COVER STORY: Workflow
Workflow at its most basic is a system with checks and balances that moves prescriptions through a pharmacy’s dispensing process. No two pharmacies are using the system the same way, as can be seen in several pharmacies we spoke to recently. What is the same is the specialization of staff and the efficiency gained by implementing a system that has built-in tracking and safety measures. Automating repetitive processes avoids both clinical and administrative errors, in the long run saving time and money. Once a pharmacy embraces the requirements put forth by work flow, it becomes the foundation for building a business plan that fits the pharmacy’s vision.
When thinking about workflow, it’s important to consider the goals for the pharmacy and how the staff will work. At Philadelphia Pharmacy, in Philadelphia, Pa., Rich Ost, R.Ph., has been using the HBS pharmacy management system for 20 years. He worked with the company to help design its first workflow system.
Richard Ost, right, at the Philadelphia Pharmacy workflow verification station, with Wilson Pagan, pharmacy manager. Ost says committing to the workflow system is the best way to ensure success.
“When buying workflow, an owner has to make the distinction that it’s not an investment in just technology, but in a new way to fill prescriptions,” says Ost. In Ost’s 1,800-square-foot pharmacy a prescription, moves through five stations, from intake through different stages, while the staff stays fixed at a station designated for each task. If the HBS workflow system flags an issue, the prescription is shunted to a problem solver, and the next prescription moves in. This flow is seamless. Ost recommends taking the time to work up a schematic of the pharmacy and how workflow stations will fit into the pharmacy’s dispensing process. Patience is a must for a successful transition to workflow. Ost estimates that it takes four to five weeks to get comfortable with the work at a station. For example, with paper prescriptions, to add document scanning of the prescriptions at intake can seem to initially slow down the fill process. Yet the reason to have the digital prescription is to link it to the patient record through the flow.
“The owner’s commitment to doing it and doing it right is critical,” he says. “It’s not really as much about the computer software as it is about the people.”
Todd Barrett, owner at Covenant Pharmacy, says implementing workflow can take time, but when everyone settles into the routine, the workflow doesn’t slow you down, but instead makes you more efficient and increases productivity.
“An interesting aspect of when you get workflow right,” says Todd Barrett, R.Ph., owner at Covenant Pharmacy in Ridgeland, Miss., “is that you aren’t slowing yourself down or impeding the prescription from getting out the door. Rather, there is peace of mind that the fill is right and you’re going to get paid the right amount.”
It took five to six weeks for the “smoke to clear,” says Barrett, and for staff to learn the ins and outs of the system when Covenant Pharmacy transitioned to the workflow structure in its new Nextra pharmacy system from Integra. Then Barrett’s chief pharmacist came to him and said, “Hey, we’ve got too many people in the back now.” “I’ve never had anyone come to me and tell me they needed fewer people,” says Barrett.
Each pharmacist’s journey to implementing a workflow system has a unique tipping point. In the case of Tim Larsen, R.Ph., at Tim’s Pharmacy and Gift Shop in Yelm, Wash., the tipping point was when he finally followed up on his wholesaler’s recommendation to consider Innovation’s workflow system.
Tim Larsen, of Tim’s Pharmacy has embraced workflow now that it’s added peace and quiet to his pharmacy.
Larsen had focused on automation as a solution to improve productivity in his pharmacy, located in a bedroom community just northeast of Olympia. He started with counting technology and smart scales. Larsen’s initial impression was that workflow involved a cumbersome intake process that seemed to counteract any efficiencies. “I thought, this really slows down the process,” recalls Larsen. “There were so many steps to input a new prescription.”
The persistent wholesaler finally got Larsen and his wife, Nancy, to visit a busy chain pharmacy. What they noticed right away was the peace and quiet. This convinced him to install a system. Before workflow, if a patient had multiple scripts spread throughout the pharmacy, the staff would have to find where each one was in the process.
“With workflow we now know exactly where a prescription is in the process,” Larsen says of the Innovation workflow system.
John Saliba, R.Ph., president of Saliba’s Extended Care Pharmacy in Phoenix, Ariz., says that for his large assisted-living and skilled-nursing home pharmacy, workflow gives him the confidence of accounting for every script that goes through the system and, in his case, workflow addresses the logistic challenge of a large physical plant.
John Saliba, president of Saliba’s Extended Care Pharmacy, spent a year planning his LTC pharmacy’s implementation of workflow. Any size pharmacy can benefit from a system’s tracking and safety features, says Saliba.
“The workflow helps us track productivity and any errors. You can assign responsibility to each step,” says Saliba. “You can only do that with the workflow turned on. Everyone has a login, and what’s really nice is that when people call, we can go in and see where a prescription is and when it will be delivered.”
The decision to move to a workflow system was not something Saliba took lightly. He spent over a year planning the switch, since at the time he had two pharmacies with different needs in each fill system. It also required a commitment to a clean NDC drug file database. Saliba’s director of operations and purchasing spearheaded cleaning up the drug file so that what is dispensed in QS/1 is what’s on the shelf. Matching NDCs is fundamental to successful workflow. “If you pull something and the NDC isn’t right, then it won’t dispense,” Saliba says. “Once you override the barcode scans, you can’t use the safety checks that are built into the system.” Workflow means that Saliba is tracking not just exceptions such as this, but any errors as well. Overall, he’s getting a data-driven look at productivity. “If prescriptions are getting stuck somewhere, I can see that and figure out what’s causing the problem,” he says.
Cindy Richart, at Phoebe Services Pharmacy, needed workflow that could tie together her pharmacy management system and an EHR system.
At another long-term care pharmacy, Phoebe Services Pharmacy in Allentown, Pa., the decision to implement workflow was founded on a need to improve the service to its facilities. And in this case, the workflow implementation includes the complexity of requiring two technology systems to work together seamlessly. Phoebe Services’ director of pharmacy operations, Cindy Richart, R.Ph., explains that an open architecture in the pharmacy’s FrameworkLTC software from SoftWriters allowed interoperability with Phoebe’s EHR system PointClickCare. In this situation, the workflow evolved from the implementation of ADT connectivity to a more robust process in which the pharmacy takes on a great deal of the work for entering and scheduling orders that might otherwise fall to the facility staff. Richart says they found that an amazing amount of information can pass between the two systems, but that what is critical for their operations is letting the pharmacy maintain control over medication data to avoid rework.
Larry Myers has invested in one technology vendor for his automation and workflow, and is happy that the security features in the workflow mean he can trust all levels of staff to handle prescriptions, leaving pharmacists to handle verification.
And much as with John Saliba, accountability is at the top the list of benefits that workflow brings to Holdrege Pharmacy in Holdrege, Neb., says owner Larry Myers, R.Ph. In his case, staff members each have a different level of authority in the ScriptPro workflow that’s activated when they scan the barcode on their IDs to log into a station. Myers says he’s set the parameters for each staff’s level of authority and he’s comfortable with technicians doing most of the work, with the final step the pharmacist’s verification.
While a busy pharmacy may see the obvious benefits of a workflow system for its tracking abilities, what’s key to any workflow system is that it keeps a pharmacy organized and accountable.
In one case, a pharmacy that uses New Leaf Rx from Key Centrix improves its bottom line by setting triggers for a gate to stop any prescriptions that meet certain criteria. Most prescriptions are going to flow right through the process. But it’s precisely those that don’t that you want to trap out and review. For example, prescriptions stopped at adjudication because they need a prior authorization are isolated so the most skilled staff can resolve the issues.
Workflow settings can even be set to review administrative tasks like credit checks, to avoid dispensing prescriptions that have a payment outstanding.
Everyone is logged on at a station when filling at Philadelphia Pharmacy, and with hourly reports, Ost can see who last handled a prescription or who had gotten backed up during the day. Reviewing and acting on reports is one of Ost’s favorite parts of the workflow technology. He can review a 48-hour time period, see what’s still outstanding, and have his problem-solving staff focus on clearing those prescriptions out of the store. The data gives Ost a complete picture of his day-to-day business operations, and he can easily change parameters to get questions answered quickly.
“People will say their store isn’t busy enough for workflow,” says Ost. “We got busy because we can track everything.”
ScriptPro’s workflow addressed the concern Myers had with accuracy. He wanted a system that is trustworthy, and since he can see everything step-by-step with ScriptPro, any issues are identified quickly and addressed.
“Usually, however, there’s not an issue because the system makes it very difficult to make a mistake. You’d have to work pretty hard to make a mistake,” says Myers.
In Myers’ experience, if a prescription hits a brick wall, it’s usually because of insurance. It stays on the data entry screen until Holdrege Pharmacy staff resolves the issue. All the other orders flow around the exceptions. “You can go back at any time and work on a prescription. Then when it gets released, anybody can fill it before the pharmacist verifies it,” says Myers.
Once you’ve decided to go workflow, each pharmacy has to evaluate how to lay the technology over the pharmacy’s requirements.
Each staff person has a very specific role in the organization working on various stages to support the delivery of both care and medications to patients. For example, there are staff who work on the prefill list and know that everything in the queue is pertinent to their role on behalf of the patient.
A workflow system was suddenly easier once the files were all digital and could move through the pharmacy station by station in the computer, rather than by staff.
The virtual workflow, the ability to look at a screen and track a prescription at any moment, is particularly important in Saliba’s long-term care pharmacy, which services 6,000 patients with a staff of 100 people. For Saliba, who uses a QS/1, the key that got him into the workflow world was his DocuTrack document management interface from Integra. Before Docu-Track, the staff was following the hard copy prescription from one side of the building to the other. A workflow system was suddenly easier, once the files were all digital and could move through the pharmacy station by station in the computer, rather than by staff.
With an intricate system that’s tied together by a number of interfaces, Phoebe Services Pharmacy’s Cindy Richart says that it’s the planning time that keeps final implementation smooth. For example, meds are received in the facility through a barcode scan at the nursing station. This step eliminates paper and redundant work. The receiving data is linked into PointClickCare. “Everything is very intricately tied together, and it works very well because we put a lot of time up front into planning and we manage our projects to a great extent before we try to implement anything,” Richart says. “We really need all three pieces — nursing, pharmacy, and IT — to make this work efficiently.”
And as part of his pharmacy’s evolution under the Innovation workflow system, Tim Larsen improved his efficiency by reducing the number of interfaces he was managing. At one point he had six interfaces and found that when there was a software problem it was time-consuming to pinpoint the problem. It was necessary for him to scale back, and now he uses his QS/1 pharmacy management and IVR system interface with just the Innovation workflow and automation system.
The beauty of workflow’s automation of the many administrative steps in the dispensing process is that the prescriptions keep moving. Barrett uses the example of an incorrect NDC. If there isn’t a match between the scan and the bottle, Barrett’s Nextra system will go back to the transaction, reverse and resubmit the transaction, and then print a new label with the NDC updated to match the stock bottle — all of which happens in seconds. Given how dynamic the generic market is, Barrett says workflow can catch the discrepancies when someone on the buying side makes a choice based on cost and then the pharmacy starts using the new stock to fill a prescription that was billed out on the old NDC. In Barrett’s pharmacy, this could happen 20 or 30 times a week with different generics, and if it’s not automated, it’s impossible to keep up with.
Another way workflow improves operations in Phoebe’s LTC services is by putting the decision-making in the hands of the pharmacy staff, who are the clinical and logistical experts when it comes to medications. For example, the Phoebe Services’ staff knows when the first dose of a prescription should be scheduled for an order, either through detailed knowledge of the pharmacy inventory and delivery schedule or by knowing that it’s stocked in a remote dispensing unit at the facility. There’s no reason to be out of compliance when scheduling a first dose simply because the order is entered at the facility and the administration schedule is set without taking into account the pharmacy’s filling and delivery schedules. The pharmacy also knows what NDC should be used, based on inventory, eliminating the rework that would come from a facility submitting an order through the EHR with a NDC selected, which won’t match up with the NDC now in stock at the pharmacy. “It puts a lot of responsibility on the pharmacy, but then we are really the ones who know what’s going on in the supply chain,” says Richart.
“No matter how many scripts you do a day, workflow will make you a lot more efficient, and your day will go 100% better.”
– Tim Larsen
And back at Covenant Pharmacy, Barrett’s staff has been able to eliminate pharmacists checking to verify that orders were packaged correctly at the back end, since the workflow requires technicians doing the packaging to barcode-scan the prescription label and stock bottle. This brings up something called a card map, which tells them which blisters to place the pills in, giving a very specific and easily followed process for not only ensuring that meds are packaged properly, but that there’s a record of what’s being done as well.
A common thread for the experience of the pharmacists we spoke to is patience in setting up workflow. Although there may be setbacks when getting started, it’s the long-term gain that matters. One example is a system that would take a pharmacist about six minutes to dispense, verify at the verification station, and label the prescription. Implementing workflow can reduce, in some settings, time on a prescription to two minutes.
Richart reinforces the need for patience. She says anyone who hasn’t tried an extensive integration before needs to realize it’s not an easy thing to accomplish. “It took us at least a year to actually pilot this in one of our facilities,” she says. “We have two full-time nurses working in our pharmacy whom we handpicked from our facilities because they had extensive technology experience and were also very good at staff development — since it takes a lot of patience to get people up to speed on these systems.”
“Everyone needs to be using workflow, because if they aren’t, they don’t know how to track what’s going on.”
– John Saliba
Workflow’s impact on creating a smooth path for an order to flow through his pharmacy is obvious to Saliba. But he also emphasizes the importance of accountability. He can respond quickly to his clients, but he can also go before a state board and answer any questions with backup materials from reports that document a prescription at each point during its time in the pharmacy. “Everyone needs to be using workflow, because if they aren’t, they don’t know how to track what’s going on,” says Saliba.
The workflow might feel slower initially, says Myers at Holdrege Pharmacy, but with time and a chance to learn, everything eventually goes faster and everyone is confident with the throughput.
“We hired a new pharmacist last year and it took her no time at all to catch on to the system,” says Myers. “In fact, I was interviewing a pharmacist once and we were so busy she jumped in and helped us. Learned the system on the go, and she loved it.”
While it took four years to get everything up and running perfectly, Larsen would never go back.
“We had a rough start, and I still feel it was worth it all,” he says. “No matter how many scripts you do a day, workflow will make you a lot more efficient, and your day will go 100% better.” CT
Maggie Lockwood is a senior editor and director of production at ComputerTalk. She can be reached at firstname.lastname@example.org.