Subject: Oral Testimony on E-prescribing
Date: July 19, 2004
Submitted to NCVHS by Kerr Drug, Inc.
Good afternoon. My name is Mark Gregory and I am Vice President of Pharmacy for Kerr Drug headquartered in Raleigh, North Carolina . I appreciate this speaking opportunity and also appreciate the subcommittee doing a thorough job of due diligence in understanding the tremendous benefits e-connectivity between the pharmacist and physician can bring to our healthcare system.
Kerr Drug is considered a regional community pharmacy chain with just over one hundred pharmacies located throughout North Carolina and a dozen of those pharmacies in the Charleston, South Carolina market. Many of the small towns where our pharmacies reside we are not only the sole pharmacy, but also the destination where our pharmacist is the key healthcare provider.
I would like to break my discussion into three main areas. First highlighting the role a community pharmacist plays in the prescription fulfillment process, then talk about efficiencies and tools utilized in the current dispensing process and conclude with a perspective on the e-prescribing process and standards.
To begin I would like to start my discussion by providing some background regarding the role a pharmacist plays today as a safety net in the fulfillment and distribution of medications. Some common questions often arise out of visit to a pharmacy and one area which is usually puzzling to a consumer is “What does go on behind the counter?” I might answer that question by listing a small subset of events which occur in the sequence of filling each prescription:
1. Intake of a prescription
- Establishment of allergies, health conditions and OTC products
- Gathering prescription insurance coverage information
2. Fulfillment of prescription
- Building a patient profile based on intake information
- Internal drug utilization review (DUR) checking for items such as drug interactions, dosage checks, compliance with medication and appropriateness of the medication
- Communication to the physician regarding any of the numerous DUR concerns or where there may be no refills remaining on a prescription
- Adjudication of a prescription and interaction with the prescription benefit manager for reasons such as eligibility, copay clarification, drug coverage or a prior authorization requirement
3. Delivery of the prescription to the patient
- Proper face to face exit counseling as required by state laws or requested by the patient
When those three sequences are clean and no alerts arise the process is very efficient. When the process detects an issue, such as a drug interaction, the important pharmacy safety net process is initiated.
Community pharmacists have accepted these processes as part of filling a prescription. A perception that any of these processes can or is able or is willing to be handled by another stakeholder or dispensing model could burden the system, jeopardize safety or create tremendous inefficiencies.
Today’s pharmacy practitioners graduate from a pharmacy school with a minimum six year doctor of pharmacy degree qualifying them as the “drug expert” on the healthcare team. The demographic reality of our aging population show the number of prescriptions that will need to be dispensed will continue to increase significantly. This increase in prescriptions position the community pharmacist to play a larger role being accessible to the aging population and managing complex medication regimens from a compliance, quality assurance and cost effective perspective.
Secondly I would like to point out the investment which has all ready been made by retail pharmacy operations to make the dispensing process safer and more efficient.
In an effort to surround the pharmacist with some prescription fulfillment tools Kerr Drug and the community pharmacy industry has integrated numerous dispensing efficiencies into our processes. Illustration of some these efficiencies may best be accomplished by itemizing a number of these tools with a short definition:
- Electronic adjudication- a standard communication process that has been in place for over a decade allowing pharmacy to establish insurance coverage (drug coverage, patient eligibility and copay information) and to initiate an expected receivable from the benefit administrator. This process which may appear complex takes seconds utilizing high speed communication networks and utilization of a NCPDP transaction standard. This communication network is also the vehicle for e-prescriptions.
- Workflow- utilizing technology and ancillary personnel creating workstations and targeted responsibilities in the filling process. Within the workflow resides bar coding and prescription scanning technology for quality assurance checkpoints. Workflow queues reside in dispensing systems where e-prescriptions are posted for fill.
- IVR- Interactive voice response allowing patients to phone prescription refills in efficiently. Technology also allows patients to know if refills remain and allows pharmacies to automatically outbound faxes to physician offices refills to request refills for patients. These outbound fax will be replaced by electronic requests as the physician practices adopt electronic connectivity.
- Counting automation- utilizing a wide range of technology from counting devices to robotics for prescription filling purposes.
- Pre-fill- allow patients to opt into a program where maintenance medications are filled based on when the prescription is due to be refilled increasing patient compliance to their medicaition.
- Electronic signature capture- electronic documentation storage of signature for situations to comply with regulatory (ie. HIPAA, Offer to counsel) and third party pickup requirements.
- Central fill and central processing- leveraging central sites to offload some prescription filling and administrative tasks from each individual community pharmacy.
These efficiency tools have all ready been integrated into the fulfillment process at a significant investment by community pharmacy in technology, time and manpower. As you can see e-prescriptions are all ready incorporated into some these processes. The additional acceptance and further development of electronic connectivity between the physician and pharmacy is a natural next step in streamlining and eliminating an antiquated paper based prescription writing process.
Next importantly, we must use the SCRIPT Standard for transactions involved with physician and pharmacist e-connectivity. The SCRIPT Standard has gone through rigors of adoption through the NCPDP process agreed upon by pharmacy software vendors, community pharmacy organizations, database providers and many other stakeholders.
At Kerr Drug we have adopted and partnered with SureScripts to not only use the SCRIPT standard but also be the entity to put in place a secure network, identify and develop technology platforms to complete the transaction, connect treating providers, and implement comprehensive community marketing and adoption programs.
SureScripts which has been organized for almost four years has the tremendous head start in this effort by having individuals within their organization experienced in transaction standards, they have leveraged the current communication networks all ready in place, connected key industry partners that are critical for completion of the transaction between the physician and pharmacy, and have approached development of the technology by consensus. This consensus is minimally witnessed by the adoption approval of all independent and chain pharmacy.
Importantly the SureScript system allows the patient freedom to choose the pharmacy where they would want to have their prescription filled. At Kerr Drug currently all of our pharmacies are prepared to receive directly into the workflow queue new electronic prescriptions and refill approvals. Integration of these transaction into our dispensing pharmacy system is critical. New prescriptions and refill requests are only a first step for the SureScripts platform. The platform is built and can be built upon due to the open architecture. It is important not to adopt an alternative standard or model which does not allow to build upon that which is currently in place and has been significantly invested in by community pharmacy.
The patient, physician and pharmacist relationship is increasingly critical today but has been clouded by stakeholders interested in driving market share or incorporating marketing messages into the medication distribution process. We should make sure the e-connectivity standard and model does not allow that to be an element of prescribing rationale. Communication endpoints in this transaction should only involve treating entities.
My final three recommendations to move the standard and process along quicker:
1. Find a way to enhance physician adoption through financial grant opportunities for investments in training, purchase and acceptance of the new technology.
2. Supplement investments pharmacy providers are making by providing grant incentives for successful adopters.
3. Provide funding to entities to measure outcome studies to measure safety and efficiency successes.