FEATURE: Networks of Care

An app is designed to support the most underutilized tool, that one- to two-minute encounter that happens 50 times a day at a community pharmacy.

There are a few consistent themes out there in pharmacy now, two of which are the changing role of the pharmacist from a pill dispenser to a provider of clinical services, and the need for pharmacy technology to be more tightly tied into the health information technology (HIT) spectrum. Of course, any pharmacist who has been into work recently knows that both themes have yet to really play out. But there’s reason to believe that the future is closer than we think. Just have a look at what’s happening with something called The Pharmacy Home Project, a Web app created by Community Care of North Carolina (CCNC) to address these very needs.

We’ll find out just what this app is from Troy Trygstad, vice president of pharmacy programs for CCNC and how it is having a real impact in community pharmacy care from Joe Moose, Pharm.D., co-owner of Moose Pharmacy, which has six locations in North Carolina.

The Project

Trygstad describes The Pharmacy Home Project as a data repository and engine that can both consume and distribute data. As a cloud model, the app lets any set of participants support the installation, whether that’s an HIE, a group of pharmacies, or another entity. It supports work in multiple-actor setting combinations, for example, a pharmacist actor might be in a community pharmacy setting, a hospital setting, or a primary-care clinic setting; a pharmacy technician actor might be in a call center setting. “We actually have more than 40 actor-setting combinations interacting with pharmacy across North Carolina right now,” says Trygstad.

Troy TrygstadJoe Moose

The app can consume complete claims histories that come from data gathered from participating payers, and it can also make a real-time call to Surescripts to pull down fill history or to pharmacy switches for fill histories. It can also pull in discharge medication or active medication lists from eMARs and from HIEs. Users can also manually input data, for example a discharge list that’s not otherwise available, or a record of adherence issues in a note to augment the automated data consumption. “All of this becomes a community record in the PHARMACeHOME,” says Trygstad.” The Pharmacy Home app can’t yet automatically consume health data other than medication records, such as labs and records of ER visits. “We’ve focused right now on med management,” explains Trygstad, “rather than trying to recreate an HIE by extending to all clinical data.” But the app does have placeholders in its database for this data. Users have to create agreements to source the data, and then the app can display it. This is in contrast to what the app can do automatically with the medication data. Trygstad reports that, in this case, the app can scrub this data, add adherence metrics, look for gaps in therapy, run models on it, and more. “This is an important data improvement step in the consumption process before the med data hits the cloud for distribution,” he notes. “But we are leaving managing and improving all the other health data to other people right now.”

Getting Data Where It’s Useful

Once you’ve got the installation up and it starts asking for data, then the issue for the pharmacy is how to get that data back into the workflow in a meaningful way. Joe Moose draws an analogy to the dashboard of a car, where you can easily see everything that’s critical while you are driving. “You can’t expect pharmacists to read a five-page discharge summary or go to a different screen to read a SOAP note and take 15 minutes to process it before they talk to the patient in every case,” he says.

With this in mind, there are two options for integrating the data, according to Trygstad. First, you can bring it into your pharmacy system with a single sign-on. This is what what’s happening with one pharmacy system partner, PioneerRx, and it means that Pharmacy Home data appears on screen within the pharmacy software. “That’s a direct integration,” says Trygstad.

The other options is to have a landing space within the pharmacy system where you can click on a link associated with the patient context. Clicking on it brings up the Pharmacy Home data. “This is what we’re doing with other pharmacy partners,” says Trygstad.

“With the right data, we can stop delivering generic messages during the regular encounters we have with patients and start focusing on high-value messages that address specific health-related goals.” – Joe Moose

Clearly, the process just described hasn’t reached Joe Moose’s standard of the dashboard yet. It’s still setting a task for the pharmacist to go out and get what he needs. This is where a logistics engine created via a partnership between CCNC and GSK can come into play. This is a cloud-based rules engine that can either function independently or be embedded within the PHARMACeHOME installation to apply specific protocols to the data from the pharmacy, crunching the numbers and producing recommended actions based on predefined
rules. “Based on how the network has been configured,” explains Trygstad, “The logistics engine will say ‘Oh, the patient was discharged from the hospital two weeks ago, and we have an ADT feed. So we want you to make this intervention. Or it will say ‘You’ve got a rule queued up that when we see a course of inhaled steroids being filled and it hasn’t been filled in the prior 12 months, we want you to counsel on how to use the device.’” The logistics engine can also apply some really complex rules that use predictive modeling to recommend a particular action for a patient, such as a comprehensive med review.

So the idea behind this logistics engine is getting right to the point of putting the critical information in front of the pharmacist that’s easily actionable. “We wanted to take clinical-decision support rules and predictive models and other things out there and do two things with them,” says Trygstad. “One, we wanted to be sure that they are in the workflow with the results of a call to the logistics engine coming back to the pharmacy system in seconds. Second, we wanted to make sure that a network can configure this tool however it needs to.” For example, you can change thresholds for protocols in real time or turn on behavioral health rules for a subset of pharmacies in a network.

The Business Opportunity

So there’s a technology platform out there that’s proposing to change what a pharmacy can know about its patients. But is there really an opportunity there? In Joe Moose’s view, there will be two kinds of pharmacies in the future. Some will be filling a very high volume of prescriptions for very low margins. Others will providing much better value and care for the prescriptions they do fill. “So if you want to be in that second group, then you are looking at shifting from a volume-based model to a value-based one,” says Moose. “You are looking for how to give value by closing gaps in care and giving extra care to the high utilizers.” And, in his view, you do this by having better data that comes from a source such as the Pharmacy Home Project.

The ultimate goal, according to Trygstad, is that networks of enhanced-care community pharmacies will be in a distinct reimbursement category, whether that means that you preserve dispensing reimbursements through future rounds of cuts or you move into a pay-for-performance model. “There are pharmacies that don’t or can’t provide enhanced care,” says Trygstad. “Let pharmacies that want to do the straight high-volume filling do it, but then you have to look at a different model for those pharmacies that have the ability to care for the complex, high-cost patients that aren’t best served by getting a prescription filled by a machine somewhere without meaningful patient interaction.”

Trygstad readily admits that this may all sound like motherhood and apple pie, but the practical effect is that CCNC has created at least one way in The Pharmacy Home Project for pharmacists like Moose and for pharmacy technology partners to establish enhanced-care community pharmacy networks. This is one example of getting beyond the talk and actually doing some of the things that will demonstrate how these networks can work to provide care.

Boots on the Ground

Another often-repeated notion is that pharmacy has the accessibility and pharmacists have the relationships with patients to make a difference in outcomes. In the abstract there’s no doubt about this. At the same time, this isn’t the role around which pharmacies are currently built. “When we’re brought into that care plan and when we have the data to take action, then pharmacy will really be working together with other health providers toward the one goal of keeping the patient healthy,” says Moose. “With the right data, we can stop delivering generic messages during the regular encounters we have with patients and start focusing on high-value messages that address specific health-related goals.” This is in addition to the more complex interventions that have been gaining traction within pharmacy, such as MTM and disease management. “These are fantastic tools that we have,” says Moose, “but the most underutilized tool is that one-to-two-minute encounter that happens 50 times a day at a community pharmacy. With better information we are going to be able to use these short encounters to move the outcomes needle.” CT

Will Lockwood is a senior editor at
ComputerTalk. He can be reached at