Expert: Pharmacists Can Set Up EMRs to Default to the Best Treatment Per Payor With the Best Reimbursement Rate

Pharmacy Times® interviewed Andre D. Harvin, PharmD, MS, executive director of pharmacy, oncology, Cone Health, on his keynote address at the ACCC 49th Annual Meeting & Cancer Center Business Summit titled “Robots, Biologics, and Advocates: Lessons from the Pharmacy.”

Pharmacy Times®:How are pharmacy teams currently utilized by cancer practices?

Andre D. Harvin, PharmD, MS: Yeah, when I think about pharmacy practice as it relates to oncology, the great thing there is that there is a level of variability that allows for some flexibility, some innovation to occur as well. What I really like to think about is that, when you think about pharmacy, it's really a program. And there's really 3 key components to that. We are a clinical program, meaning that pharmacists are deeply involved with is this the right care for this patient at that point in time? And so, a question may come from that, well, isn’t that the medical oncologist’s responsibility? And absolutely, right? Like, they have ultimate accountability there. But when we look at medical practice, and how fast it's advanced over the last just few years—not even last decade, just like the last like 4 or 5 years—the difficulty in keeping up with all the new drugs, all the new different genetic testing procedures that are coming out, real evidence that's coming to the table, it's almost impossible for one person to try to remember that. And so, it takes a village, and pharmacy is part of that village because we are medication experts.

And so from that clinical perspective, we are that kind of eye in the sky, that’s looking at every regimen every single time that patient comes in the door. And we’re asking those questions. What happened to that patient last time? Did they have a reaction? Do we need to think about a reduction of the dose or reduction of the weight—I’m sorry, the rate—or do we need to add on premedications that could prevent infusion-related reactions? Is this the best drug for that patient right now? Are they at a part in their journey where we need to think about other medications that need to be brought on board to prevent potentially future adverse events that haven’t been seen yet? So, those are all the questions from a clinical perspective that we can start to ask, and we start to be integrated into that conversation.

Operationally, we are like a manufacturing, you know, whole site that’s going on within your cancer center. When you really think about it, there’s very few other things that happen in a hospital system that you can really apply that manufacturing lens to, but you have to remember that your pharmacy is typically one of your most highly regulated environments throughout your entire health system. Like more so than the OR [operating room], your pharmacy is so tightly regulated, when we think about USP 797, USP 800. I mean, it’s really fascinating, and just breathtaking all of the things that we take on to ensure that our patients are safe. And we have to do that, while also making sure that we get the drugs quick enough to the patient that we don’t cause bottlenecks in the clinic, therefore upsetting our patients or increasing their length of stay.

And then finally, one of the most important things and ones that I really want to address in my topic when I talk about it for the keynote is that pharmacy is a profit center. And a lot of people either don't appreciate that or they don't necessarily attribute that to the department. But that's really the big part of the conversation that pharmacy has to be a part of as well. Yes, we are one of the most expensive departments to have for a cancer center practice, but when you look at the revenue that's generated for those services, it typically far outpaces the costs associated with that. And so therefore, when you look at the finances of your oncology practice, you're going to see that typically pharmacy is at the top. If not, they're going to be in the top 2 in terms of your profit center.

And so that’s an opportunity to bring pharmacists into that conversation, to ask about, hey, are we controlling cost appropriately? Are there ways for us to maximize different therapies or different contracts that are out there? Are we getting paid enough for how much it actually costs us to acquire the medication? So many questions, so many conversations can come up. A lot of times, it’s just making sure that we’re at the table. And then we’re seeing more as, not necessarily an ancillary service, but again, a program that involves the clinical, the operational, and the financial means to help make your cancer center more successful.

Pharmacy Times®: How can pharmacy teams be better utilized by cancer programs or practices?

Harvin: When we think about how pharmacy teams can be utilized in cancer practice, I start to divide into a few different buckets. And so probably one of the first buckets, which a lot of people don’t think about, is really that patient journey and that patient throughput, right. So a lot of times we talk about, okay, well, we’ve got to maximize our infusion calendar and our infusion scheduling, we have to try to get in as many patients as possible. But we also are, a lot of times, thinking about that in the lens of nursing. And our nursing colleagues, I mean, they're so important. We know there are shortages out there right now with them. We want to support them as much as possible.

But a lot of times, unfortunately, what gets overlooked are some of those upstream bottlenecks that may occur. And so it's one thing to have a schedule that's jam-packed with as many patients as possible. It's another thing to be able to deliver on that for the patients. And I think that's where a lot of cancer center practices find themselves getting tripped up sometimes. And so, we have seen that, and what we do is we brought data to the table. So, we were able to say, well, hey, look, we have regulatory requirements that we have to adhere to from a USP-797, -800 perspective. We can't just have a bunch of different drugs being reconstituted in hood, and as we need it, we're just jumping around pulling them up. No, a lot of times what this regulatory environment says, you can only compound 1 thing in that hood at the time, then you have to sterilize it right afterwards. So, we can’t have leucovorins over here and rituximab (Rituzan; Genentech USA) over here, or a couple of [pembrolizumab (Keytruda; Merck & Co)], and these kind of drugs on. We just can’t do that. It’s unsafe. It’s not what we should be doing for the patient. And so what we did is we actually started bringing data to the table that would directly impact that patient journey.

We would say, okay, hey, if patients are coming in for these medications, we need to spread them out and move them around a little bit, because this drug by itself takes the pharmacy about an hour to produce it, start to finish. Order verification, compounding, getting it to the clinic—it’s going to take us an hour to do that. What are some ways that we can cut down on that, right? So, could we get those labs ahead of time, so that we could potentially compound that medication in advance? If not, let's make sure that we don't put all those medications, in terms of delivery or demand, at the same period of time. So, as we started collaborating with our nursing colleagues, with our scheduling colleagues, the schedule really started to morph for us, where we were able to actually, over a year, cut out over 4,000 hours of wait time for our patients, which was really fantastic. So, now patients were able to kind of walk in and really cut down on their visit, cut down on that expected time that they were going to be at the clinic.

So, for me, when I think about if I was a patient, and you said, hey, this appointment is going to take you 3 hours, well that’s already 3 hours of my day. And if it ends up taking me 4 hours, then I’m going to be upset a little bit about that, right? I'm going to start to think about, gosh, if someone else needed treatment in here, would I recommend them to come here? Regardless of how much I liked my physician or how I how much I liked my nurse, in the back of my head, I'm going to think a lot about whether or not they respected my time, whether or not if they told me 2 hours and it ended up being 3 or it ended up being 4, because things were occurring and the clinic was backed up. Those things matter to patients over time. And so, we really found ways to really take that out of it.

The other aspect is just focusing on patient financials as much as we could. So, there were opportunities for us to find ways to bring in cheaper drugs by the way of biosimilars, and also making sure that patients got connected with the manufacturers’ pharmaceutical programs, so that we could reduce their out-of-pocket. So, those are kind of like some of the 2 big areas that we really focused on in terms of practice advancement and program advancement here at our cancer center.

Pharmacy Times®:How can oncology pharmacists help guide patients through their treatment experience and the goal of their treatment and symptom management?

Harvin: Yeah, absolutely. I think it's a fantastic question as well. So, where does an oncology pharmacist fit into that patient journey? I think is such a conversation that needs to occur on a national perspective that I could probably spend the next hour having my opinion about it. And I think a lot of my colleagues would agree and probably expand on that as well. So, I’ve—you know, my dad’s gone through cancer care treatment in his past as well, and we’ve had those same exact conversations. So, when we think about putting the patient at the very center of what we do when it comes to cancer diagnoses, we should really all come to the conclusion that they need that time to sit down with a pharmacist that has been trained in oncology to really help them prepare for that journey, right.

When you receive a cancer diagnosis, when someone receives a cancer diagnosis, that’s probably one of the hardest things that they’re going to hear. And everyone that is involved with their care, I think, needs to play a specific role. And for pharmacists, we are the drug experts. Like, this is what we train for. This is what we do. This is what our years and years of education and typically 1 or 2 additional years of residency training prepares us for, is that we’re able to answer questions about every drug that that patient may be on, what they can expect, what are things that they need to watch out for, when it occurs if it occurs, who do they need to contact, and then ways to help them manage that to ensure that they get the very best outcomes from that therapy. And there are so many critical examples of that, but I’ll just kind of touch on a few.

So, similar to what led to this question, we have also had similar responses from our patients here, where we only have 1 embedded oncology pharmacist, and it's a new one that we were able to get, but across our 6 cancer centers, we only have one. And that's just because with smaller cancer centers, a lot of times, it's difficult to justify the budget to have pharmacists embedded in every single clinic. However, our pharmacist that's embedded in the clinic is a fantastic practitioner, that probably has a mile long of stories that he could tell of just being that difference factor for that patient. So, an example that that he likes to tell a lot is that he was making his way through the infusion clinic.

Typically, he’s embedded with our physicians, where they’re kind of doing the overall exams for the patients and patients may be discussing that. But he happened to be working through our infusion clinic one day and overheard a conversation between a patient and one of our nurses, and the patient was saying, well, hey, I got this prescription to go pick up this medication afterwards, I guess it’s supposed to help me with nausea. And the nurse, not to say that they intentionally did something wrong, they looked at that list of medications, and they said, well, you only have to take this one if you start to feel as though you may have nausea and vomiting. And he overheard that and just kind of stepped in at that point in time, and just said, hey, can I take a look at that really quickly, and was able to quickly correct that to say no, no, maybe in other circumstances, but with the medication you’re taking, you actually want to go ahead and take this one as prescribed for at least the first few days, because it’s going to prevent you from ever getting to that point of nausea and vomiting. And the other 2 medications, you can actually put them on as you start to feel certain symptoms. And as they start to increase, you want to do this, and then if that occurs, this is what you want to do next. And it was a very quick interaction. You know, you’re talking about something that maybe took him all of a minute to make that quick correction for the patient. But when we look at the regimen they were on, it is something that would prevent that patient from potentially ending back up in the ED or just saying, you know what, I can’t tolerate this, this is something that’s too much.

And so, a lot of times, it's just those smaller actions. I mean, pharmacists, we know what we're talking about. And again, it's not a slight towards any of our colleagues. But it's so important, especially when you're talking about oncology care, that we align the skill sets appropriately. And when it comes to patient education, as it relates to medications, there is no discipline better than a pharmacist. And when you start talking about oncology, the pharmacists that work in oncology are highly dedicated, they're highly trained, and this is what they do. And so really, the call to action is how do we create a model where we can have more pharmacists embedded in clinics.

You know, that’s the challenge for us is that we're not recognized as providers from a CMS perspective. So, sometimes it's difficult for us to be reimbursed for those interactions that we have with patients. Whether we manage them independently, or with a practitioner, we're not able to easily be reimbursed for those services. But if we were, we always know, we know that we would be impactful to patient outcomes, because we could make sure that they stay on their medications, that they have less adverse drug events, and that we connect them to other vital services that may help either reduce financial toxicity or provide them some level of support services from a social perspective as well.

So, you can tell I'm really passionate about this subject that pharmacists need to be at the elbow level of the patients. I think that until we can get there, there's always going to be that gap. There's always going to be that we're not caring for our patients to the level that we know how to get there. But we're going to keep pushing on it. And our hope is, is that sooner or later that's not a question of why aren't patients having access to a pharmacist. It's going to be well, what more can pharmacists do now that they have access to those patients?

Pharmacy Times®:How might pharmacists be particularly able to help cancer practices and programs realize cost savings and efficiencies through technology?

Harvin: Yeah, I think when we look at what drives cancer practices, still to this day, we are still a volume-driven environment. I know we speak a lot about our transition to value-based contracting, and I'm a person that's 100% supportive of that. But right now, it is still based on volumes, right? It's getting patients through their visit; it's making sure that your providers see enough patients in a single day; that if you have APPs, they're seeing enough patients, that they're being able to drop their charge; that you're getting patients diagnosed; you’re getting them into treatment faster. So, not only does that obviously have financial implications, but it certainly has patient outcome implications as well when we think about time to treatment. And so really what I've seen, what we've been successful with here, and what I've heard from a lot of different pharmacy practices, is pharmacy leaders starting to lean into those areas that are not necessarily traditionally seen as areas for pharmacy, right?

We understand, whether people realize that or not, like, we are drug experts but a lot of us understand the business of pharmacy and the business of oncology care as well. And so what we can do from that kind of volume perspective, a lot of that comes to the electronic medical record, which is how do we ask those questions about what causes us bottlenecks, and how can we more effectively utilize the tools within our electronic medical records to reduce the communication, reduce redundancies, move patients through their visits safely and efficiently.

So, we've done that a lot here, which is—I’ve been here for a little bit over 3 years—and we went on patient journeys to say, okay, let's take a patient through. How is the exchange of information happening, right? How is the patient physically moving? What product is moving from point A to point B? And then, let's understand every single failure point that's occurring there, and start to ask questions about, well, what's contributing to this? What's contributing to that? Is there a more efficient way to do this? And a lot of it just comes from either retraining staff or finding ways to leverage new features within your electronic medical record that are sometimes being developed but there's sometimes that difficulty of actually operationalizing it and bringing to the table.

Photo Credit: Adobe Stock - Paulista

So, one of the key things that we did was we said, okay, we have an okay-to-treat problem, right? So, a patient comes in. Their treatment parameters may be located in the electronic medical record, but sometimes, maybe they’re not consistent with that patient, right? What if you have a patient that we already know that they have elevated serum creatinine, and the physician doesn’t modify their treatment parameters and say, well, hey, I know they always have an elevated serum creatinine, only if it's over this level do I actually have a concern about it. And so we actually looked in and said, let’s figure out those events. How often is that occurring and what’s occurring for that clinician, the nurse, the pharmacist, the patient, when some of those events are occurring?

And, what we found is that every single time you had patients coming in, we expected that their labs are going to be at certain levels that were already outside of just the normal parameters that were involved in the building of that treatment plan. And, every single time that patient's journey just grinded to a halt once they got over to infusion. And we recognize that as a preventable action, right? It didn't have to occur, if you already expected that their value was going to be higher. There are things that we could modify. And so, a lot of that came into, well, who's going to do it, who has the accountability.Is on the provider? Is it on the APP? Could someone else do it? And what we started coming up with was, was there opportunities for the pharmacists, being the clinicians that they are, to help modify some of those treatment parameters, obviously send that back to the provider to say, hey, this is what we continue seeing with this patient, we already know they have slight kidney failure. So, they're always going to be outside these parameters. Are you okay If we tweak these parameters a little bit, and you'll now only get called and we’ll only slow down that patient when they go above or outside of these ranges? And more times than not the physicians were like, yeah, absolutely. Because every single time, these labs come back once the patient has moved on and they're sitting in infusion, they're around this area where I know they're going to be but I forget or I don’t think about changing the parameters because I’ve got another patient waiting outside my door, they’re waiting for me to get rid of that, get done with that patient, so I can go out and tell them it's okay to treat. So, what we did is we just started working backwards. So, what are those okay-to-treat actions that are occurring, that clinically can be managed by someone else, under the provider’s guidance, of course, that will prevent our patients from getting held up, and then therefore, it helps them work through the clinic a lot faster.

On the financial side, though, we also looked at things like biosimilars. So, that was kind of where our other big bucket of cost savings came from, from our system, which was how do we integrate biosimilars? And biosimilars are a little bit difficult to implement. A lot of practices have done it, but the question is, have they done it to the degree that maximizes their bottom-line financials? And that’s the part that’s actually a lot harder. And I’m going to talk about this a lot within my keynote address, is that there’s so many nuances and there’s so many pieces there that I think a lot of practices don’t understand. So, biosimilars, they’re not generics. They are drugs that are highly similar to the reference product or the brand name product. And, a biosimilar is just a new kind of classification that the FDA put out to say that we’re going to recognize these, again, not as generics, but as drugs that are highly similar that show no clinically significant differences there. What then occurred after that is that insurance companies said, well, we’re going to see these biosimilars and we see our cost savings opportunities, and though there may be several biosimilars on the market, we’re only going to choose a few of those biosimilars to be our preferred items. And the other ones, even though they’re in the same pharmaceutical class, it’s the same principal drug or same principal biologic, they are now no longer on our preferred item. And so therefore, it’s hard for any practice to say, you know what, we’re just going to put everybody on this pegfilgrastim biosimilar because you may have several different payors that have a preferred drug.

So then how do you manage that, now? Because now it’s going back to, as a provider, are you expecting them to say, oh, you know, this patient has Blue Cross Blue Shield, I’ve got to remember this month that Blue Cross Blue Shield likes this pegfilgrastim and not that pegfilgrastim? Well, obviously not, right? Like, that’s not something we want them to spend their time on. But who can do that is your pharmacists. And we can find ways to actually leverage that decision more from our electronic medical record perspective, where we actually built in to say, okay, let’s reference their insurance, let’s see what is available in terms of the preferred for maybe the 2 or 3 different biosimilars that they say they will allow. But then let’s also ask a deeper question, what is the best net acquisition cost or net cost recovery for each of these 3 different biosimilars? Because they’re different, right? So, the price may be different than what we purchase it for, the reimbursement rate from a payor may be different as well, and therefore, the net margin for each of those biosimilars—even though they’re all pegfilgrastim—may be drastically different from one product to the next. And so, the question would be, well, if you're going to administer a prefilled syringe, of pegfilgrastim, and you've got 3 options, and one can give you a higher reimbursement rate for doing the same exact work, wouldn't you choose that? Right? And so that's where we got to.

We were able to work with our managed care division, we worked with our revenue cycle team, and us as the pharmacists in the lead there, we said, okay, when we look at all the financials, all things being equal, this is actually the best per payor. And we actually broke that down in our electronic medical record, where it defaulted to the one not only that was preferred by the payor, but the one that actually gave us the best reimbursement rate. And that was a new wrinkle. And now, our providers don’t have to think about it. By and large, our pharmacists don’t have to intervene as much, because we were able to build that into our electronic medical record.

And now, we’re actually seeing a pretty measured increase in terms of, hey, we were expecting this amount of dollars per administration of this drug. And now we’re seeing a slight lift by doing the same amount of work, right? We’re not having to do more work to do it. We don’t have to jump through more hoops. There’s not more communication. It’s just happening now because we’re managing that in the EMR. And the interesting thing is, we have to manage that on a monthly or quarterly basis as rates change, as ASP changes, as we get new contracts. But now that we understand those formulas and how to put it all together, it really puts pharmacy in the driver’s seat to help quickly make those decisions, get it to our IT build team, they update the groups in the background, and then, without the providers even knowing about it, those decisions are being made for them so they don’t have to worry about it as much.

Pharmacy Times®:How might better aligning infusion nurse and pharmacist scheduling impact operations and the patient experience, and what might the implementation of that look like?

Harvin: Yeah, I think this is a great question and, I think, an area for a lot of discussion. So, when we think about infusion scheduling, a lot of times if you just look at, if you go out and Google, right, like how do you optimize the infusion scheduling, how do you get more patients into your clinic a lot faster, so much of what’s out there—whether you’re talking about a third-party solution, whether they’re saying, hey, you can do this on an Excel chart, if it’s saying that you can do it within your electronic medical record—so much of it is focused from the nursing perspective. And again, I get it. Nursing, they’re a much bigger department than we are, the work that they do is so critical, so without them, we couldn’t administer these drugs to the patient. They are the face of the clinic more times than anything else. When patients really think about their journey through their oncology care, a lot of times it’s about that interaction with the nurse. So, we have to put them at the forefront, that we want to make sure that the schedule is not overwhelming to them, that they are able to meet the demands of those patients in a timely manner.

But the interesting thing is, if you go a layer deeper and actually ask nurses, what prevents you from meeting the demands of your patient and providing the very best patient experience in that clinic, they're going to start talking about all these things. And probably pharmacy is going to be in there, right? They’re going to say something like, well, sometimes I have to wait a really long time to get the drug from pharmacy, and the patient started getting upset. They're going to say, hey, sometimes the analyzer may be backed up. And so, they sent the patient over, and I've got a line in but we don't even have their labs yet, so we don't know if they're going to be able to go forward or not. Maybe the physician didn’t put their orders in. Maybe the prior authorization is still outstanding. The pharmacy is certainly going to be in there.

As much as we think we do a great job, we do all this process improvement, the truth is that people want their drugs when they expect it, right? And the reality is that there are a lot of regulatory things that prevent us from doing too many things ahead of time. And there are some drugs that just don’t have the stability to be compounded the day before. There are a lot of drugs out there that we use every single day that maybe they’re only good for an hour, you’ve got to start that infusion or injection within an hour. Some of them are 2 hours, 3 hours, 4 hours. And so it’s really difficult. And then you don’t want to compound those drugs ahead of time, because what if the patient doesn’t show up? Or, what if the labs come back and it says, yeah, they can’t get the drug today? So, now I got to throw that away, and now it’s impacting my bottom line. So, there’s kind of 2 competing demands there, right? It’s the patient experience and their journey, but there’s also the financial accountability and responsibility that we have as a very expensive cost center.

And so, from that, nursing and pharmacy and I would say, obviously, providers in our lab services, we really have to look at this from a collaborative perspective. And so we actually have a third-party solution that we've worked with for a number of years to help maximize our infusion calendar. They've been a great partner to us. And several years ago, when I started here, I came to the table with him. I said, well, how do you account for those upstream bottlenecks, like pharmacy, like the labs, like provider behaviors? Like, how do we account for that? Because what I'm seeing is that this calendar is supposed to be perfect. And yet, I walked down to the clinic, and I still see a bunch of patients sitting in a lobby waiting. I see them, you know, waiting to go back to infusion We hear the complaints about patients in infusion being upset because they’re waiting so long. So yeah, it looks good on paper, right? You know, the graph looks great, everything looks smooth, there's no red on it—all those kinds of things. But the reality of it was different.

And so, we actually started collaboratively working with them to say, well, we likely just need more data points, right, we need to really understand what are some of those upstream bottlenecks that can occur? And how do we break that down into very distinct data elements that can maybe help build out and really drive a more effective template for us. And obviously, on a behavior side, what behaviors did we need to change and manage as a practice, that would allow us to also implement what the template in our third-party solution was telling us that we could achieve, and what others had achieved, right? Because they can compare us to other clinics of similar sizes and similar resources to us. And so, that's what we did.

We were able to, in pharmacy, break down and look at each individual drug, we leveraged some of the technology and automation that we had in the pharmacy—so we do have these IV robots that I'll talk a little bit about in my keynote address—but the really great thing about it is that we could go to our IV robotics vendor and say, hey, let's actually break down when that robot starts to get overloaded. Like, what causes that robot to start to take longer and longer to produce medications? And what are some of the things that we could change in terms of either what's going to the robot or how demands are going to the robot to actually maximize his productivity? And then other aspects, so if the drugs were not going to the robot, we had another platform that was connected to it, that we could also get data from them as well. And so we actually got to a point is that we could say, well, hey, once your demand reaches X number of drugs, your wait time, your processing time for pharmacy, starts to go up logarithmically, right? Like, all of the sudden, something that was ,you could have got it out in 10 minutes, now, it's going to be an hour because of the demands coming in.

And so we're able to take that information and get it back to our third-party vendor to say, here's when that bottleneck is occurring, and because you're only looking at the infusion business based on the time, but not the drug and the acuity of that patient, we're at a mismatch right now. Right? And so, from that we started really collaborating and working to say, okay, well, it's a little bit hard for them to adjust the drugs and the acuity from there, but can we attach some level of pharmacy intensity score to the distinct number of different demands that may come to pharmacy during that period of time?

And that’s where the rubber really started to hit the road, was now as we're scheduling, we can start to see, okay, yes, you have some gaps here on the schedule and the template is saying that you could potentially do it. But we are seeing that some of those have so many demands in them, different drugs that are in them, that if you put this one more patient on, now you're going to start creating a downstream backlog for patients that are scheduled later on in that day. And so again, it's about kind of leveraging data, leveraging our unique expertise in areas to say how do we make a more robust patient experience that really focuses on that, like the experience itself? Our goal is we want our patients to come in and for them to go straight back to whatever visit may be. If we're saying a patient, hey, we're asking you to be here at 9 o'clock. They shouldn't still be sitting in the lobby at 9:30, right? Like, something has failed there.

So, a lot of times it really was breaking it down. And not saying that we had to take nursing out of that driver's seat, we just had to say this was part of an assembly line, and so if one of us is failing or one of us is not considered and how we bring all this together for that patient experience, then we're going to fail. And so we have to be at the table when we're building these templates, we have to be at the table when we're talking to the vendor in terms of like, how do we build certain things in, what the experience is truly, truly looking like for that patient. And, we have to find our way at that table. They can still absolutely be the face of the clinic—we want them to be that. They're fantastic at it. But at the same time, the work that we do is so integral, so important I'll say, to their ability to be able to execute as the face of the client, to be able to ensure that the patients are having that very best experience possible. So, it can be done, right. Egos just have to be put to the side, and you have to bring the data to the table.