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In an effort to make it EASIER FOR PATIENTS to fill their prescriptions, some doctors’practices are bringing in VENDING MACHINE STYLE dispensers.
BY JEAN LAWRENCE
When patients leave Abbott Northwestern hospital in Minneapolis, they can now head straight home rather than to the drugstore. They already have their medications in hand, having extracted their first prescription from an ATM like vending machine in their doctor’s office. Ken Rosenblum, M.D., CEO of Mendota Healthcare in Minnetonka, says the need for such a system hit him one night when he was roaming the city looking for an open pharmacy to fill a prescription. Though there were many nearby pharma cies, Dr. Rosenblum couldn’t find one open at that time of night. After doing some investiga tion, he found that pharmacies are facing a crit ical, nationwide pharmacist shortage. Along with pharmacists, doctors, and engineers, Dr. Rosenblum spent the next two years develop ing the InstyMeds prescription dispenser. An onsite pilot program that began in April 2001 has been completed successfully and the system is now being expanded to other locations. The InstyMeds dispenser holds about 80 commonly prescribed medications, doses, and quantities, including pills, liquids, suspensions, creams, inhalers, and eyedrops. The doctor enters a prescription electronically, using a PDA or similar device, with the software sup plying the correct dose for the patient’s weight. The physician then asks the patient: “Do you want to get this from the drugstore or would you like to pick it up on the way out?” PREPACKAGED DOSES Pharmacy Direct INOFFICE dispensing If the patient elects to pick up the prescrip tion on the way out, a voucher with a security code is issued instead of a standard prescription. The prescription is entered into the patient’s chart and merged with insurance information, thus ensuring the drug is on the formulary. To obtain the medication, the patient inserts the voucher into the machine, supplying their credit card, debit card, or cash if there is a copay or if they don’t have insurance. After passing through three barcode checks, the medication is dispensed like a candy bar. A standard label is applied by the dispenser and all required usage and warning instructions accompany it, just as they would in a pharmacy. “It’s very simple to use,” reports Keenan Richardson, M.D., of South Lakes Pediatrics, which conducted a pilot study using InstyMeds. “There is no legibility issue. I have not found an error.” The medications are repackaged into unit ofuse containers and are sent via courier to the doctor’s office, where they are loaded into the machine. Dr. Rosenblum emphasizes that the system reduces errors to almost zero and increases compliance. One in four prescrip tions are never filled, he points out. The InstyMeds system ensures the patient receives the medication that the doctor prescribed. “This system sure beats dragging sick kids to the pharmacist,” Dr. Richardson adds. Of the 60% of patients who have opted to use InstyMeds, 94% say they want to use it again. 49 PharmaVOICE J u l y / Au g u s t 2 0 02 InstyMeds prescription dispensing system is the first fully auto mated,ATMstyle dispenser of prescription medications.There are cur rently a number of handheld prescription entry devices and electron ic medical record (EMR) systems on the market. Interfaces can be developed with any of these systems to automatically receive pre scription information.However, the company also has created its own PDAbased prescription entry application. Its unique interface allows a physician to conveniently enter a prescription using only one hand (and no clicks) and no graffiti writing. A patent is pending on this design. Drug dosages are calculated automatically. Thepatient has the choice of receiving a printed prescription to bring to a pharma cy, or receiving a voucher for medication at the InstyMeds dispenser in the medical clinic. Whichever method the patient chooses, handwriting errors are eliminated. Although the company anticipates that future models will vary in size, the current model holds 80 different medications and from 8 to 22 bottles of each drug. (For most specialties, 45 drugs represent more than 80% of what is prescribed.) Theunit is capable of labeling anddispensing nearly any formofmed ication, including tablets, capsules, inhalers, sprays, creams and oint ments,suspensions, and syrups. Since InstyMeds interfaces with the medical facilities registration system,there is no need to reenter insurance information,and insur ance approval is obtained real time. If there is an insurance issue, it is routed to the InstyMeds call center freeing up the medical staff from timeconsuming pharmacy callbacks. PDRx Pharmaceuticals’ “SOS” Program is a pharmaceutical sam pling program designed to save managedcare organizations and selfinsured organizations money in pharmaceutical care expendi tures in several therapeutic categories. Prefilled medications of the most commonly prescribed drugs are purchased from PDRx. Depending upon the preference, prefilled medications can be in the form of brand name or generic drugs and Patient Point of Care Options overthecounter samples. Medical professionals provide these pre filled prescriptions directly to MCO and SIO patients free of charge or for a small copay.The result is a significant cost savings to MCOs and SIOs, based on a reduction of inappropriate usage of brandname medications,cost shifting to samples of OTC products,and a reduction in dispensing fees based on the direct sampling of the “SOS” products. Allscripts Healthcare Solutions’ FirstFill is a new service that enables the physician to fill the patient’s first prescription, for the most com monly prescribed medications, at the point of care.Instead of handingout a sample,doc tors can now provide patients with a com plete prescription and save thema trip to the pharmacy. The FirstFill advantages include improv ing outcomes, since patients take their first dose at their physician’s office, increasing compliance (one out of five prescriptions are never picked up at the pharmacy),pro viding instructions directly to the patient, increasing patient satisfaction (97% of patientsprefer to receive their medicationat their physician’s office),saving patients both time and additional has sles, improving bottom line for a practice, and reimbursement for pro viding this service to patients. FirstFill automates the entire medication delivery process.For the first prescription, the functions that a pharmacist would typically handle (counting pills, clarifying handwritten scripts,checking for potential drug interactions,checking for formulary compliance,printing a label,manag ing inventory) are handled automatically through the TouchWorks soft ware provided with the FirstFill program.The process is simple: the pre scription is checked for insurance formulary compliance,theprescription is checked for prior adverse reactionsand potentialdrug interactions,the claim is handled online, and the medication is prepackaged with a tam perproof safety seal. An automated inventory management process reduces time spent answering pharmacy calls. And, only the most commonly prescribed medications are kept in stock. INOFFICE PRESCRIPTION FULFILLMENT — EASES BURDENONPATIENTSANDPHYSICIANS D I INOFFICE dispensing With the oneyear test a success, Dr. Rosen blum has contacts with three hospitals, and is negotiating with a 15hospital system. Another customer may be the retail pharmacies. “There is nothing more frustrating than seeing your pre scription behind a barred window after hours,” Dr. Rosenblum says. “In this case, the individu al would call in the prescription and be given a code to retrieve it from the machine in the drug store. InstyMeds dispensers could save the aver age chain drugstore $100,000 a year in staffing costs.” INOFFICE FULFILLMENT Taking a somewhat different approach, First Fill, a program offered by Allscripts Healthcare Solutions, supplies about 15,000 doctors with special computer stations and fulfillment cabi nets stocked with the mostprescribed drugs in prepackaged form. Using the FirstFill software, the doctor checks the patient’s chart for allergies and adverse reaction, before the office nurse issues the properly labeled bottle. Patients take their first dose on the spot. What’s more, the physicians collect the copay and can make as much as $10 profit on each medication. According to IMS Health, U.S. pharmaceu tical manufacturers distributed almost $8 bil lion of product samples in 2000, more than half of the $15.6 billion the industry spent in promoting its products to both doctors and consumers. In a third variation, PDRx Pharmaceuticals Inc., a pharma ceutical packaging company, offers usedosing in the doctor’s office to managedcare and self insured companies as a way to steer patients to the most cost effective medicines. “We have provided more than 1.5 million prescriptions to man agedcare companies,” says Jack McCall, executive VP of PDRx. “If the MCO buys a month’s dose of a diuretic, for example, for a cou ple of dollars and the patient begins taking this medication instead of a $30 brandname drug, the savings can add up quickly.” Managedcare companies alert PDRx as to which drug classes are showing high activity. For example, the MCOmight note that prescrip tions for NSAIDs are high at that time. “Why not dispense 800mil ligrams of ibuprofen free instead of sending the patient to buy Vioxx, which costs the insurer more,” Mr. McCall says. “It can be a month’s worth or just a trial, in either case there is substantial savings to the MCO and the patient.” One company, Mr. McCall says, saved $1.2 million in one year this way. And the patients like it because there is no copay and it is con venient. “These are firstline therapies,” Mr. McCall says. “Generic medications are always a costeffective firstline consideration and can be the best choice.” A study in the Journal of the American Medical Association asserts that 10% of 548 drugs studied were taken off the market or given belated serious sideeffect warnings after approval. Researchers suggested that older drugs be pre scribed when possible unless the new medication represents a true breakthrough. DETERMINING SIDE EFFECTS What are the implications of prescription dispensing shifting to the emergency room? Firstly, Dr. Rosenblum notes that doctors need to give use instructions and follow up on side effects. In addition, a telephone link to a licensed pharmacist is provided. As for the pharmacists’ recordkeeping func tion, Dr. Rosenblum explains that the overview of the patient’s medication use now rests with the insurance company paying the claims, rather than an individual pharmacy. Followup pre scriptions, of course, are filled by a local or mail order pharmacy. “If 25% of prescriptions never make it to the pharmacy, that’s 25% of the mar ket lost,” Dr. Rosenblum says. All three companies insist that their sys tems reduce errors from illegibility of pre scriptions to dosing, allergies, or contraindica tions, all of which are doublechecked by the systems’ software. Not everyone, however, is in favor of in office fulfillment, including the National Community Pharmacists Association. “We are opposed to anything that inter feres with the patientpharmacist relation ship,” says Douglas Hoey, NCPA’s VP for practice affairs. “Our pharmacists have a min imum of six years education in the proper use of drug products. To substitute a vending machine circumvents that relationship.” Mr. Hoey also says even though prescribing information comes with every bottle, “studies have shown that, unfortunately, a large propor tion of people are illiterate or functionally illit erate. There is no substitute for that facetoface conversation with the pharmacist.” F PharmaVoice welcomes comments about this article. Email us at firstname.lastname@example.org. 50 J u l y / A u g u s t 2 0 0 2 PharmaVOICE Experts on this topic DOUGLAS HOEY. VP for practice affairs, National Community Pharmacists Association, Alexandria,Va.;NCPA represents the pharmacist owners, managers, and employees of nearly 25,000 independent community pharmacies across the U.S. JACK MCCALL.Executive VP, PDRx Pharmaceuticals,Oklahoma City, Okla.; PDRx Pharmaceuticals provides a complete line of pharmaceuticals, packaging services, software development,and clinical pharmacy consulting services KEENANRICHARDSON,M.D.Practicing physician, South Lakes Pediatrics, Minnetonka, Minn.; South Lakes Pediatrics is a pediatric healthcare facility KENROSENBLUM,M.D.Founder and CEOof Mendota Healthcare,Minneapolis, Minn.;Mendota Healthcare developed the InstyMeds prescription dispensing system — the healthcare industry’s first fully auto mated,ATMstyle,dispenser of prescription medications If the MANAGEDCARECOMPANY buys a month’s dose of a diuretic for example,for a couple of dollars … instead of a $30brandnamedrug, THESAVINGSCANADDUPQUICKLY. JACK MCCALL