TY - JOUR
AU1 - Kappenman, Ashley M
AU2 - Ragsdale, Russell
AU3 - Rim, Matthew H
AU4 - Tyler, Linda S
AU5 - Nickman, Nancy A
AU6 - 
AB - Abstract Purpose The development and implementation of centralized mail-order pharmacy services in an academic healthcare system are described. Summary The use of mail-order pharmacy services continues to increase, as mail-order services offer patient benefits such as reduced copayments and improved clinical outcomes. Prior to undertaking an initiative to improve its mail-order pharmacy services, the University of Utah Health system’s pharmacy department offered decentralized mail-order pharmacy services at all of its retail pharmacies, but there was no standardized process for processing mail-order prescriptions or providing phone support to mail-order patients. Centralized mail-order pharmacy services were developed and implemented by creating (1) a standard process for mail-order pharmacy services, (2) a centralized mail-order prescription filling center, and (3) a call center to support mail-order pharmacy services. Implementation of centralized mail-order pharmacy services resulted in an almost 50% reduction in time spent by pharmacy team members on mail-order prescription filling and packaging tasks. Use of a central call center resulted in a decreased call abandonment rate and contributed to a decreased pharmacy workload resulting from an overall reduction in call volume due to an increased rate of first-call issue resolution. Conclusion Establishment of a centralized mail-order pharmacy service along with operational and infrastructure improvements resulted in improved quality and regulatory compliance and enhanced labor efficiency and patient communication. call center, labor efficiency, mail order, pharmacy, standardization Nationally, retail pharmacy prescription drug sales, including both community pharmacy and mail-order services, totaled $322.7 billion in 2016; 33% of retail sales were mail-order pharmacy sales, accounting for $105.3 billion of that total.1 Mail-order pharmacy sales are growing, as represented by an approximately 7.3% 1-year sales increase in 2016 versus 2015 ($98.1 billion) and a 72.9% increase over 4 years from mail-order pharmacy sales in 2012 ($60.9 billion).1 Part of the growth in mail-order pharmacy services is due to their use by pharmacy benefit managers (PBMs), which use mail-order pharmacies to contain prescription drug costs. PBMs may require that maintenance medication prescriptions be filled by a mail-order pharmacy or may offer notable discounts for plan members who use mail-order pharmacy services.2 In addition to the potential financial benefit to patients realized through discounts or reduced copayments, mail-order pharmacy services may benefit patient outcomes. In a study of patients with diabetes prescribed a new medication to treat hyperglycemia, hypertension, or hyperlipidemia, the average adherence rate was 84.7% for patients using mail-order services, as compared to 76.9% for patients using more traditional community pharmacy services.3 Improved adherence affects patient outcomes and increases pharmacy prescription volumes, because adherent patients fill prescriptions more consistently. Additionally, research indicates that patients who use mail-order pharmacy services have fewer preventable emergency department visits.4 Therefore, implementation of centralized mail-order pharmacy services by large health systems has the potential to enhance the financial strength of an academic healthcare system while also improving patient experiences via decreased costs and improved patient outcomes. Background The University of Utah Health (UUH) system is an integrated delivery network with 4 hospitals, 11 community clinics, and 16 community-based pharmacies. UUH previously offered decentralized mail-order pharmacy services at 13 outpatient pharmacy locations to enhance patient care, but there was no standardized procedure to handle mail-order requests. Communication with patients us- ing mail-order pharmacy services can be challenging, because patients do not receive in-person communication that is typically provided with traditional outpatient pharmacy services; this places greater importance on the quality of communication that patients receive from mail-order services, which is primarily provided by telephone. Other organizations have reported the impact of a centralized pharmacy call center and concluded that implementation of a centralized pharmacy call center helped to increase patient access to pharmacy services and decrease the pharmacy workload.5,6 However, the impact of centralizing communication services provided to patients served by mail-order pharmacies was not described. Program development and implementation Our institution recognized that in order to further develop a centralized mail-order pharmacy service, it was im- portant to address the issues mentioned above. Therefore, the goal was to establish a standardized, centralized mail-order pharmacy service that would result in improved patient safety and workload efficiency. In addition, the scope of our previously established centralized pharmacy call center was expanded to include mail-order phar- macy services with the goal of improving communication with mail-order customers by decreasing the call abandonment rate and call frequency within individual pharmacies while also in- creasing the speed of call answering and first-call issue resolution.7 In 2015, the ambulatory care pharmacy department began evaluating existing decentralized mail-order phar- macy services provided by the UUH system. In a survey of all outpatient pharmacy managers in 13 of the UUH system’s outpatient pharmacies, re- spondents were asked in a pre- liminary email, “Has your pharmacy provided mail-order services to patients within the past 90 days?” Based on their responses, all outpatient pharmacies that reported providing mail-order pharmacy services within the past 90 days were included in a detailed best practices survey. The survey asked for specific information on mailing practices related to the Utah Pharmacy Practice Act,8 including storage temperature, package integrity, the offer to counsel, and tamper detection. Package integrity must be addressed by providing patients with information regarding what to do if they have concerns about the condition of their package or medications upon receipt. Questions pertaining to the types of medications mailed, mail carrier selection, policy awareness, and other items of interest were also included in the survey. The University of Utah institutional review board determined the study to be non-human subjects research on November 4, 2015. Of the 13 UUH outpatient pharmacies surveyed, all 13 responded. Ten of 13 pharmacies reported providing mail-order services to patients within the past 90 days. Best-practices survey results from these pharmacies demonstrated opportunities for standardization in 4 key areas: storage temperature, package integrity, tamper detection, and the offer to counsel.9 In addition to the best practices survey, the 10 pharmacies that reported providing mail-order services to patients within the past 90 days also were asked to provide detailed information about mail-order processes for a 1-week period. A data collection form was sent to the pharmacy manager for completion by the appropriate pharmacy employee (the name of whom remained confidential and was collected but used only if clarification was needed). This survey requested quantitative information related to mail-order pharmacy services in each outpatient pharmacy, including the amount of time pharmacy team members devoted to mail-order packaging tasks, the numbers of mail-order prescriptions and packages delivered, the number of mail-order prescriptions provided to University Health Plan members, the mail carrier used, the cost of delivering each mail-order package, and the cost of medications delivered. All prescriptions delivered via delivery service or mail carrier (e.g., FedEx, U.S. Postal Service) were counted and cataloged each day for 7 business days (Monday–Sunday). Completed mail-order details forms were scanned and collected at the end of each day. No patient-specific information or personal health information was collected. Three pharmacies did not mail any prescriptions during the week of data collection.9 A total of 673 prescriptions were mailed by the remaining 7 pharmacies, with 1 pharmacy processing 566 (84%) of the mailed prescriptions. Based on the survey and data collection results, the following quality-improvement opportunities were recognized. Development of a standard process for mail-order pharmacy services. Implementation of a standard process for providing mail-order services was identified as an opportunity to enhance patient safety, quality, and regulatory compliance. Data from the 2015 survey of pharmacy managers were used to outline UUH best practices already used by outpatient pharmacies to support standardization of all UUH prescription mail-order services and to meet Utah Pharmacy Practice Act8 common carrier delivery requirements. Standard workflow mapping techniques described the mail-order pharmacy services currently provided, and a standard operating procedure was implemented to standardize decentralized mail-order services provided to patients (Figure 1). Considerations such as requirements of United States Pharmacopeia chapter 1079 (“Good Storage and Distribution Practices for Drug Products”),10 financial impact, regulatory compliance, and workflow efficiency were addressed when identifying necessary interventions to implement. Figure 1. View largeDownload slide Standard operating procedure used by University of Utah Health pharmacies to process mail-order prescriptions. Figure 1. View largeDownload slide Standard operating procedure used by University of Utah Health pharmacies to process mail-order prescriptions. Development of a centralized fill center to provide mail-order pharmacy services. As an integrated health system, UUH designed and implemented a central fill center, which opened in the summer of 2016. Due to efficiencies gained from this central fill center, the return on investment in the new facility was reached in less than 1 year. A centralized mail-order pharmacy service is a component of the new central fill center; it has a high-volume pharmacy automation system intended to centralize all existing mail-order prescriptions and prepare for future growth. Initiatives such as standardization of work were implemented in synergy with this infrastructure improvement to provide safe and efficient services. The standardized, decentralized mail-order phar- macy processes formed the basis for creating a high-quality workflow for the new centralized mail-order pharmacy service. The 10 pharmacies that reported providing mail-order pharmacy services collected data for a 1-week period (in November 2015) before centralization and during a 1-week period (in February 2017) after centralization, with the exception of 1 pharmacy (delays in hiring and training team members to take on additional workload at the central fill center, as well as delays in contracting with some insurance providers, contributed to the implementation delay at that pharmacy). All centralization of mail-order pharmacy services has since been completed. The total volumes of mail-order prescriptions were similar in November 2015 and February 2017, but efficiencies were gained. As of June 2017, a central fill center team of 3 pharmacists and 6 technicians were filling approximately 100 prescriptions per hour. An already filled mail-order prescription takes approximately 30 seconds per standard item to package, apply all needed labels, and seal for delivery. The process for creating mailing labels is highly automated and uses scanning technology. For a mail-order prescription for a refrigerated product, the same process takes approximately 1 minute to complete due to extra requirements (e.g., ice packs). During the February 2017 data collection week, members of the 9-member central fill pharmacy team spent approximately 3.5 hours each, or 32.0 hours collectively, filling and packaging 339 mail-order prescriptions. The remainder of the central fill pharmacy team’s time was dedicated to processing and filling non–mail-order prescriptions for pa- tients at UUH community pharmacies. In contrast, the only remaining pharmacy still completing decentralized mail-order pharmacy services dedicated approximately 1.5 people working full time, or 60 hours collectively, to fill and package a similar number of prescriptions. These data show that implementation of the central fill center, with an emphasis on automation and standardization, provides increased efficiency and has decreased the time spent by pharmacy team members on mail-order services by approximately half. Development or expansion of a call center or phone service to sup- port mail-order pharmacy services. UUH developed a pharmacy services call center (PSCC) in 2014 to centrally answer all outpatient pharmacy and specialty phone calls.7,11 The PSCC team consists of 10 pharmacy technician full-time equivalents who each answer approximately 1,600 phone calls per month. The PSCC has demonstrated a decreased call abandonment rate, increased speed of call answering and first-call resolution, increased labor efficiency, and improved workplace satisfaction for pharmacy team members.7 Mail-order telephone calls have traditionally been transferred to each individual pharmacy. The pharmacy that had previously provided the largest volume of decentralized mail-order pharmacy services used a voice-mail line for patients calling in when the 2 mail-order team members were completing other tasks and could not answer directly. Centralizing mail-order pharmacy services provided the opportunity to centralize mail-order phone calls as well. Data on PSCC mail-order phone call volume and abandonment rates over a 6-month period are shown in Figure 2. The PSCC received a total of 4,560 mail-order pharmacy services telephone calls from October 2016 through March 2017 (a mean of 760 calls per month); of these calls, 4,343 were answered, representing a mean of 724 calls per month. The average speed of answering for patients calling the centralized service (as opposed to reaching a voice-mail box and leaving a message with the decentralized service) was 19 seconds in March 2017. The average handling time for mail-order pharmacy services phone calls was 291 seconds in October 2016 and fell over time to 220 seconds in March 2017. The average handling time decreased by over 1 minute as PSCC team members became more comfortable with the mail-order phone line standard operating procedures. The call abandonment rate for mail-order pharmacy services also fell over time from 8% in October 2016 to 2% in March 2017. The decreased call abandonment rate contributed to a lower number of phone calls overall, as patients did not hang up and call back in an effort to reach a pharmacy team member. Figure 2. View largeDownload slide Monthly mail-order call volume and call answering rates at the University of Utah Health pharmacy services call center during the period October 2016–March 2017. Figure 2. View largeDownload slide Monthly mail-order call volume and call answering rates at the University of Utah Health pharmacy services call center during the period October 2016–March 2017. Discussion Using a standard operating procedure to plan for new services resulted in standardization of all mail-order pharmacy services within the health system. Standardization can improve patient safety, quality, and regulatory compliance. For example, a standard process for maintaining the proper storage temperature of a mailed prescription improves patient safety and quality by ensuring that patients receive medications that are safe and effective. A standard process for sealing all packages with tamper-resistant tape improves patient safety by allowing easy identification of package tampering, which could cause harm. Providing all patients with information about whom to contact about concerns with package integrity improves patient safety and quality of service by empowering patients to take action if they notice any irregularity. Standardizing the offer to counsel and the provision of counseling to all mail-order customers decreases medication-related problems by en suring that patients know how to take their medications and what to expect from the medications,12 in addition to improving the quality of service by giving patients an easy and consistent contact to address any questions. Finally, standardizing procedures related to storage temperature, package integrity, tamper detection, and the offer to counsel all improved compliance with the Utah Pharmacy Practice Act.8 One opportunity to improve services that was aligned with standards described in the Utah Pharmacy Practice Act was ensuring access to appropriate mailing materials, including temperature requirement stickers, tamper-resistant tape, and patient information regarding package integrity and the offer to counsel. These materials are now purchased centrally and distributed to each individual pharmacy to ensure standardization in case the central fill facility is bypassed. Another challenge associated with providing mail-order pharmacy services is collecting payment remotely when copayments are required. Payment information for mail-order prescriptions is collected using an unrecorded telephone line and is stored in a secure system for use prior to shipment. Identifying and overcoming these barriers is an important component of successful standardization of mail-order pharmacy services. Reducing mailing workload in pharmacies also offered many benefits to health-system staff and allowed for reallocation of resources, including the opportunity for pharmacists to spend more time in clinical activities. Clinical activities are varied but include providing transitions-of-care services to patients recently discharged from University of Utah Hospital who see primary care providers in UUH clinics. The results of this workload shift are in the process of reaching full realization, with the expectation of expanded roles at all levels for pharmacy team members. Centralization of mail-order phone calls to the PSCC also standardized phone services provided across the UUH system. Patients have commented on the change, noting that they trusted the mail-order team at the pharmacy and were excited about not having to leave voice-mail messages. A central call center may not be a solution that fits every mail-order pharmacy service’s needs, but each mail-order pharmacy service needs a plan for meeting the needs of patients receiving the service. Mail-order pharmacy services must consider establishing a call center/service in order to be able to meet mail-order requirements and regulations for providing patient counseling and responding to patients with concerns, such as concerns about package integrity. Separating responsibility for handling phone calls from the team filling prescriptions has also allowed the UUH PSCC to gain efficiencies in answering the phones. One limitation of the best-practices survey was that although pharmacy managers completed the survey, pharmacy technicians most often completed mail-order tasks. This also impacted the standardized operations workflow mapping process, because there may have been variations between a pharmacy manager’s perception of a workflow and the pharmacy technicians’ actual workflow in practice. A limitation of the process for collecting detailed data about mail-order processes was that pharmacy personnel were expected to manually complete the data collection form, but completion of the form may have been forgotten at times in a busy pharmacy, leading to possible underreporting of mailed packages or inaccurate reporting of the time spent providing mail-order services. This project was conducted at an academic medical center with outpatient pharmacies distributed across a wide geographic area, and the results may not be generalizable to other practice settings. Conclusion Establishment of a centralized mail- order pharmacy service along with operational and infrastructure improvements resulted in improved quality and regulatory compliance and en- hanced labor efficiency and patient communication. Ashley Kappenman, Pharm.D., M.S., BCPS, is a pharmacy supervisor at the University of Utah Health Pharmacy Ambulatory Clinical Care Center in Salt Lake City, Utah. Dr. Kappenman received her doctor of pharmacy degree from the University of Iowa College of Pharmacy in 2015. She completed a combined postgraduate year 1/year 2 residency in health-system pharmacy administration at University of Utah Health and received an M.S. degree in health-system pharmacy administration from the University of Utah College of Pharmacy in 2017. Her interests include specialty pharmacy services, clinical services development, and transitions of care. Disclosures The authors have declared no potential conflicts of interest. References 1. IQVIA Institute for Human Data Science . Medicines use and spending in the US: a review of 2016 and outlook to 2021 , 2017 . p. 43. www.iqvia.com//media/iqvia/pdfs/institute-reports/medicines-use-and-spending-in-the-us.pdf?=1528237846366 ( accessed 2018 Jun 5 ). WorldCat COPAC 2. Federal Trade Commission . Pharmacy benefit managers: ownership of mail-order pharmacies , 2005 . p. 4. www.ftc.gov/reports/pharmbenefit05/050906pharmbenefitrpt.pdf ( accessed 2015 Oct 1 ). 3. Duru OK , Schmittdiel JA , Dyer WT et al. Mail-order pharmacy use and adherence to diabetes-related medications . Am J Manag Care. 2010 ; 16 : 33 - 40 . Google Scholar PubMed WorldCat 4. Schmittdiel JA , Karter AJ , Dyer WT et al. Safety and effectiveness of mail order pharmacy use in diabetes . Am J Manag Care. 2013 ; 19 : 882 - 7 . Google Scholar PubMed WorldCat 5. White CA , Jones MR , Kuester MK et al. Impact of a regional pharmacy call center on telephone access metrics within the veterans health administration . Hosp Pharm. 2015 ; 50 : 370 - 5 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Kharlamb V , Erato M , Foldes D et al. Implementation of a pharmacy call center . Am J Health Syst Pharm. 2011 ; 68 : 2018, 2020, 2022 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Rim MH , Thomas KC , Chandramouli J et al. Implementation and quality assessment of a pharmacy services call center for outpatient pharmacies and specialty pharmacy services in an academic health system . Am J Health Syst Pharm. 2018 ; 75 : 633 - 41 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Utah Pharmacy Practice Act , Chapter 17b. Occupations and Professions Title 58, common carrier delivery R156-17b-608 (updated 2017). https://dopl.utah.gov/laws/R156-17b.pdf ( accessed 2018 May 30 ). 9. Kappenman AM , Ragsdale R , Rim MH et al. Designing and implementing centralized mail order pharmacy services . Poster presented at Vizient University Health System Consortium Pharmacy Network Meeting . Las Vegas, NV ; 2016 Dec . 10. The United States Pharmacopeia, 39th rev., and The national formulary . 34th ed. Rockville, MD : United States Pharmacopeial Convention ; 2016 . WorldCat COPAC 11. Rim MH , Smith L , Kelly M . Implementation of a patient-focused specialty pharmacy program in an academic healthcare system . Am J Health Syst Pharm. 2016 ; 73 : 831 - 8 . Google Scholar Crossref Search ADS PubMed WorldCat 12. American Society of Health-System Pharmacists . ASHP guidelines on pharmacist-conducted patient education and counseling . Am J Health-Syst Pharm . 1997 ; 54 : 431 - 4 . Crossref Search ADS PubMed WorldCat © American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Implementation of a centralized mail-order pharmacy service
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxz138
DA - 2019-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/implementation-of-a-centralized-mail-order-pharmacy-service-oakoMNFGdd
SP - S74
VL - 76
IS - Supplement_3
DP - DeepDyve
ER -