Pharmacy-Based Clinical Services: From Pharmacogenetics to Chronic Care

Pharmacy has been in a state of evolution for some time now, with consistent effort from many sides within the profession to integrate a clinical model into practices. Here we’ll review different ways in which this movement has gained traction, and cases across the practice spectrum in which pharmacies are having success in providing cutting-edge clinical services to patients, pushing forward into a role as providers, and collaborating effectively with prescribers and other providers.

You need to have an open mind, but building a practice based on patient care is entirely possible right now, as we’ll see.          

Pharmacy as Healthcare Hub

Amina Abubakar, Pharm.D., has spent the last several years building a clinically oriented practice at Rx Clinic Pharmacy, starting with clearly defined workflow tasks for staff members within her PioneerRx pharmacy system that put the patient at the center of her model. This was just a beginning, though, and Abubakar has been building the practice further through collaboration with local medical providers, creating what she describes as a population health management hub, in which clinical pharmacists provide chronic-care management services and annual wellness checkups for patients.

Rx Clinic Pharmacy puts together a care plan in collaboration with prescribers that is patient- and disease-state specific. But the real work, and the real benefit, notes Abubaker, come from following up on that care plan month after month. “We are able to focus on helping manage not just adherence,” says Abubakar, “but behavior as well. Let’s say we develop a care plan for a diabetes patient and we want that patient to stop drinking soda. We are checking in with them and asking them, how many did you drink last month? Or we realize that our delivery driver is bringing a patient’s prescriptions back at the end of the day. That’s an adherence problem, and we follow up.”  These interactions are driven by the workflows within PioneerRx and documented within a care-plan platform.

El Rio Community Health Center deploys a similar model in the health-system setting, according to Josh Carzoli, Pharm.D., director of operations, using two distinct arms of pharmacy services. “We have the traditional brick-and-mortar retail pharmacy setting,” he says, “where there’s an emphasis on preparing and dispensing medications. And then there’s what we call our advanced practice pharmacy team. These pharmacists have one-on-one visits with patients as part of their appointments with other providers in our system. Our pharmacy team members are typically spending half an hour to an hour with these patients, doing chronic disease state management.” At El Rio Community Health Center, the pharmacist can access a patient’s complete record directly in the electronic medical record (EMR), while also accessing all the dispensing history and notes in the pharmacy management system, in this case from Liberty Software.

This is a crucial time, notes Carzoli, for effectively helping to manage a condition such as diabetes and its associated comorbidities, such as hypertension or high cholesterol, or to address behavioral health. The El Rio Community Health Center pharmacy staff also manages annual wellness visits, which focus on preventative care.

Josh Carzoli on How Technology Drives Efficiency

“We’ve installed a wide array of technology at El Rio Community Health Center pharmacies, with the goal of increasing our efficiency and creating time for our pharmacists to focus on clinical care. We have automated dispensing machines to handle the counting and vial-filling tasks, for example. But I think overall I would absolutely highlight the impact on efficiency that our change to the pharmacy management system from Liberty Software has made. I think that that has been a tremendous upgrade for us. You know, prior to that we did not get interactive voice response [IVR] that lets patients call in their prescriptions and then get an automated call back when they were ready for pickup. We’re working right now on rolling out an app so patients can manage refills that way, too.

Another thing: We have our pharmacy system integrated with a display board in our lobby that can both notify patients when their medication is ready and inform them about offerings like flu shots.

Many patients come down to see us right after their provider visit, so they’re able to see when their prescription is ready right on the board, or they’ll get a call from our IVR system — both of which are a great convenience for them and make life easier for our pharmacy staff.”

Clearly, this is a model with real traction now. And this is being driven, as Abubakar notes, in large part by the outcomes measurements that have come to be front and center for providers. “Doctors have 15- or 30-minute visits with patients,” says Abubakar, “and then they may not see that patient for another three months. This limits the extent to which they can truly impact outcomes.” But these prescribers’ limited resources have proven to be, as we’ve seen, an opportunity for Rx Clinic Pharmacy to deploy a collaborative approach that leverages the pharmacy’s structured workflow within PioneerRx and high rate of interaction with patients. The documentation of these interactions by Abubakar’s clinical pharmacists is now a regular source of information for prescribers, with insight into a range of issues that they can identify during regular talks with patients. “For example, we see a prescription coming from urgent care,” says Abubakar. “So we talk with the patient and find out that she fell. We add this to our history and make sure that the patient’s doctors know.”

Pharmacists at El Rio Community Health Center can provide extensive services around certain disease states, explains Carzoli. “We’ve worked with our chief medical officer and our pharmacy safety therapeutics committee to develop collaborative practice agreements and implement certain therapeutic interchanges and changes to records that are initiated by the pharmacist, including initiating certain prescriptions on the primary care provider’s behalf,” says Carzoli. For example, if a prescriber writes for a medication that’s non-formulary for a patient’s insurance, the pharmacist can be authorized to change it to a formulary or preferred drug right at that point, without having to go back and request the change from the prescriber. The change gets made, the patient’s cost is lower (and lower costs are one factor leading to better adherence), and because the pharmacist has access to both systems the change is noted in both. That’s real efficiency in clinical care.

“We have a variety of literature that’s been published on the amazing success that we have with this model,” says Carzoli. “We are truly able to demonstrate that the intervention of a pharmacist in the day-to-day life of a patient makes a significant difference.”

Pharmacists at the Center of Community

NCPA Pharmacist of the Year Lynn Connelly has made Medicine Mart Pharmacy a mainstay in West Columbia, S.C., over the years, with a long history of providing health screenings and services such as blood glucose and blood pressure monitoring. Connelly also started a pharmacy residency program about five years ago, in conjunction with the University of South Carolina. “With that we’ve really broadened our clinical services,” says Connelly. “We’re offering medication synchronization, medication therapy management, and comprehensive medication reviews, as well as one-on-one health coaching and a hypertension coaching program. We’ve got a pharmacogenetic testing program, and we offer a wide array of immunizations.”

Lynn Connelly on Medicine Mart Pharmacy’s Residency Program

We have seven different pharmacy students working here right now on a part-time basis, and they’re in every every year of pharmacy school. We are precepting students from five different pharmacy schools right now, including one from New York. It’s a good learning experience for them and a good resource for us.

While that’s an impressive list of clinical services offered by Medicine Mart Pharmacy, Connelly reports that med sync tops his list for impact for improving outcomes and pharmacy performance, with immunization programs coming in a very close second.

The pharmacy residents are the driving force here, according to Connelly, tasked with running this broad array of programs down to the level of making those all-important monthly calls to med sync patients to check for any changes. But Connelly also points to a recent transition to QS/1’s SharpRx pharmacy management system as an important step. “There are more ways to document what we’re doing now in SharpRx,” says Connelly, “and this is critical when we’re providing so many services as a pharmacy that go beyond dispensing.” Connelly is a Community Pharmacy Enhanced Services Network (CPESN) luminary, leading the effort in South Carolina to bring together performance-focused pharmacies around a set of clinical services and, perhaps most importantly, the Pharmacist eCare Plan. This, says Connelly, is a standards-based pharmacy services documentation transaction, which a range of pharmacy technology vendors, including QS/1, are working to build into their platforms. “With the eCare Plan, we collaborate with prescribers and show payers what we’re doing to help patients,” says Connelly. “It’s all new right now, but CPESN pharmacies are successfully billing for clinical services. For example, when you sit down and do a 30-minute medication review with a patient, you can get reimbursed for that.” But it’s critical to have up-to-date systems in place to participate. “That was among the top reasons that I did choose to move from QS/1’s NRx to its SharpRx,” explains Connelly. “I felt that this was what we needed to do in order to be able to keep up with the changes in pharmacy.”

Building Services on Technology

Rutland Pharmacy is another example of a pharmacy that’s built a central role in the community over the years by offering everything from retail prescriptions to adherence packaging, wellness programs, immunizations, DME, nonsterile compounding, and URAC-accredited specialty services. Just ask around for Smilin’ Steve, and people will point you to pharmacist Steve Hochberg and his sons Jason and Jeff at their four pharmacies in the area.

“Obviously, in today’s world you have to have the technology,” says Jason Hochberg. “We’ve had ScriptPro robotics for well over a decade, which has helped us with inventory and dispensing speed. It helps our technicians to focus more on answering calls and doing data entry, and our pharmacists to actually be pharmacists, talking with prescribers and counseling patients.” Hochberg reports that the pharmacy’s technology path toward greater efficiency and a stronger customer focus has led to integrating all four pharmacies on ScriptPro’s SP Central pharmacy management software as well.

Jason Hochberg on Building Pharmacy’s Profile at the State Level

We’ve been looking to have Rutland Pharmacy play a central role in promoting the value of pharmacy to key decision-makers, for example in the Vermont legislature. We’re lucky here in Vermont, because we’re a small state and that allows us to get to know a lot of our state representatives and senators personally. We saw a few years ago how important it was for pharmacy to have a voice, to be talking to decision-makers. My brother Jeff stepped in, and he is very active now in Montpelier. He’s there regularly, and he’s now the go-to guy when there are questions about where healthcare is going.

Our legislature has successfully passed a couple of pharmacy-friendly bills, including an audit protection bill and a PBM [pharmacy benefit manager] transparency bill, and we’re very proud that the state has recognized pharmacists as providers. This is a big step in the right direction. And it’s allowing us currently to work on a couple of other bills that will expand the scope of pharmacy practice, with real benefits both day to day and in emergencies, like when Hurricane Irene came through and there were areas of the state where people were stranded and couldn’t get to their doctor.

Rutland Pharmacy has now also rolled out ScriptPro’s Third Party Management System (TPMS) to manage reconciliation, reimbursements, and contract adherence for payers — especially important across four locations.
Even more critical, though, is the recent addition of ScriptPro’s Advanced Pharmacy Clinical Services (APCS). “This is going to allow us to have a tool integrated into SP Central for managing and documenting our clinical work and key clinical data, like lab results,” says Hochberg. The Rutland Pharmacy staff can communicate with a physician’s office about patient progress and any changes to his or her medications that may help in reaching goals. “It’s going to allow our pharmacists and doctors to communicate much more easily and seamlessly, all via the web,” explains Hochberg. “There’s no lag time in the communications with this platform, and it makes it very easy for us to have the same goals for patients.” On top of  this, Hochberg reports, Rutland Pharmacy also gains documentation that shows its proactive work in keeping patients healthy by staying on top of their chronic disease states.

Returning to El Rio Community Health Center, Josh Carzoli points to the transition to Liberty Software’s RXQ pharmacy management system about 18 months ago as a big step in moving pharmacy services forward. “We made this move as part of a push to really give our pharmacists more time,” says Carzoli. “We had the goal of supporting them to provide more comprehensive services and provide more support for patients. You don’t realize how important the efficiency of your pharmacy software is at first.”

“We’re tasking our pharmacists with looking at and updating the patient record not just in the pharmacy system, but in the EMR as well, so it’s critical to be able to navigate quickly and efficiently,” explains Carzoli.

The new pharmacy system is also supporting El Rio Community Health Center’s current project of taking a larger look at adherence. Carzoli reports that this project makes use of the medication possession ratio metric in the Liberty pharmacy system as a flag to identify significant sets of data for the project. “This is giving us the data we need to put a stronger focus on 90-day prescriptions,” says Carzoli. The goal, however, is not to use 90-day fills to reduce touches with patients, but instead to convert what would have been filling events into times for pharmacists to actually speak with patients between scheduled visits with other providers in the system.

Pharmacogenetics: Personal Care for Populations

And when you talk about building pharmacy services on cutting-edge technology, it’s important to note that there are now a number of pharmacies deploying what may have sounded like science fiction just a few years ago as a key component of patient-centered clinical management: pharmacogenetic testing, which assesses how a patient’s genome impacts drug efficacy.

Theresa Tolle, Pharm.D., has been working at bringing pharmacogenetic testing to her patients at Bay Street Pharmacy for over six years, after hearing from a vendor that physicians were struggling to make it work in their practices. That’s not a commentary on the value of the testing, according to Tolle. Rather, physicians would order the tests, but then often had a hard time reviewing and interpreting them.

Bringing new information like this into the pharmacy workflow can be a challenge, too, which is why Tolle is so enthusiastic about the myRightMeds partnership between Rx30, her pharmacy system vendor, and pharmacogenetics testing lab Alpha Genomix. “Getting the process and the results integrated into the pharmacy system has really been the missing piece,” says Tolle.

For Marcus Wilson, the power of pharmacogenetic review was brought home personally through an event he and his wife experienced with their special-needs daughter, Lydia. “Our daughter had a severe cold,” explains Wilson, “and my wife and I, who are both pharmacists, agreed to give her a time-release cough syrup. Unfortunately, what happened was our daughter reacted to this medication by pulling an all-nighter. None of us got any sleep, and our daughter certainly didn’t get the relief from her cold symptoms and the rest that she desperately needed.”  Wilson and his wife were determined to figure out what happened, during which process they did a pharmacogenetic test. “What we got back was a report that showed the graded medications for our daughter in green, red, or yellow. And now that list is part of every conversation we have with Lydia’s doctors.”

Marcus Wilson Defines Pharmacogenetics

Pharmacogenetics is a branch of personalized medicine that utilizes genetic analysis to determine how a patient will respond to different medications, which in turn reduces the traditional trial-and-error approach to selecting an effective drug therapy. The test is able to determine, based on a patient’s phenotype and genotype, which drugs are inappropriate based on each patient’s genetic makeup. The goal is to decrease the risk of detrimental and often life-threatening side effects from prescription drug usage.

With this personal proof of how important pharmacogenetics was, Wilson began to look for a way to make this a standard part of his pharmacy practice. He began using testing and drug-gene review software from MedTek21 in January 2017, with a focus on panels that review for interactions with pain management, cardiovascular, and psychiatric drugs, as well as for medications used for diabetes, urology, infectious disease, and cancer. “We’re using this at Integrity Pharmacy not only because we believe in it from experience.  We’re utilizing the MedTek21 app to cross-check in real time any new medications prescribed for our daughter so that we know while we’re still in her doctor’s office if she is going to react in a positive or a negative manner. But we are also using it because we know professionally that there’s clear evidence that the more meds any patient is taking, the greater the chances are that there’s a drug-gene interaction occurring,” says Wilson. “Integrity Pharmacy’s population is high acuity and is prescribed on average 10 drugs. So pharmacogenetic review has become a central part of what we offer.”
Integrity Pharmacy is now able to leverage this application in conjunction with its FrameworkLTC pharmacy management software from SoftWriters to monitor these drug-gene interactions, much in the same way, Wilson notes, as pharmacies have normally done drug-drug interaction checks. “The applications can look at a patient’s current medications and allow us to suggest alternatives to their physician for better outcomes,” he says.

Tabula Rasa HealthCare is one more example of a company seeing the impact of pharmacogenetic testing on high-acuity patients — in this case, as part of the call-center-based population health management programs the company provides for special-needs Medicare Advantage plan patients who are residing in the community, but are nursing home eligible. According to Robert Alesiani, Pharm.D., “We’ve developed proprietary tools and expertise in pharmacogenetics that give us the ability to know, based on genetics, how the patient is going to manage particular medications. Our job is to make sure people stay independent by reducing the medication-related risk of hospitalizations or nursing home admissions.”

Tabula Rasa focuses the pharmacogenetic review of patients using high-risk medications in cardiology, behavioral health — including antipsychotic and antidepressant therapies — and diabetes management, as well drugs for both chronic and acute pain. Frequent hospitalization is another indicator for this testing, particularly since adverse drug events are often the cause.

Focusing on the right patients has been important for Theresa Tolle as well. The myRightMeds module in Rx30 provides screens for identifying not just patients who are candidates for pharmacogenetic testing based on their medication profiles, but also prescribers whose specialties and prescribing histories make their patients candidates. “This allows us to have targeted conversations with patients and physicians,” says Tolle. “I’ve found it’s particularly important to reach out to doctors and let them know we have the capabilities to do drug-gene interaction reviews for their patients. I want to make sure they are comfortable with this, and it helps for them to understand that this is something special that we offer.”

The genetic profile is derived from a one-time test, but the value of the review is ongoing, notes Wilson. “Once we have the test results, we’ll get any potential drug-gene interactions flagged in MedTek21’s application,” he explains. “Then we utilize this clinical data and communicate with the patient’s physician on medication alternatives and dose changes based on the patient’s genetic analysis. The next time the doctor adds or changes a drug in the patient’s regimen might be the time when an adverse drug event puts them in the hospital,” says Wilson. “Now we are at the point where we are assessing these risks before the prescription is dispensed, and using our patient-specific insight to make recommendations to prescribers that can eliminate adverse events and keep our patients in their homes longer.”

Theresa Tolle has this information integrated directly into her Rx30 software, where it’s presented as a interaction for review just as a traditional drug-drug interaction would be. “With this integration we don’t have to disrupt our workflow,” she says. “The results are right there, and we’re able to quickly review the interaction for its severity and significance, and then take the appropriate action.” For example, says Tolle, after double-checking the pharmacogenetic alert, she might talk with the patient and let him or her know that she needs to have a conversation with his or her doctor before dispensing. “I can let the patient know that I think there could be alternative medications that we should use that are more appropriate,” says Tolle.

This Doesn’t Happen Overnight

Amina Abubakar has been building the care management model methodically at Rx Clinic Pharmacy, and that diligence is paying off. She participated in the CPESN pilot program in North Carolina and saw that physicians really engaged and appreciated the collaborative care relationship.

“We’re using all the touches we have to provide the ongoing care management,” says Abubakar. “It’s the phone calls and the time we can spend with chronically ill patients face to face to prevent another doctor’s office visit or to prevent hospitalization. Medical practices don’t have the staffing to manage a couple of hundred patients, much less a couple of thousand, month after month. We have been able to demonstrate that we can help with managing large patient populations.”

For those prescribers’ offices that are using cloud-based patient management systems, Abubakar’s clinical pharmacists can receive log-in credentials that permit access for documenting care. For those prescribers without that capability, Abubakar uses a chronic-care management platform that interfaces with physician’s office servers. At the end of the month, Rx Clinic Pharmacy captures all the care management work pharmacists have done and sends it to the physician’s office billing staff to submit for payment using the chronic-care management code available to providers. That’s revenue that Rx Clinic Pharmacy then shares in. “In less than two years, we grew from just me and one clinical pharmacist doing this to where we now employ 10 clinical pharmacists to manage chronic care,” says Abubakar. The pilot program provided proof of concept that pharmacy-based chronic-care management does indeed work. And it led to Rx Clinic Pharmacy having a solid business and care plan case to make as it is marketing its services to new prescribers.

Demonstrating Results

Addressing drug-gene issues, adherence, and behavioral issues greatly reduces the potential for ADEs (adverse drug events), which makes for improved outcomes and reduced ADE-related hospitalizations.

The value for Marcus Wilson is in having the real-time monitoring alerts and reports for drug-gene interactions. “This is a tool that is desperately needed,” says Wilson. “It’s allowing us as clinical pharmacists to do work that directly impacts adverse events, changes outcomes, and increases performance. When you change somebody’s pain medication from not working to maximum efficiency and they become a new person within two days, they feel as if they’ve been healed. It’s powerful.”

Theresa Tolle has seen the power of pharmacogenetics firsthand as well, and relates a story about how it impacted one of her patients at Bay Street Pharmacy. “I have an elderly patient on Percocet, and his doctor was doing regular urine testing as part of his pain management protocols — to ensure the patient was actually taking the medication and that there wasn’t a risk of diversion,” explains Tolle. “But this gentleman was testing negative, and his physician was about to fire him as a patient because the test was saying he wasn’t using the Percocet. The doctor was worried he was selling it. Now, I know this patient and I didn’t believe for a second that he was selling. I suggested pharmacogenetic testing, and it turned out that the patient was a slow metabolizer for Percocet. He was indeed taking the medication and actually benefiting from it, since it was controlling his pain, but he wasn’t converting all of the medication into the active drug form, which is what is being tested for in urine.” The test Tolle recommended saved that relationship between the patient and the doctor because the doctor was able to justify still prescribing pain medication. “This was about two years ago,” says Tolle, “and the gentleman is still my patient and he’s still with the same doctor. This is clearly the best outcome for that patient, and it’s also an example that has led me to have some very good conversations with other doctors.”

Integrating Care Now

The work happening now across a range of pharmacy settings is a great demonstration of the power of better integrating pharmacy services into care. And Amina Abubakar sees more to come here. “Team-based care doesn’t require that all providers are part of a vertically owned entity,” she says. “Instead, it can rely on integration for effective sharing of information about the care plan. Building a clinical practice really means connecting to other providers to manage that patient. As a community pharmacist, I’m a very valuable part of the team-based care because I know the patients so well. As pharmacists, we are able to leverage our interactions with patients to make better plans of care for patients, and this is a benefit to the whole care team’s performance.”

The tools available range from highly efficient, modern pharmacy management systems that provide adherence management and med sync functionality to pharmacogenetic testing and review platforms and documentation and care plan management platforms. Pharmacists, too, are in the right place, taking on the clinical roles an integrated care system requires and stepping up as providers. “We’re reaching a tipping point,” says Theresa Tolle. Tolle see expertise in pharmacogenetics as a leading exemplar of where pharmacy is with enhanced clinical services. “I especially think that, with the pressure on physicians now to prove outcomes, pharmacogenetics is a really good fit and a great role for pharmacists. I have long said that this is a space that pharmacy and pharmacists should own, because we are the experts in pharmacology.” Tolle’s point is indisputable, and from the examples here, it’s possible to extend it to say that pharmacy should trumpet its expertise in clinical care more broadly. CT