Wednesday, November 29, 2017

Workflow Optimization: Takt Time Reduction Vs. Remote Script Processing + Local Fill {RSP+LF} Vs Improved Digital Adoption

With the increased adoption of Electronic prescribing in the last 10 years, Value Stream Mapping represents primarily the singular element that has thrown the pharmacy workflow and dispensing systems alike a curve ball. It has changed the access and behavioral pattern of many pharmacy patrons. The game changer has essentially altered the retail pharmacy landscape. It has rendered hitherto calculated workflow algorithms rather useless requiring major recalibration.

 Electronic prescribing now accounts for 65 – 75% of new prescriptions filled in US pharmacies today. This is a complete departure from the past where majority of new scripts came from patients who walked into the pharmacy with a script in hand. Today, the interaction is often limited, and when it does happen, it’s only at the Pick Up terminal. Nowadays, the average patient only visits the pharmacy to pick up already filled prescription, meaning you only one chance to make an impression. This is definitely affecting the very dynamics of the retail pharmacy workflow as we know it. This is definitely getting very interesting with Amazon.Com showing some interest in the business space. Hence, in order to remain competitive and provide the highest possible level of customer satisfaction, the pharmacy workflow will benefit from some major adjustments in order to accommodate the changes of the situation today.

Workflow is defined as the sequence of steps or stages a piece of work needs to successfully traverse in order to become the finished/expected product. It’s the way information/article is passed from one participant to another for action according to some clearly established algorithm. Up until now, workflow is essentially “ManFlow” characterized by the movement of employees between stations rather than the digital information. When we talk about workflow it is important to visualize the assembly floor within a car manufacturing company. It is customary for the employees to man a certain station and are assigned defined tasks within that workstation, there is rarely movement form their assigned workstations. This is similar to what is expected in the pharmacy. There should be unhindered digital flow of prescription information between participants at various stations.


Deficiencies of Current System

1} Pharmacist have less time to interface with patients and are often rushed thru consultation sessions. The patients are thereby missing out on the extremely important Value-added activity of consulting with the pharmacist especially in new to therapy regimens. This is a State Board of Pharmacy requirement {in most States} and a service recognized by Insurance payers

2} Studies have shown that 68% of patients end up waiting 20 – 43 additional minutes upon arriving at the pharmacy to pick up their medication. This is definitely a serious issue with patient satisfaction. The proposed system will allow prescribers set {based on certain criteria} a more realistic pick up expectation.

Optimization Strategy

Optimization is a necessary too in order to meet the patients pick up expectation and render the critical care necessary to remain compliant. Studies show that pharmacist consultation increases the adherence rate and cuts down the therapy drop rate. It is becoming a selling solution for insurance payers who are encouraging a 90 day fill as opposed to 30 in order to further improve adherence and lower the chances of developing complications secondary to chronic ailments.

Strategy 1:

This involves trying to shave off seconds or minutes from the current takt time. Takt time is the time allotted to accomplish a task {within a process} in order to meets patients’ expectation. This is often known as the heartbeat of the process. Contrary to popular believe, this is not a measure of the time to fill a prescription {Cycle time}, rather it measures the time per task in order to meet patients pick up expectations. This does not represent a major change and hence has not been able to address the deficiencies above.
In the last decade pharmacists as a community have largely twigged existing workflow and dispensing systems to accommodate electronic prescribing features rather than a general overhaul. This is more so as more prescriber client interfaces are now DEA & SureScript Certified to send electronic controlled substances alongside legend drug prescriptions. There is no doubt the current dispensation is riddled with a lot of Waste and re-do activities in order to achieve the finished product, such wasteful activities have further widened the time to fill prescriptions, and are affecting patient satisfaction. This will also reduce the takt time to complete a prescription.

Strategy 2:

A rather more robust, scalable strategy is to remove some or all of the seemingly unproductive activities that take place in the pharmacy prior to a successful online 3rd party adjudication. This is referred to as Remote Script Processing + Local Fill {RSP+LF}
This is most likely the method will pursue if indeed they do venture into the pharmacy world. The will leverage Wholefoods locations for delivery while the prescriptions are proceeded remotely.

 Remote Script Processing + Local Fill. {RSP+LF}
This helps free up the pharmacists and technicians alike to allow central focus on the patient as a Value Add Activity. It is customary for staff members to spend a great deal of time addressing the various exceptions in the pharmacy before a script gets filled. It is thought that only 25% of new prescriptions follow the happy path where a successful adjudication is achieved immediately, which means ¾ of scripts will encounter some form of exception. This proposed solution will aim to remove the heavy lifting associated with script processing from the in-house pharmacy staff and leverage a remote team to accomplish this.  The remote team will be able to interact with the patient in the same manner the store teams do today. These include, exceptions such as Prior Authorization, Patient not covered, Product not covered where an interchange is necessary to continue, or for medications with exorbitant co-pay.

Script processing is defined as all the preliminary steps associated with the prescription fill prior to Quality Assurance Verification.
Additionally, telephone enquires will be handled by a call center. It is determined that an average pharmacy with a daily volume of 400 scripts/day will entertain 60 to 80 calls per hours, with most of the enquiries based in the status of their prescription. Fine tuning the work flow in such a way that such information can be provided in a timelier and time saving manner will be helpful.

This methodology will leverage the broadband technology to further enhance the patients in store experience. All electronic scripts {via e-prescribing, voice, fax,etc} will be shunted to a remote workstation. All 3rd party adjudication exceptions will be resolved at this stage, except cases secondary to inventory insufficiency. Upon successful adjudication, the pharmacy will be notified by queuing the Read To Print {RTP} prescriptions in a queue based on some predefined priority algorithm. This solution allows for on the fly corrections requested by the QA Pharmacist. This can either be done in-house or sent back to the remote team. New scripts being dropped off are scanned in and triaged the same way. However, the pharmacist may request local processing in some cases but will be limited to a sizeable number of scripts as Waiters within a time slot, this is to prevent store team from been overwhelmed

Strategy: 3

It is no doubt that any pharmacy outfits will benefit from an expanded improved digital presence available to the patients thru their app. Patients should have the ability to access more medical information in real time, it only makes more sense to improve technology to further facilitate access.

Ways to improve Digital Adoption:

         a} Patients should be able to access relevant information regarding medications. It is perfectly appropriate to have a dedicated text message service to help patients better understand their therapy plan. I have a dedicated text message app for this immediate access to information. Upon sending a request the patient will have the information on their phone within 5 to 10 minutes. This will eventually be rolled into other offerings within the app.

         b} Patients should be able to have access to their information upon entering the pharmacy. The pharmacy staff should be alerted when a patient gets into the pharmacy. This will further improve the changes of a positive experience for this patient. It will be a win-win situation for all. Patients whose prescriptions are not ready can be informed as soon as they approach the pharmacy. The pharmacy team can get into expediting the patient’s needs.

Optimization Benefits

1} The proposed optimization strategy will benefit both the staff in the pharmacy and the patients alike. The elimination of some of the mundane activities will improve the morale of staff and allow them to focus on specialized areas of the pharmacy management such as Inventory, Just In Time {JIT} supplies mechanism, etc. The pharmacy staff will not have the need to address all incoming prescription to the detriment of valuable consultations with the patients. This is a win-win situation for all parties concerned.

2} With immunization becoming a staple in the healthcare delivery system in community pharmacy today, such a solution will afford the pharmacist enough time to review a patient’s profile holistically to identify immunization opportunities.

3}. The free time will allow pharmacist to engage with patients to address gap in care that will improve their journey to a sound health.

4} Allows pharmacist to have more effective face time with patients during pick up, also allows other support staff advocates to help the patients.

         a} Adherence Outreach initiatives will have a much more personal touch to it, the pharmacist will be able to comprehensively review the patients profile during such interaction. It is a known fact that patients tend to be more adherent in cases where there is a consultation with the pharmacist, additionally, caregivers will be able to ask any questions they may have

b} Expanded Immunization Uptake. This will free up the pharmacist to perform a more thorough comprehensive review of the immunization status of the patient and make appropriate recommendations

c} In store OTC Consultations will improve.

5}  Prescriber Relations. The pharmacist will be able to focus in educating the prescriber community regarding formulary changes, prescribing guidelines, etc.

6} New to Therapy Genuine Mandatory Consultations performed with a renewed purpose rather than just rush thru as it is done today

7} This will encourage further education of pharmacists to certify as disease medical conditions specialist, like Diabetes Certified Educator, HIV specialist, and render assistance to other practitioners and further help the patients on their way to better understand their medical conditions and make informed choices regarding exercises, nutrition, life style modifications,

8} Optimization in this case will better address missed pick up expectations, prescribers can append expected pick up time to new prescriptions. This is to be determined by certain criteria. Currently, more than 60% of electronic scripts are not ready by the time the patient arrives in the pharmacy. Remote Script Processing will help address this. Pharmacy staff will have real-time access to status and be able to coordinate pick up with patients.

9} Increased Expanded Delivery options. This is fast becoming a service differentiating solution as we have more baby boomers retiring in great numbers and some of whom are often plagued with reduced mobility. This option will be extremely helpful and offer them the similar access to our pharmacists

4} As more pharmacy operators deploy more sophisticated applications online or mobile app, it is definitely the way forward to leverage current computer platform to deliver more services to the patient.

The 21st century retail pharmacy platform is one that is primarily designed to take advantage of the current increases in electronic prescribing, this is expected to exceed 80% by the year 2020. The Graphical User Interfaces {GUI} of such systems are more user friendly and much more capable of delivering superior quality services Insurance Payers and patients find attractive and willing to pay for. The proposed workflow is patient centric and aware of the fact that the only interaction with the pharmacy may only be at POS, as a result, all efforts are being deployed to ensure the dispensing system is more clinically robust to address the deficiencies and plan for the further.

Besides the much-needed system enhancements, other areas contribute greatly towards improving thru put & takt time in the pharmacy
Such areas are as follows:

·      Enhanced Inventory Management
·      Improved Resources Deployment
·      Waste & Variation Reduction

Improved Resource Deployment

Here we are looking at staffing the pharmacy with experienced pharmacy technicians in order to allow the pharmacist to be more readily available for value added services such as;
·      Patient Consultations
·      Prescriber Relations
o  Assisting prescribing community
·      Immunization Practices
·      Addressing other potential sources of prescriptions
·      Patient adherence initiatives

WASTE & Variation Reduction Strategy

WASTE is defined colloquially as
Worthless Activities, that Steal Time & Energy
Waste is formally defined as that extra activity that is performed over and above what is needed. There are 3 main attributes of activities that must be present for a task not to be qualified as Waste

·      The customer must be willing to pay for it
·      It must involve a transformation or change of material and or information, and lastly,
·      It must be done right the first time. Customers never pay for re-dos.

Common examples of waste are,
·      Over-producing
·      Waiting: Do you have staff or information queued up waiting unnecessarily?
·      Staff Movement: This limited when you have people assigned to stations and assigned tasks within their reach
·      Variations in processes
·      Variations in Measurement Parameters

Implementing any one of the strategies above or some hybrid thereof will help in the following areas;

1} Identify your bottleneck: It’s not always beneficial to throw resources at a process without identifying the critical step that causes delay. Upon isolating this step, you can deploy measured resources in order to bring production up to a level where the patients pick up expectations can be achieved

2} What tasks can be done simultaneously in order to reduce time to produce. What 2 tasks can be handled by the same station, and what 2 tasks cannot be managed, for example you cannot be responsible for taking the order in the restaurant & simultaneously be involved in the actual food preparation of the meal. However, you can combine handing out the check after meals with taking in the order. Some tasks are just diametrically opposed

3} Workflow layout Improvement: U shaped process flow is always preferable, as it is easier to accomplish a task by making a body left turn rather than right turn since most people are right handed

4} Enhanced capability at POS. This should be managed by skilled tech and not pharmacist, with the patients challenged if their need to consult with a pharmacist regarding the medication in question or other medications of importance to them

In the final analysis, it is obvious that strategy 2 will deliver a more benefit. Workflow optimization is a low hanging fruit that can be improved upon. Needless to say, this is not a panacea in itself but definitely a move in the right direction…/.

Dr. Leke Agbejule
Principal Partner, LeanGuistics Consulting Group, LLC

Friday, March 3, 2017

Improving Expanded Immunization Uptake Using SHARPS methodology

It is a fact of life that people will oppose immunization because of several reasons, some of which are borne out of hearsay, which are of course baseless in themselves, and other concerns are firmly rooted in religious beliefs, cultural background, together with personal experiences, and of those of friends or family members. For the most part, the general population has limited knowledge and information regarding immunization and vaccines. They are in need of good old education. It’s not only fair, but it’s the right thing to do. Patients need information and who else to come to their aid other than their trusted community Pharmacists. As Pharmacists, we are  uniquely positioned to help address concerns of patients in our immediate sphere of influence regarding healthcare matters. We are currently in uncharted territory where immunization is common place and the access to which is largely unhindered. They are trying to make sense of the disease states we are trying to protect them from in the first place. In order to address these disparities and barriers certain concepts must be understood first.
Pharmacists need to acquire an unparalleled level of information regarding immunization and their disease states. For example, we need to be able to articulate to our patients what Shingles is and how it can present and be contracted, why pneumonia shots are recommended for a certain age group, etc.

Firstly, we need to ask ourselves the question; What do Adult patients want to know when it comes to immunization? Examples of such are:
1)    How likely am I to get this disease?
2)    How serious could this disease be for me?
3)    What are the side effects?
4)    How much will it cost me?
Since adults are rational patients and of course more curious than their younger counterparts, effective communication is key! It is imperative to deploy the most effective communication tool to address their concerns, questions, and comments.
a)    Stress the importance of timely immunization;

1)    Highlight susceptibilities
2)    Explain severity and potential cost of getting the disease
3)    Use empowering messages and highlight the benefits of vaccination. Getting vaccinated is part of staying healthy
4)    Provide transparent and plain language information on the disease states and the immunization protocols available.
5)    Finally, tailor information to your audience. Ensure your messages highlight the benefits that support your efforts

S Share: The information shared here should be tailored to your audience, highlight why vaccination is right for the patient given age, health status, lifestyle, job or other risk factors. We need to ensure we share this information at a level where the majority of our captive audience can understand and relate.
H Highlight positive experiences with vaccines to reinforce benefits and strengthen confidence in vaccination. Sometimes you may want to call on own experiences with immunization or share some of the experiences that have been shared with you. Sometimes you may have a patient nearby trying to shed negative light on the act of immunization. It’s not your job to try to make this person understand. The best you can do is to  step back and don’t engage in a conversation, approach your target patient at a later time
A Acknowledge & address the patients questions and any key concerns about vaccine generally and side effects in plain language that can understood. Be that as it may, many a patient have several questions and concerns about immunization period. Your best ally here is sound education. With the advent of the internet, a lot of pharmacy patrons use the internet tools such as Google as a resource. Ensure the information you are providing is true. Patients  are always in search of unadulterated pure information to help them make an informed decision regarding this and other healthcare decisions
R. Patients need to often be reminded that vaccination is not only to protect them from diseases, but to protect their loved ones who will be affected if the patient becomes infected. With this in mind,  adult patients are more likely to buy into the idea of getting vaccinated to protect their grandchildren and other family members
P Price: Explain the potential cost of getting the vaccine and the cost of not getting it. Since most seniors are on a fixed limited income, cost of immunization will arise, such as;
 1} Is this covered by Medicare Part B or D?
2} What will my copay be?
3}  Are there manufacturers coupon that can be leveraged to further lower my copay?
S Support after immunization is key to building a lasting relationship with our patients beyond the pharmacy counter. This level of support is integral to showing empathy and be tailored to each patient. It is customary for a follow up phone calls to patients after immunization to address any concerns/questions they may have. It is vitally important for your patients to know you care and are always available.
As pharmacist, its incumbent upon us to search the internet and use our relationships to help lower the out of pocket cost for our patients. This will definitely help improve the uptake in adult immunization.

 Efforts To Improve Uptake
1} To further get patients and staff engaged, you could provide novelty gift items to patient and the support staff that has the highest number of referrals. The intra-team rivalry is very healthy to ensuring team members are truly committed to this cause. Try to figure out what your patients will like and present as a gift for immunization, examples include pens, stress balls, etc.
2} Partner with the local practitioners in your neighborhood to help spread the word and provide support.
3} Provide pictorial printed materials they can peruse even after leaving the pharmacy. Invest in some brochures that address concerns the patients may have. It is always valuable to address concerns upfront before they are asked
4} Ensure to have a space that is convenient to facilitate immunization, it’s important to have an area in the pharmacy that is carved out for immunization to provide some level of privacy. Patients don’t appreciate other people looking at them as they get vaccinated, or as they solicit further information regarding immunization.
5} Leverage your relationship with manufacturers of vaccines to help with outreach programs. Work with the neighborhood nursing homes, medical facilities to organize a rally that will bring seniors together where you can share vital information.
These are proven efforts that will help you improve expanded immunization in your sphere of practice…./.

Author: Dr. Leke Agbejule

Friday, October 3, 2014

#Ebola...The 411.../.

Ebola, previously known as Ebola hemorrhagic fever is a rare but deadly disease caused by the virus of the family Filoviridae. Ebola has manifested fatally in humans and nonhuman primates {such as monkeys, gorillas} alike. There are 5 different strains of the virus primarily and they have caused devastation in different countries at different times The first identified strain of Ebola was discovered near the river Ebola in Zaire, now the Democratic Republic of Congo in 1976, hence the name Ebola. Since then, there have been sporadic outbursts here and there, but the current outbreak is the deadliest ever. The natural reservoir host of the virus remains largely unknown. However, based on available evidence, it is thought the host is animal, while the bat is the most likely culprit. Because of the usual sketchy information surrounding the first case in an outbreak, it is often very difficult to determine how the first infected human came in contact with the virus. The general consensus is through contact with an infected animal

When an infection does occur in humans, there are several ways to spread the virus during an outbreak
1)      Direct contact with blood or body fluids (including but not limited to feces, saliva, urine, vomit and semen of persons sick with Ebola
2)      Contact with objects like needles and syringes that have been contaminated with the blood or body fluids of a person sick with Ebola
During an outbreak this can spread fairly rapidly within the healthcare setting especially those where proper precautionary protocols are not in place, or not adhered to as a standard practice. Secondly, family members of the persons sick with Ebola as they are mostly likely to come into contact with the body fluids of Ebola patients
Dedicated medical equipment, preferably disposable where possible, should be used by healthcare personnel providing care to persons sick with Ebola. Where disposable items are not possible, proper sterilization techniques have been known to help. In fact, the deadly nature of this outbreak is secondary to the ease with which it can be transmitted.

Signs and Symptoms…/.
A person infected with the Ebola virus is NOT contagious until symptoms appear. Such symptoms include
1)      Inexplicable fever in the region of 101.5o F
2)      Severe headache
3)      Muscle pain
4)      Vomiting
5)      Diarrhea
6)      Stomach pain
7)      Inexplicable bleed or bruising
Symptoms can develop between 2 – 21 days post exposure to the Ebola virus, but the average is 8 – 10 days. Recovery from Ebola depends on the patient’s immune response. Persons who recover from Ebola go on to develop antibodies that last for at least 10 years

Diagnosing Ebola in a person who has been infected for only a few days is difficult because the early symptoms exhibited such as fever are no specific to Ebola virus infection. Several infections show similar early symptoms such as malaria fever, and typhoid fever. However, if a person has symptoms of Ebola and have had contact with blood or body fluids of a person sick with Ebola, or come into contact with objects that have been contaminated with blood or body fluids of persons sick with Ebola, the person should be isolated and public health officials notified at once, while awaiting results of test on samples from the person.
Currently there are no vaccines or medicines such as antivirals available in the market to treat Ebola. However, there have been successful cocktail of medicines used to manage the signs and symptoms of Ebola. The symptoms are treated as they occur. The following basic interventions when instituted in a timely manner will help reduce the mortality associated with Ebola outbreak. They are
1)      Providing IV fluid and balancing electrolyte {salts}
2)      Maintaining oxygen status and blood pressure
3)      Treating other infections if they occur
A stitch in time they say, saves nine. Whenever there is an outbreak of Ebola as we have on our hands now, healthcare workers are often at risk, as well as family members that are in close proximity to the Ebola patient. Measures include, but not limited to;
1)      Isolate all Ebola patients as well as those with common symptoms and have come into contact with persons sick with Ebola
2)      Don protective garment when caring for persons sick with Ebola
3)      Observe other universally acceptable protective measures as deemed necessary
4)      Avoid  touching the bodies of persons who have died from Ebola
5)      Contact tracing: Finding everyone who has come into direct contact with sick Ebola patients. These contacts are watched for 21 days from the contact date. If they develop fever or other cardinal symptoms consistent with Ebola infection, they are in turn isolated or quarantined, tested and provided corresponding care.
Every outbreak of the Ebola virus since 1967 has been a major threat to our healthcare delivery systems worldwide, especially the African countries. It is a constant test of our resiliency and ability to contain the outbreak. It seems like it is mother-nature’s “drill” to ensure we don’t rest on our oars, and we are always prepared to handle disasters. It’s obvious the best measure to counter this is prevention and early detection. The international community in partnership with organizations as WHO & CDC are harnessing their resources to addressing this and perhaps come up with a vaccine in the next couple of months. With the ever expanding role of the pharmacists in the community coupled with the immunization responsibilities, the pharmacy may be the first port of call for patients exhibiting early symptoms. We should be cognizant of the fact that the patient’s social history is equally important, such as recent travel history. All hands need to be on deck here as we deal squarely with this outbreak…/.