Technology in Specialty: Implementing a Central Intake and Distributed Dispensing Model Across Multiple Channels

The central intake model allows specialty pharmacies to manage patient information from multiple sources more efficiently. The potential benefits of centralized information and administration include better therapy management and increased customer loyalty.

IntroductIon

Patients suffering from chronic disorders and complex conditions, such as cancer, hemophilia, multiple sclerosis, hepatitis C, and transplant recovery, among others, will require specialized therapies and personalized care throughout the course of their care management plan. Managing such disorders and conditions requires the use of costly specialty medications. Ease of access to and enrollment into specialty pharmacy (SP) services for patients and providers is a key differentiator for specialty pharmacies.

As they continue to strive for increased patient satisfaction, improved outcomes, and increased cost savings, SPs will need to ensure that both patients and providers have immediate access to their services, regardless of the pharmacy dispensing the medication. In an effort to capture additional cost-saving efficiencies while offering this flexibility, many SPs are turning to a central intake and distributed dispensing model in order to provide patients and providers increased access to their services.

Although there are certainly many variations, the term “central intake” generally involves utilizing a single location/access point to receive and manage patient and order information from multiple sources. Sources may include providers, hospitals, diagnostic labs, and clinics—each with their unique submission formats or media.

Ensuring that the SP’s pharmacy management system can accept and process information received from various stakeholders as well as support the corresponding response/confirmation requirements will be critical in providing providers and institutions immediate and streamlined access to submit patient and order information. A central intake model also supports increased patient satisfaction by offering patients a full service model and continued support as they interact with various providers within their care management plan.

Patients and orders received through a central intake are subsequently routed through the following patient and order management work flow processes:

• Enrollment—Gathering the necessary information from the patient and/or provider required to process the order.
• Insurance Verification (IV)— Confirming the patient’s eligibility and insurance coverage for the prescribed medication as well as securing appropriate prior authorizations.
• Clinical Management—Implementation of clinical pathways and follow-through on regulated programs such as Risk Evaluation Management Strategies (REMS).

Once processed through the patient and order management work flow, the order will typically move to the fulfillment work flow of one of the SP’s available dispensing channels. Fulfillment work flow processes involve:

• Screening—Verifying the accuracy of the prescription and reviewing the order for drug-to-drug interactions, patient allergies, and appropriateness of use.
• Dispensing—Preparing the order.
• Quality Assurance—Confirming the prescription is dispensed correctly.
• Delivery (or customer pickup)— Ensuring that the patient receives the medication as required.

Distributed dispensing channels may include (1) dispensing directly from an SP or mail order pharmacy location with delivery to the patient’s home or physician’s office; (2) dispensing the medication at a traditional or specialty retail pharmacy location for customer pickup; or (3) dispensing at a hospital pharmacy for administration and/or customer pickup.

Business Drivers: Efficiencies, Patient Convenience, and Capability

In addition to patient and provider accessibility, there are many unique business drivers steering SPs toward a central intake and distributed dispensing model across multiple channels. Focused on greater efficiencies, economies of scale, and a more consistent delivery of services across channels, SPs may centralize their therapy management teams and patient care representatives into a single location/operating platform. In support of this effort, SPs may utilize a central intake and distributed dispensing model to seamlessly enroll and track patients within a centralized therapy management program, regardless of the dispensing channel utilized.

This centralized view and administration of their therapy management programs provides an SP and its payers with full clinical insight into the patient’s fill history, while still allowing for focused reporting based on a specific dispensing pharmacy. As many SP organizations now provide 24/7 clinical support for patients and providers, it will be critical for centralized therapy management and customer service teams to seamlessly access patient, order, and dispensing information across all channels of dispensing.

National and regional chains promoting specialty services at their retail locations may also utilize a central intake and distributed dispensing model to provide patients and providers immediate access to their services. The ability to receive prescriptions through a central intake as well as dispense the prescription throughout their numerous locations (distributed dispensing channels) may also lead to:

• Increased patient convenience
• Increased foot traffic in stores
• Chain loyalty based on providing a full service model
• Personalized interaction within the pharmacy

Key advantages

As the trend toward home health and community-based services continues, the model of central intake and distributed dispensing again provides key advantages. While specialized resources, such as payer-based reimbursement teams with expertise across medical and pharmacy benefits insurance verification, can be located in a centralized remote location to reduce costs, dispensing may occur at the community-based pharmacy. Operating under this model is expected to increase patient satisfaction through one-on-one patient interactions as well as lead to improved outcomes through increased compliance monitoring. Local dispensing may also aid nurses who are providing patients with support for the administration of medications and training for injections as they build relationships with and interface directly with local pharmacies.

Another key business driver relates to acquisitions. Larger organizations and private equity firms are increasingly targeting small SPs for acquisition. Many SPs that have limited capabilities and/or rely on multiple internal systems to support their operations are being targeted for consolidation under a single entity. Implementation of a central intake model can quickly position these SPs to enter into markets not permitted through the available distribution channels of stand-alone pharmacies.

In addition, an entity may acquire a single SP based on its access to a limited distribution program. Implementing a central intake and distributed dispensing model in this environment allows for centralized enrollment and data gathering, while ensuring dispensing occurs through the appropriate distributed dispensing channel approved for the limited distribution medication.

While the introduction of the specialty line of business into an existing pharmacy may be a critical business driver for establishing a central intake and distributed dispensing model, it may also result in significant operational challenges for that pharmacy. In addition to managing the fulfillment requirements for each distribution channel, each channel requires unique front-end customization, dispensing processes, and back-end differentiators. Upon entry into the specialty arena, pharmacies with multiple channels will need to support their operation and business partners with the ability to aggregate and segregate utilization as needed as well as support the multiple process work flows within the organization. Technology is critical to appropriately addressing these requirements.

The Technical Challenges

Operations

Centralizing the technology into a central intake location allows the specialty organization to leverage its technology investment across multiple dispensing locations. Under this model, development and implementation of critical intake processes (ie, developing HL7 interfaces to receive patient information at the point of hospital discharge, facilitating work flow processes through bar-coded enrollments, and designing triggers for clinical pathways) could take place at 1 central intake location while providing immediate benefits to all of the available dispensing locations. This is a tremendous benefit to smaller pharmacies where limited technology keeps them from entering into partnerships with more sophisticated payers and datadriven manufacturers.

Although preferred, utilizing a single pharmacy management system to drive fulfillment across all distribution channels could be very difficult to accomplish. In cases where multiple systems are in use throughout the distributed dispensing channels, interfaces and system enhancements will need to be in place to support streamlined work flow processes. Such interfaces and systems enhancements could support communication of patient clinical information, fulfillment data, and financial details across the distribution channels and within the intake center.

Utilizing system interfaces to support consolidated call tracking can provide the dispensing location critical visibility into all patient-related communication. Call tracking information is especially valuable if the patient is utilizing a retail pharmacy. At the point of pickup, a pharmacist could assist the patient with specific questions regarding their therapy as well as access a detailed view of all prior communications that have occurred with the patient regarding the order. In a central fill scenario, the order is shipped to the pharmacy for customer pickup, where copay collection with the patient can be a challenge. If the retail location and the central fill pharmacy do not utilize the same pharmacy management system, the copay amount and subsequent collection will need to be tracked between systems for appropriate accounts receivable reconciliation. In an effort to ensure customer satisfaction, this process should be as automated as possible.

Interfaces and system enhancement should also be in place to support bidirectional flow between the intake center and the dispensing pharmacy, as the dispensing pharmacy will need to provide fulfillment-specific information, including the time of patient pickup or the shipment tracking number and delivery details.

To ensure timely delivery of the medication, inventory must be considered prior to committing an order through a distributed dispensing channel. Developing interfaces to support call center agents and staff access to inventory levels at each of the dispensing locations while scheduling orders with patients and providers makes for an efficient work flow process when products may be in short supply or unavailable at particular locations. In addition, interfaces into integrated data sets within the systems should also be supported as the inventory levels available will also need to account for committed quantities (ie, orders already being processed for that item which have not been dispensed yet).

Information flow across platforms is also important for demonstrating compliance with the SP’s accreditation and licensing requirements. As a result, interfaces and systems enhancements should be implemented to ensure ongoing compliance with the SP’s policies and procedures as well as the operational and subsequent reporting requirements involving intake- and dispensing-related activities. Additional consideration should be applied to data transfers across the SP’s distributed dispensing channels in order to ensure compliance with state licensure regulations.

Reporting: Providing a single view Into the organizatIon

Data consolidation plays a key role in the day-to-day and long-term success of a central intake and distributed dispensing model. The main objective of a data warehouse is to join data that are difficult to pull together. In support of this effort, the design of a data warehouse must allow for data acquisition from multiple internal databases, remote locations within a companywide area network or WAN, and a variety of external sources (Figure 1). Since no 2 SPs are the same, there may also be significant differences in operational processes, payer requirements, management needs, and the overall quality of data extracted from the fulfillment process. Each with unique and complex data warehouse design requirements, the data warehouse will need to combine clinical, operational, fulfillment, and financial information across channels to achieve the following:

• Single management views across multiple locations and lines of business
• Single view for clients across lines of business (ie, Specialty, Infusion, DME)
• Single platform for financial data extracts to support financial reporting requirements
• Increased operational efficiency across multiple locations and lines of business
• Enhanced reporting tools to support reporting and extract requirements including:

-Pharmaceutical Manufacturer Reporting and Extracts

-Credentialing Reporting and Extracts

-Executive & Operational Dashboard Reporting

-Inventory Trending & Management Reporting

Enter the Aggregators

Manufacturer relationships with SPs are built upon 2 critical pillars: patient services and data gathering and delivery. Pharmaceutical manufacturers rely on data captured by the SP to measure the performance of their medications. The de-identified data provide the manufacturers with aggregated rudimentary patient outcomes measurements, which can be used to support discussions with payers for admittance to their formularies.

In addition, data shared from specialty providers enables manufacturers to recognize issues with compliance, dosing, and other treatment regimens that may need to be addressed before becoming a detrimental issue in the marketplace. In return for these data, pharmaceutical manufactures may provide physician and patient referrals as well as rebates. For most SPs, de-identified data are transmitted from their distributed dispensing channels directly to the manufacturer via a data aggregator. Typically, the aggregator categorizes the SP into a class of trade and reports the data as such. Classes of trade include Retail, Mail Order, Home Infusion, Long-Term Care, Clinics and Physicians, Home Medical Equipment, and others. In turn, pharmaceutical manufacturers subscribe to receive data sets from the aggregators at the class of trade level.

Therein lies the crux of a significant problem for SPs with multiple dispensing channels (as well as many new SPs)— their class of trade categorization may prevent them from being reported to manufacturers. For example, a retail chain executing on a strategy to develop its specialty business could easily be shut out of referrals and rebate earning opportunities due to limitations in the aggregator’s categorization process. As a result, the SP industry needs to be vigilant to address this problem, as the impact of manufacturers not receiving complete information from the aggregators may result in a harmful financial impact for SPs.

In summary, SPs may implement a central intake and distributed dispensing model in order to provide patient and provider immediate and streamlined access to their services, improve patient satisfaction, gain greater efficiencies within their work flow processes, and achieve additional cost savings. While many business drivers may also promote implementation of this multiple channel model, several technical challenges may exist prior to fully implementing this solution. Development of appropriate interface and system enhancements to support the patient enrollment, order management, and fulfillment work flow processes should be considered under this model. Data integration and reporting needs for the SP’s internal and external audiences should also be considered, as this may influence the model design (Figure 2). As a result, the technology investment required for implementing a central intake and distributed dispensing model should be properly leveraged to achieve the desired model.

About the Author

Jim Maguire is the chief executive officer of BioMed Intelligence, Inc, a firm specializing in health care information technology support solutions. With more than 20 years of experience, Mr. Maguire was formerly the chief information officer of a top pharmacy benefit manager and also led information technology operations at a leading specialty pharmacy. He can be reached at 347-847-3570; jmaguire@biomed-intelligence .com; www.biomed-intelligence.com