time of a phone call and the pharmacist time answering the questions." For another example of Brandell's ingenuity, consider the out-of-the-box Palm calendar that he's set up to show which patients are due for filling at each LTC facility each day. "Every week we print it out and I use it to schedule my staff," he says. What Brandell's come to realize is how much easier technology can make life. Whether it's designed specifically for pharmacy or is a generic application that anyone might buy, like this calendar, there are tools that make sure the pharmacy's staff is calm, focused, and informed. Technology supports a service level that's worth talking about, in Brandell's opinion, and it even helps him make the time to do just this - marketing the pharmacy to potential clients at clinics and LTC facilities. "When I bring in a  facility or a medical director who is a prospective customer, they are amazed," he says. "Our pharmacy looks like the Bridge of the Starship Enterprise to them. I show them the workflow and the RDS. I tell them we have these systems in place to safeguard against error and ensure the information they get when they call us and ask what's going on is 100% correct."

Helping Heroes

There's even more to what Brandell's been able to accomplish at Madison Avenue Pharmacy. As mentioned earlier, he's found the time and the capacity to build a rather unusual service on the pharmacy's success: being a pharmacy benefits administrator (PBA) for a program called Health for Heroes, which provides care for uninsured World Trade Center first responders. "A clinic at Mount Sinai came to us about five or six years ago and told us about the program and said they were looking for a central pharmacy to fill the prescriptions," explains Brandell. The program started out small. Two of the clinic's requirements were that Madison Avenue Pharmacy needed to be able to handle the billing and to provide the clinic with detailed reports that would support a study based on the program. Once the clinic gathered enough data to issue a report about the many healthcare issues first responders face, the program's profile grew and so did the number of participants. "We went from handling 50 prescriptions a quarter for Health for Heroes to maybe 1,000 prescriptions a month," says Brandell. The growing program, originally privately funded, now attracted federal money. This meant that the clinic had to put the prescription portion out to bid.

Far from quietly letting a for-profit PBM answer the request for proposal (RFP) and take over the administration of this program, Brandell got to work on his own proposal. "Our McKesson Access Health membership provided us with the resources to go out and find a boutique company that could help us become a PBA offering totally transparent pharmacy benefit administration services on a cost recovery model," explains Brandell. With this help, Brandell put together a response to the RFP that he felt was in the best interest not only of the Health for Heroes patients, but of independent pharmacy in general. "We created a model that is competitive in the market and offered three tiers: open network, select network, and an exclusive network," Brandell says. It was such a sound proposal that the competition finally came down to one of the big New York chains and Madison Avenue Pharmacy. The chain won - at first. Just four months later, the clinic was back talking with Brandell, who had promised to honor his original proposal if needed. "They weren't happy dealing with the big chain," he says. "They wanted to know how soon we could be up and running. I said: ‘Two weeks.'"

Participating in the program has been a big responsibility, with patients who deserve the best care and the federal government keeping a close eye on the money spent. "The Health for Heroes program is audited more than any program you'll see in your life," says Brandell. But, overall, it has been a tremendous opportunity that Brandell wouldn't have had the time or expertise to pursue if he hadn't put Madison Avenue Pharmacy in such a competitive position. And while Madison Avenue Pharmacy recently ceased to be the exclusive pharmacy providing the benefit, as a result of the program's desire to offer patients more access points, Brandell isn't worried about the resulting drop in volume. "First of all, our pharmacy is about healthcare, not wealthcare," he says. To him, this means that the primary goal is looking after patients. When this is done right, the bottom line takes care of itself. Moreover, Brandell is confident that his focus on service is going to help Madison Avenue Pharmacy come out on top. "We understand this program and can make decisions for it in a snap," he explains. And he's taken action, using his technology, of course. "When our volume went down, we went into our Opus-ISM software and created a report showing the people who were due for refills on a certain day. We call them, maybe 20 each day, and tell them that we know they have a choice of where to go, but we're still in the picture. You wouldn't believe the relief people have expressed."

Ultimately, everything works together at Madison Avenue Pharmacy, in Brandell's opinion. "Without the automation and workflow we wouldn't have grown, we wouldn't have been ready to meet the new challenges," he says. "And without Access Health, I wouldn't have been able to find the people I needed to know to write the proposal and we wouldn't be a PBA." Brandell continues by saying that he's learned that who you partner with is extremely important. "You need to know what your vendors offer that you aren't using. What might seem like ancillary services a vendor offers can have real value that will affect your bottom line and the volume that you do."

Village Fertility Pharmacy

Village Fertility Pharmacy opened in 1986 in a medical building in Brookline, Mass. According to pharmacist, co-founder, and president Stuart Levine, this first location was in a big medical building, with 40 or 50 offices and about 80 or 90 doctors. "We aimed to be a busy medical-building pharmacy," he says. Then two fertility practices opened. "All this stuff was in its infancy at the time," Levine explains. "So we made a point of working with these fertility specialists. We learned very quickly and assimilated this into our regular business." This medical specialty grew quickly and Levine and his partners hired sales representatives to detail other fertility clinics that were opening in New England. This led Village Fertility Pharmacy to evolve from a retail pharmacy to one that specializes in fertility medications, according to Levine. And what started out as a single pharmacy with two pharmacists and a couple of technicians now employs 40 people, including not only pharmacy and nursing staff, but also a dedicated team to manage IT, communications, sales and marketing, and business operations. The company has two locations, one in Waltham, Mass., and one in Lincoln, R.I.

The Specialty

"Fertility is very different from regular pharmacy, and even within the specialty field it's unique," explains Levine. The first reason for this is that fertility medications are almost all self-injectables that the patient administers in her own home. Second, the length of treatment is relatively short, generally 10 to 12 days. Third, the number of medications used within that period is high, with two or three typically used on each day of the cycle. The complexity doesn't stop there, according to Levine. Dosages change within the cycle, which means that Village Fertility Pharmacy needs to stay in touch with the patient. "We have to be able to react very quickly and make changes in a patient's medications," says Levine. "Contrast this with a more typical specialty pharmacy that's filling prescriptions for, say, growth hormone. They know the dose and, while they may call
to verify it, they can still automatically ship every month. This is a night-and-day contrast with what we do in fertility."

Now consider these points in combination with the fact that there aren't many fertility specialty pharmacies out there — roughly 40 across the country, by Levine's estimate. This means that as Village Fertility Pharmacy has grown, it has been building a significant mail fulfillment operation that serves patients nationwide. It has to manage this alongside walk-in patients who live near the two locations. This has meant a transition to technologies that fit the special demands. Village Fertility Pharmacy's business operations manager, Charlie Chagnon, who also oversees the company's IT department, has been behind many of the changes. "When I came on board at Village about five years ago, it had already grown into a pharmacy with complex ordering and distribution demands," says Chagnon. "At the time, we still had the retail HBS pharmacy management system. This was good, but it didn't have nearly the mail-fulfillment capabilities we needed." As a result, Chagnon helped orchestrate a move to HBS's RxAXIS mail-order system, which is now the hub of the business.

System Specifics

Chagnon points to several major elements in this software that are critical for Village Fertility Pharmacy's mail-fulfillment needs. First is support for an integrated call center. "When our technicians take calls from our patients, they can log into the software, access the patient record immediately, and take all the standard call-center notes, which are then permanently associated with that record," he says. This access to a common profile for the two locations is made possible because the HBS application is hosted on a server in Virginia, which each location accesses by VPN. "We own the software, but we don't own any of the server hardware," says Chagnon. He points to other big advantages from this leased hosting arrangement. "When I arrived we had all our data on a server sitting on the floor of the pharmacy," relates Chagnon. "Now this hardware is in a full-blown, managed data center with security, backup power, a RAID 5 backup array, and huge bandwidth. I had an easy time convincing Stuart that the server was his business and the pharmacy was not a state-of-the-art environment for such important data."

Another big piece is that the mail fulfillment software can group prescriptions in orders and then process them together. "Our typical order is for six to ten medications," says Chagnon. "These are batched and then stay together as they are adjudicated and go through the workflow." Next, the RxAXIS system also has features that let it tie into Village Fertility Pharmacy's UPS WorldShip tool. For example, it can keep multiple addresses on file and can track these by date, so a shipment goes to the address where the patient is. Chagnon explains further: "There is an ODBC connection between the two that allows us to generate the UPS label and add the order to that day's manifest by putting our system's order number into WorldShip. When we close out the manifest at the end of the workday, UPS transmits the information, including tracking number, back to RxAXIS where it is then accessible to techs and on-call pharmacists." Shipping information is also available to patients who have provided the pharmacy with an email address. "Many of our patients are at work during the day," notes Chagnon. "This integration means it is really easy for us to make sure they get an email that lets them know when a package has been delivered."

This tight control over order fulfillment and shipping is also critical to the major insurers that contract with Village Fertility Pharmacy to dispense fertility medications. "Insurers have limits on what we can dispense at any time," Levine explains. "There's an underground market for these drugs because of their cost. This makes it all the more imperative that we have a distribution system that allows
us to keep patients supplied with the right amounts, without oversupplying, and to document what we've done."

Payment Tools

Village Fertility Pharmacy also has particular requirements when it comes to billing and taking payment. "In the past, in the late 1980s and early 1990s, there was very little insurance coverage for fertility treatments and medications," says Levine. "Then the Massachusetts legislature passed an act that mandated that insurance companies cover the medications and services involved." Other states have followed suit, and there are now similar mandates in 14 states. Still, points out Levine, that leaves a lot of states that are self-pay for fertility medications, something that is not the case for other specialty pharmacy segments. These circumstances affect how Village Fertility Pharmacy collects payment from patients. "Drugs we dispense to patients with insurance are adjudicated normally," explains Chagnon. "But we still usually need to collect a co-pay, which can be significant. Then there are the cash patients, of course." This makes the credit-card features built into the HBS system extremely important. Not only can the system store card information securely in full compliance with PCI standards, but it can also process a payment automatically when an order is released. "In the retail system, we'd have to punch the numbers into a credit-card terminal manually each time we wanted to submit a claim," points out Chagnon. "We also wouldn't have an easy way to keep a secure, PCI-compliant record of the card number, which would mean that we'd have to ask patients for the number each time it's needed." Easing the task of charging credit cards is a huge advantage, according to Chagnon, since it creates a high level of patient service while also helping to ensure that an order never leaves Village Fertility Pharmacy without being paid for.

Using the Web

Village Fertility Pharmacy is also making good use of the Web. Levine cites two key features: online videos for patients that show how to inject each of the medications involved in the cycle, and a secure Web site that doctors can use to submit orders. "We produced the videos ourselves," says Levine. "Many manufacturers provide videos, but for some ancillary injectables, there aren't any." Six months ago, Chagnon changed these videos from MPEG format to pure Flash, which plays in the browser window. "This eliminated the problems patients had accessing the videos in MPEG, which depends a lot on the individual's computer setup," he explains. "Our bandwidth charges also went way down." While Village Fertility Pharmacy is part of the SureScripts network and can also receive prescription orders by fax, the Web-ordering functionality supports the many smaller fertility clinics that have not yet brought in electronic prescription writing tools. "Our ordering site is specifically tailored to the needs of fertility doctors," Chagnon says. "It is a very popular way for many of our doctors to build profiles and submit orders based on them."

Making Changes, Making a Difference

Both Village Fertility Pharmacy and Madison Avenue Pharmacy are prime examples of how pharmacies can make a difference for their patients by carving out unique offerings and services. As Stuart Levine puts it, finding a niche is the wave of the future. "Develop a niche for yourself, whether it is specialty, compounding, HME, infusion, or something else," he says. "This is where independents can shine down the road." And as both pharmacies demonstrate, getting the right technology is an important step in creating your niche. "Any pharmacy that wants to compete and increase revenue streams, even if you are only talking about filling prescriptions, needs to have automation," says Marc Brandell. "It's the only way you are going to be able to get a leg up and improve your service levels. I talk to people and I ask: ‘Are you automated?' They say: ‘Well, I'm only doing 250.' I say: ‘Want to do 300? Automate.'"
Finding your niche can be very rewarding. "Yes, it's hard work," says Brandell. "But, ultimately, it's simply about providing the best healthcare. I consider myself an average Joe pharmacist. We only have 1,400 square feet, but we employ about 25 people. We've invested in the technology and we've let people know what we can do. We try not to say no." Stuart Levine and his partner and staff have seen great rewards from their niche at Village Fertility Pharmacy as well. "Our patients develop real relationships with us," says Levine "They will call and ask for pharmacists and technicians by name. What's even better is when they bring their babies in to see us." CT

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