COVER STORY: September/October 2013

Long-term care pharmacy can present quite a puzzle. Consider the range of facility settings that LTC pharmacies serve, the various levels of care and special needs that residents have, the variety of packaging types and fill cycles, and the broader market and regulatory forces in play, and you’ve got a complex field that makes stringent demands on pharmacies that are looking to compete successfully.

The most valuable assets to apply to a puzzle like this may well be the creative thinking of the staff and owners. But a wide array of technology is proving to be quite valuable as well, and pharmacies are showing that with the right combination of smarts, software, and hardware there continue to be new ways to streamline operations, lower costs, and create innovative service models.

Creating a Technology Suite

Finding the exact combination of technology to fit the demands of the LTC pharmacy business is an ongoing process. In the case of Integrity LTC Pharmacy, according to Marcus Wilson, the technology suite is multidimensional and includes packaging robotics, a pharmacy management system that has bidirectional communication with the facilities, and a Web-based LTC application for the facilities. “Each piece of technology plays a large role in how we practice pharmacy,” says Wilson.

At Wellfount, for another example, the technology equation has five parts to it, according to Eric Orme. There are the pharmacy and document management systems, in-facility dispensing automation, in-pharmacy strip packaging automation, facility EHRs, and physician technology. “And the secret sauce is having every piece work together,” says Orme. “That’s how you get the delivery of a high level of service.” Wellfount has even given the whole technology package a name: TED Rx, which stands for technology-enabled dispensing. And while this is a clever stroke of marketing on the pharmacy’s part, it also makes it clear how important it is to look at the technology system as a whole.

Marcus Wilson, R.Ph.,
Co-owner, Integrity LTC
Pharmacy, Springfield
and Grandview, Mo.
12,000-square-foot independent pharmacy offers a full range of LTC services.

Returning to examine Integrity a little more closely, it’s clear Wilson sees the keystone in the suite as the link between the Speed Script pharmacy management software and its Web application Speed Script LTC (SSLTC), a real-time communication tool that keeps data flowing into the pharmacy 24/7. If an order is discontinued on the facility side, it comes up in the Speed Script system in a notification window, and on the flip side the facility sees an order on the resident’s medication profile in a dashboard as soon as the pharmacy fills it. “Because of these software additions, our facilities have significantly reduced medication errors, increased resident safety, and become more efficient with their daily duties — all while remaining compliant with on-time med passes,” says Wilson.

And while there are five parts to Wellfount’s suite, Kelley Wells also points to the pharmacy systems, in this case FrameworkLTC and Integra DocuTrack, as the core of the suite, which then connect via SoftWriters’ HL7-based interface protocols with Talyst dispensing automation in the facilities. Wellfount also layers in TCGRx’s ATP strip packaging at the pharmacy. “There are lot of details that you have to make sure are right to have all these systems work together,” says Wells. “We fill 240 NDCs with the Talyst machines, and then there are another 2,000 or 3,000 meds that aren’t that common that we will fill with the ATP and mail out to facilities.”

Eric Orme, CEO and President
Kelley Wells R.Ph., VP
of Pharmacy and Quality
Wellfount, Indianapolis, Ind.
Pharmacy operating in eight states with a primary focus on skilled-nursing facilities, and also serving assisted living and other types of homes and residents.

Building a Productivity Pipeline

Keith Hartman has his eye on how he is combining technology as well, with a particular focus on creating an organized workflow that increases Jersey Shore Pharmacy’s capacity. “Our automation has made our productivity pipeline bigger,” he says. “We can shove more information into the front end, without hitting bottlenecks as that data flows through our systems, because of the workflow we’ve built.” In fact, Hartman estimates he could increase his business by 25% and still operate comfortably. 

Hartman points to two key components of the data pipeline that fuels the pharmacy workflow: DocuTrack and DeliveryTrack by Integra, both of which interface with Jersey Shore’s HBS pharmacy management system. “We could not manage the 1,200 faxes we get a day without DocuTrack,” says Hartman, who initially installed the technology to handle the incoming fax volume when Jersey Shore Pharmacy was serving 800 beds.

The change in workflow has been dramatic. Prior to the digital system, the pharmacy would print the prescription, and then the pharmacy staff had to manage the one copy, following it around the pharmacy wherever it went in the workflow process. Now DocuTrack triages all the prescriptions based on the incoming fax number, with intelligent routing that moves the incoming information directly to the correct department within the pharmacy. “When an order comes through we can recognize from the fax number whether it’s a new order, which should go to our filling queue, or if it’s coming from facility’s business office fax machine, in which case we want our business office to get it,” Hartman explains.

Keith Hartman, R.Ph.,
Owner, Jersey Shore
Pharmacy, Galloway, N.J.
Independent pharmacy serving skilled-nursing, assisted-living, and subacute care facilities; continuing-care retirement communities; substance abuse centers; and adult day centers.

Jeff Kirchner of Streu’s Pharmacy has found a route to vastly reducing the manual filling process and creating a more efficient and productive dispensing pipeline through a new offering in adherence packaging automation. Kirchner has been a long-time user of Medicine-On-Time’s multidose packaging cards, with this adherence packaging forming the backbone of the LTC business that has allowed Streu’s to grow from servicing a few hundred beds to over 1,000 beds. The automated system is called Versi-Fill 2. It handles the pharmacy’s top 250 drugs, about 80% of the dispensing volume.

The impact on productivity has been clear. “We can do what we used to do with six people now with two,” Kirchner says. The true measure of the value of the new machine came about two weeks into using it, when Kirchner says the pharmacy, which usually tried to work two days out, was working seven days out on orders. “When a pack is ready for filling, pharmacy staff scans the card and puts it on a tray in the machine, and it drops the doses for a selected drug into the card,” explains Kirchner. The card then moves to a verification station, where another staff member can do any necessary manual work, including splitting doses and sealing the card.

Jeff Kirchner R.PH,
Owner, Streu’s Pharmacy
Inc., Green Bay, Wisc.
Independent that includes a closed-door LTC operation serving skilled-nursing and assisted- living facilities.

Building an efficient production process can also offer flexibility to meet changing trends in prescription volume and reimbursement, as Marybeth Terry has found. Southern Pharmacy has seen prescription volumes increasing in recent years. At the same time, the pharmacy has experienced lower revenues because of reimbursement cuts. Southern Pharmacy has invested in DOSIS automated blister card fillers from Manchac, in part to address these changes in the market. “Automation does so well, with its accuracy, dependability, and predictability,” says Terry, “while also allowing us to cost-effectively and flexibly meet changes in volume.”

This investment in automation has also allowed Terry to develop innovative steps in Southern Pharmacy’s workflow using the technology and barcode scanning to streamline the pharmacist verification process, contributing to a level of accuracy that has led Southern to be without a clinical error for the last two years.

Marybeth Terry, Pharm.D.,
President, Southern
Pharmacy Services, Pink
Hill, N.C.
Pharmacy with two locations in North Carolina and one in Virginia serving a range of LTC facilities.

Thrifty White’s Justin Heiser provides yet another good example of how to create a strong production pipeline, in this case by creating a foundation of automation and then leveraging it with central fill. At Thrifty White the elements of automation come from TCGRx and include automated BullsEye pill splitters; ATP strip packaging in two central-fill locations, one for retail and one for long-term care; and InspectRx for verification. Supporting this automation is TCGRx’s Beacon inventory system, which Heiser reports using in LTC central fill to manage the inventory needed to replenish the ATP machine and in a number of retail locations. “The Beacon system allows us to organize inventory by lot number and expiration date, and in a very compact area.” Explains Heiser, “it also positions our fastest movers and those medications closest to expiration closest to the staff member stands running the packaging station.”

Two aspects of this automation platform bear closer inspection: automated pill splitting and automated verification and spooling of the strip packaging. In the first case, Heiser reports that some of the pharmacies highest-volume items are half tabs. “It’s an art to split some of these meds,” he says. “It is a tricky, labor-intensive part of dispensing that we’re glad to be able to apply automation to.” These half tabs then also enter the automated dispensing pipeline easily, according to Heiser, because there are canisters for the ATP packaging automation that are calibrated specifically for them. “And if the tabs don’t fit the formulary we want to stock in the automation, we can use trays that the machine calls for as needed,” he says.

Justin Heiser, Pharm.D., SVP
Pharmacy Operations, Thrifty
White Pharmacy, Plymouth,
Employee-owned company with 90 corporate-owned pharmacies and 85 affiliated pharmacies in North Dakota, Minnesota, Montana, South Dakota, Wisconsin, and Iowa. Combines local pharmacies and central fill to serve a variety of LTC environments.

And then, after the strip packaging is filled, comes automated verification and spooling. “As we run the packaging through InspectRx, it takes an image of the front of the bag, with all the key prescription label information, and the back of the bag, where you can see the actual medications,” explains Heiser. An interface with Thrifty White’s pharmacy system means that the verification automation knows exactly what it is looking for, from the color and shape of the pill to any indentations and markings. “It uses all of these factors to identify whether the right pills are in the right bags,” says Heiser. “And then we can either check by exception, where that’s permitted by regulation, or our pharmacists have the ability to do an on-screen verification, where they can easily see both the front and the back of the bags.”

Meeting Changing Needs

Technology is also playing an important role in helping LTC pharmacies meet the demands of a dynamic market. For example, Brian Beach points to an important trend he’s been seeing and on which Kelley-Ross Pharmacy has put technology to work. Beach reports seeing an increase in adult family homes and other settings where there’s a high demand for medication packaging that supports adherence but that does not require skilled caregivers for administration and management. And while Kelley-Ross has extensive experience with strip packaging to serve skilled nursing facilities, the traditional answer for other settings has always been the multidose punch card, which Kelley-Ross has filled by hand.

So in response to this trend, Beach reports that Kelley- Ross has recently added SynMed dispensing automation from Synergy Medical for this specific packaging type. “We saw that SynMed directly addresses one of our major needs in automating the filling of the multidose cards we use to serve nonskilled settings,” says Beach. “And we felt that it offered a small-enough footprint, combined with a high-enough capacity, for it to make sense in our pharmacy.”

Brian Beach, Pharm.D.,
Director of Long-Term
Care Services, Kelley-Ross
Pharmacy, Seattle, Wash.
Independent serving residents in skilled-nursing, assisted-living, and rehabilitation facilities, as well as those in adult family homes. Specializes in patients with HIV and mental health conditions.

This automation is also helping to create more efficiency in the filling cycle that Kelley-Ross uses to serve these nonskilled facilities. “Skilled nursing has the mandate from CMS to be at 14 days or less,” says Beach, “but there are these other facilities that want us to dispense in a shorter cycle, too.” For example, group homes and adult care facilities want the multidose punch cards delivered from Kelley-Ross weekly. When Kelley-Ross was filling these cards manually, the only practical way to do so was to build four weeks of cards at a time and then send one out each week. Any changes meant significant rework and possibly a burden for the facility staff, which is not trained to handle significant medication management tasks. “Filling that far ahead often wasted a lot of time and medications,” says Beach, “and it left too much room for error.” But since adding the SynMed automation in March, Kelley- Ross has been able to move to just-in-time filling for multidose cards. “We are filling cards and dispatching them to a home within a day, versus what used to be up to 21 days. This lets us deliver exactly the medications patients should receive per the most up-to-date orders that we have.” Beach reports seeing customers happier now. “I think at the end of the day there are many advantages to our automation of the multidose card packaging process,” says Beach. “It’s more elegant, less error prone, and keeps the medications delivered in the packaging that is easiest for residents.”

Dispensing and Billing Cycles

Of course, just as important as being able to dispense on shorter cycles is being able to bill for this more complex process effectively. For example, Jeff Harrell is providing short-cycle fills for SureCare Rx customers using the strip packaging technology Parata PASS. But at the same time he’s chosen to use what he calls preconsumption billing to submit claims for a 28-day supply. This means having to be very careful about reversing and rebilling claims whenever a change occurs in an order. To do this Harrell reports taking advantage of streamlined billing management features within his QS/1 Primecare pharmacy management system. “I think the nicest thing about the billing software is that we can take care of changes with one keystroke,” he says. “From one screen we can reverse a claim, change the quantity, and rebill, and all literally in one click.” He also points to a robust reporting package that he can customize to pick up all these changes and make sure everything is properly accounted for when he runs his end-of-month statements. “It would definitely be easier for us from a claims management standpoint to fill for the month and then bill,” says Harrell. “But that would also be very costly. We’re talking about fronting a month’s worth of meds for 1,300 to 1,400 people, and that’s hundreds of thousands of dollars.” 

Jeff Harrell, Pharm.D.,
President, SureCare
Rx, Seattle, Wash.
Independently owned and operated pharmacy serving residential-care communities throughout the Pacific and inland Northwest.

Working All Together

Effective interfaces are another critical area where the LTC technology puzzle has been coming together. And it’s an area where there’s great opportunity to respond to the tremendous pressure to deliver better and better patient care at lower cost, according to Consonus Healthcare’s Neil Marshall. “There’s a very real pressure based on market conditions and the role that government is playing,” says Marshall. “For us technology is a big part of our strategy to address these pressures, and the most important area of technology for us is connecting to our customers’ systems to share patient information and exchange orders.” 

Marshall reports an increasing need to interface to two main kinds of systems: eMARs at assisted-living facilities and EHRs at skilled-nursing facilities. And with the great variety of choice in eMARs and EHRs, Marshall has found that successful interfacing is built on operating to a clear standard. In this case, Consonus Healthcare is relying on the HL7-based standards that SoftWriters has developed to define how various partners can interface with FrameworkLTC. “That was one of the things that was very attractive to us when we purchased FrameworkLTC about two years ago,” says Marshall. There’s patient data, for example ADT details, and then medication order data, which is where there’s a much greater level of complexity, according to Marshall. “There are a number of different order types, some of which are straightforward,” he says. “Others can get pretty tricky to handle from an integration perspective.” Marshall ultimately expects to interface with somewhere between five and 10 different facility-based systems. “If we had to treat each one of those as a one-off, it would be a substantially slow crawl process,” he says. 

Neil Marshall, Vice President,
Pharmacy Operations,
Consonus Healthcare,
Milwaukie, Ore.
Pharmacy with locations in Portland, Seattle, and Sacramento serving both skilled-nursing and assisted-living facilities.

These eMAR and EHR software packages really are something to keep your eye on, according to Keith Hartman. He is offering facilities ExactMed’s iMAR at Jersey Shore Pharmacy, which has a bidirectional interface with his HBS system that lets pharmacy staff send and receive orders. There are several clinical components that are helpful, reports Hartman: Software will indicate if a drug shouldn’t be administered with a specific OTC — for example, an antacid with levothyroxine — or it can stop a med pass if certain parameters aren’t met — for example, if a blood pressure medication should not be administered because the nurse hasn’t checked the patient’s blood pressure first. Hartman is also able to set efficiency benchmarks, with a color-coded system giving management an idea of where staff is ahead of or behind schedule. Hartman tells a great story that illustrates the power of these systems properly deployed: “The first facility that implemented our eMar had so few issues during two consecutive state audits it was referred to the federal level for review,” says Hartman.

Strategic Thinking

Talking about building out connections with facility software introduces the important topic of the strategic thinking that’s helpful for making these efforts successful. For example, Neil Marshall reports that Consonus has taken the step of creating what he calls an “e-pharmacy team.” “This group has a cross-functional set of skills, including nursing, pharmacy, and technical,” he explains. “We did this so that we could provide a high level of support to facilities installing eMARs and EHRs, particularly during startup and conversion times. We found that we accelerate our customers’ adoption of new technology. So we went ahead and invested in the kind of resources that we think it’s going to take to help facilities succeed.” The first task for Consonus Healthcare’s team is to work with facilities to plan their conversion in a structured way. Then, according to Marshall, the team will do the prep work required for an integration — for example, certifying the facility-side business processes such as order entry to make sure the facility will be creating and submitting actionable orders.

Evolving the Model

As all these different technology pieces come together, LTC pharmacy providers are finding that there’s also some important strategic thinking that needs to be done about changing the traditional clinical and business operations models. In the case of Southern Pharmacy, for instance, the streamlined verification process has resulted, according to Marybeth Terry, in more time for pharmacists to work closely with doctors — managing Part D plans to reduce co-pays, for example; to be proactive with problem resolution; to look at strategic projects to improve services and efficiency; and to generally engage in more clinical activities.

Justin Heiser at Thrifty White reports that the pharmacy has developed a patient care center that is staffed specifically to support the local pharmacies in managing patient care. This model allows Thrifty White to field pharmacy care teams that, for example, are taking the lead in managing and coordinating care for residents moving from skilled-care facilities into transitional-care settings. “These patients are discharging on multiple medications, including blood thinners,” says Heiser. “We know that many of these patients aren’t adherent traditionally. They may not get prescriptions filled at all. This is very challenging to address, but the toolbox that we have built with our technology platform gives us the ability to have pharmacy staff available to address these challenges and support the residents and the facilities.”

At Wellfount the model is very different indeed, relying as it does on a single pharmacy location and distributed in-facility dispensing automation. “One resounding theme we have is that the way and the time to distribute drugs, the way to use technology, and the level of service offered at the resident level are all things that need to be changing,” says Eric Orme. “Our approach is that we don’t want to be five miles away from where the meds are needed — we want to be five feet away, because we’re going to come and put the inventory in your facility.” He says homes report saving 16 hours of nursing time per day. “And we also feel that we are offering facilities a distinct advantage in keeping their census up.”

Work Hard, Get Results

Getting all these pieces to fit together, both at the pharmacy and at the facility, is a significant piece of work, notes Neil Marshall. “But what you get on the other side is worth the trip,” he says. “And what we’re doing today in a nonintegrated state is even more complex — exchanging faxes, looking at electronic documents, and doing double order entry all in the name of trying to make sure our records match, for one example.” Marshall feels that pharmacies can play an active role in helping their customers with technology. “Take eMAR and EHR interfaces,” he says. “We want to help our customers get those systems in place before they become a competitive necessity. We may already be in the necessity zone at this point.”

In order to make sure that the hard work really brings the returns you are expecting, you have to have real buy-in from all the people who will make it work. That means your own staff first of all, according to Marcus Wilson. “I feel any pharmacy should be sure that its staff fully understands that technology is something that we use not to reduce our overall staffing, but instead to increase our capacity and efficiencies,” he says. “Any automation needs intelligent people to run it, no matter what it is.” And then you need buy-in from facility staff and administration, too, points out Kelley Wells. “Our experience is that if the administration doesn’t buy into your plan, and the nurses start complaining because it’s different, then that’s a bad situation,” she says. “The nursing home sector has probably been a little slower to change than other areas of healthcare, and in the next few years we’re going to have to make sure we have buy-in in order to get all the players on board and working toward improving care and reducing costs.”

And with the central role medications play in the provision of care, Brian Beach sees LTC pharmacies having a real opportunity to take on the role of the common denominator in a patient’s care. “From a pharmacy standpoint we see a benefit to creating and preserving that continuity of care by using technology to really hold onto patients throughout the transitions they may make from home to hospital to LTC facility and maybe even back home,” says Beach. “I think that when the LTC pharmacy has a strong presence, it preserves a level of support and continuity for the patient and their healthcare that you wouldn’t get otherwise.” And so with the right kinds of creative thinking, hard work, and engaged users, the pieces of the technology puzzle can really come together to create a new picture of care for LTC residents, pharmacies, and facilities. CT

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