Development and implementation of a centralized comprehensive refill authorization program in an academic health system

Expansion of Pharmacy Services During COVID-19: Pharmacists and Pharmacy Extenders Filling the Gaps Through Telehealth Services

Purpose: The Coronavirus 2019 (COVID-19) pandemic created a significant disruption in healthcare. In our health-system located in New York City, the provision of care in the ambulatory care setting moved to a remote model virtually overnight. We describe interventions made during the pandemic to transform ambulatory care pharmacy through expansion of telehealth services. Summary: In March of 2020, the closure of primary care clinics and provider appointment cancellations due to inpatient redeployment created a void. Collaboration with other health care providers and development of standardized telehealth workflows served as a conduit for creating new roles and opportunities for pharmacy team members. Three main interventions where the pharmacy team filled gaps include; (1) Expansion of pharmacist telemedicine visits for high-risk patients to improve access to primary care visits, (2) Partnership with nursing to create a centralized refill call center workflow, (3) Integration of pharmacy extenders into the prior authorization process to prevent medication access issues. Existing collaborative practice agreements for chronic disease management were utilized. A virtual pharmacist model for patient care contributed to an increase in telehealth visits from 51 in 2019 to 2997 total visits in 2020. In addition, the health-system refill call center expanded its services through collaboration with our pharmacy team. Pharmacists and pharmacy interns partnered with nurse practitioners to improve the call center workflow and address the significant increase in refill requests during the outbreak. Furthermore, a prior authorization process was created across multiple ambulatory care clinics to expedite medication access and prevent delays in therapy. Conclusion: Our ambulatory care pharmacy team leveraged technology, innovative workflows, and collaborative teamwork to catalyze a shift in pharmacists' and pharmacy extenders' roles in healthcare delivery to expeditiously meet patients' needs during a pandemic.

Impact of a pharmacist-run refill and prior authorization program on physician workload

BACKGROUND

Pharmacist-led programs centralizing prescription renewals and prior authorization processing have been implemented within health care systems; however, their impact on physician efficiency and the perception of impact on workload are unknown.

OBJECTIVES

The primary objective of this study was to measure the change in physician efficiency score after implementation of the refill and prior authorization pilot program (RPAPP). Secondary objectives included changes in physician and staff perception of workload, changes in Center for Medicare and Medicaid Services (CMS) Star Measures, and program productivity.

METHODS

This was a retrospective cohort study comparing patient and physician data 12 months before and after RPAPP implementation at an academic medical center. Physician efficiency was an average of 5 metrics that measure performance utilizing the electronic health record. Physician and staff perceptions were measured at baseline and 12 months via a pre- and postsurvey. Changes in CMS Star Measures were captured using the institution's Population Health Department data. RPAPP productivity was defined as the number of refills/prior authorizations processed and laboratory parameters ordered.

RESULTS

On implementation, positive results were seen in average physician efficiency scores for 1 of 2 clinics (P < 0.05). Survey results indicated significantly positive changes in physician and staff perception of workload and satisfaction. The RPAPP appeared to help improve institutional performance for 2 of the 3 CMS Star measures evaluated (P < 0.05).

CONCLUSION

Evaluation of primary care physician workload is complex. Although external variables may have impacted consistent results, the RPAPP appears to have positive effects on physician efficiency and satisfaction. These results may assist other health care institutions interested in initiating an RPAPP.

The high-value pharmacy enterprise framework: Advancing pharmacy practice in health systems through a consensus-based, strategic approach

Purpose

The high-value pharmacy enterprise (HVPE) framework and constituent best practice consensus statements are presented, and the methods used to develop the framework’s 8 domains are described.

Summary

A panel of pharmacy leaders used an evidence- and expert opinion–based approach to define core and aspirational elements of practice that should be established within contemporary health-system pharmacy enterprises by calendar year 2025. Eight domains of an HVPE were identified: Patient Care Services; Business Services; Ambulatory and Specialty Pharmacy Services; Inpatient Operations; Safety and Quality; Pharmacy Workforce; Information Technology, Data, and Information Management; and Leadership. Phase 1 of the project consisted of the development of draft practice statements, performance elements, and supporting evidence for each domain by panelists, followed by a phase 2 in-person meeting for review and development of consensus for statements and performance elements in each domain. During phase 3, the project cochairs and panelists finalized the domain drafts and incorporated them into a full technical report and this summary report.

Conclusion

The HVPE framework is a strategic roadmap to advance pharmacy practice by ensuring safe, effective, and patient-centered medication management and business practices throughout the health-system pharmacy enterprise. Grounded in evidence and expert recommendations, the statements and associated performance elements can be used to identify strategic priorities to improve patient outcomes and add value within health systems.

Comparison of Interventions Made in an Ambulatory Pharmacist-Managed Refill Model to Usual Physician Care

Background: With the current practice model, there is less time for physicians to address refill authorization requests (RARs) while performing consistent quality care, which creates an opportunity for pharmacists to assist in refills. Currently, inadequate evidence is available to support this intervention. Objective: To compare the rate of medication management interventions (MMIs - drug therapy changes, laboratory monitoring ordered, or office visit scheduled) initiated by the pharmacist-managed authorization center (PMAC) to usual care. Methods: A retrospective, noninferiority study looked at 4000 RARs from 6 primary care centers from January 2016 through March 2017. The primary endpoint compared the rate of MMIs between PMAC and usual care. Noninferiority was concluded if the upper limit of the 95% CI of the difference in interventions was <2%. Secondary endpoints included total, type, and acceptance rate of PMAC recommendations. Results: A total of 3830 patients were included, with 4732 medications requested (2183 reviewed by PMAC and 2549 by usual care). MMIs occurred in 153 medications within PMAC (7.0%) versus 90 for usual care (3.5%). The difference in total MMIs between PMAC and usual care was -3.5% (95% confidence interval = -4.8% to -2.2%). Medications reviewed by PMAC had significantly higher number of laboratory monitoring (P = .036) and scheduled appointments (P < .001). There were 294 PMAC recommendations (13.5%) with a 52.0% acceptance rate. Conclusion and Relevance: This study showed that PMAC was superior to usual care for reviewing RARs. There was a statistically significant improvement in medication monitoring and patient follow-up, supporting the idea of including a pharmacist in the decision making.

Rebuilding the Standing Prescription Renewal Orders

BACKGROUND

Managing prescription renewal requests is a labor-intensive challenge in ambulatory care. In 2009, Vanderbilt University Medical Center developed clinic-specific standing prescription renewal orders that allowed nurses, under specific conditions, to authorize renewal requests. Formulary and authorization changes made maintaining these documents very challenging.

OBJECTIVE

This article aims to review, standardize, and restructure legacy standing prescription renewal orders into a modular, scalable, and easier to manage format for conversion and use in a new electronic health record (EHR).

METHODS

We created an enterprise-wide renewal domain model using modular subgroups within the main institutional standing renewal order policy by extracting metadata, medication group names, medication ingredient names, and renewal criteria from approved legacy standing renewal orders. Instance-based matching compared medication groups in a pairwise manner to calculate a similarity score between medication groups. We grouped and standardized medication groups with high similarity by mapping them to medication classes from a medication terminology vendor and filtering them by intended route (e.g., oral, subcutaneous, inhalation). After standardizing the renewal criteria to a short list of reusable criteria, the Pharmacy and Therapeutics (P&T) committee reviewed and approved candidate medication groups and corresponding renewal criteria.

RESULTS

Seventy-eight legacy standing prescription renewal orders covered 135 clinics (some applied to multiple clinics). Several standing orders were perfectly congruent, listing identical medications for renewal. We consolidated 870 distinct medication classes to 164 subgroups and assigned renewal criteria. We consolidated 379 distinct legacy renewal criteria to 21 criteria. After approval by the P&T committee, we built subgroups in a structured and consistent format in the new EHR, where they facilitated chart review and standing order adherence by nurses. Additionally, clinicians could search an autogenerated document of the standing order content from the EHR data warehouse.

CONCLUSION

We describe a methodology for standardizing and scaling standing prescription renewal orders at an enterprise level while transitioning to a new EHR.