Patient safety should always be the primary goal of all health care providers, but when operating an ambulatory care pharmacy, there are additional priorities that figure into the provider-patient relationship, including customer service and satisfaction expectations. A patient’s needs are rarely fully met by inpatient care; rather, ensuring comprehensive care often requires extended medication therapy. When a patient requires medication on a short- or long-term basis, measures must be put in place to enable those activities to occur with as few barriers as possible. Given that ongoing medication therapy maintenance is often an area of concern for inpatient pharmacy operations, providing a way for patients to request medication refills, receive education on medication use and interactions, and be able to follow therapy duration guidelines is essential to mitigating readmissions and maintaining the momentum of inpatient care.
At University of Utah Health Care’s 16 ambulatory pharmacies, we chose to implement interactive voice response (IVR) systems in 2006 in order to better serve the needs of our patients and improve medication adherence. In addition to the patient benefits, this approach also offers benefits to our institution. The system is fairly simple in design, was relatively easy to implement, required minimal training, and increased the efficiency of our overall workflow. Simply reducing the amount and duration of interruptions to staff can vastly benefit the quality of pharmacy operations, which brings us back to our original goal of providing the best possible care for all our patients throughout their course of treatment.
Staff and Resources to Include
As with all systems implementations, an integration team with the proper expertise is essential to success. In this case, we brought the IVR system vendor together with our internal team of information technology (IT) and telecommunications staff, along with pharmacists and pharmacy technicians that had experience with the necessary technology, including transaction, verification, and patient interaction software. As director of our ambulatory care pharmacies, I served as liaison between the vendors and our internal team to address any issues or process changes necessary for the implementation or subsequent use of the system.
It was vital to include our IT staff in this process, as that is largely what an IVR system is; a network of logistical interfaces to a facility’s existing medication distribution system. Telecommunications staff members are also necessary, as a server interface was required at each of the 16 pharmacies that use IVR. While our vendor did have the option of setting up one central server, our IT group decided it was best to use an individual server at each pharmacy. When operating a large number of ambulatory sites, if the IVR system is running on a single central server, a breakdown will shut down the entire system. In our case, if a single server goes down, it will only affect that one site.
Because patients have two different methods by which to interact with the system—phone and Internet—we also had to engage our internal Web team. The combined team of IT, pharmacy, and Web representatives were tasked with performing background research into the individual system vendors to determine how best to interlace the system with our own medication distribution system. As an IVR system simply creates a separate queue of medication orders and refills in our fulfillment process, it did not impact the method by which we fill traditional medication orders. Given that some medication ordering systems can be rather inflexible, we wanted to make sure we could monitor and control the queue without having to alter our ordering system.
When we began this process, we had no experience with IVR systems, so to ease the learning curve we first installed the system in one of our smaller, lower-volume pharmacies. As the pilot pharmacy, we also applied any subsequent upgrades to the system through this pharmacy first to ensure compatibility with the overall system. By approaching the new system this way, we were able to learn and test it over a few weeks to make sure it worked with as few issues as possible. This also gave us an opportunity to see if patients would be averse to the system. As with any new process, there are always going to be a few people who are initially uncomfortable, but we found our patients quickly adapted to the ease of the system. We subsequently rolled the system out to each pharmacy, bringing all 16 locations on board within four weeks. A key lesson we took away from the initial implementation was that patients do appreciate some advanced notification of process changes, so we made up a small information card that we included in prescription bags emphasizing the benefits of the coming system.
When implementing IVR at multiple sites, it is best to plan those individual configurations ahead of time. Each site may have different hours of operation or reporting hours and because the initial site setup is somewhat detailed, you need to establish elements such as whose voice will be used to operate the system and develop a script tailored to the facility’s operations. Our vendor recommended a woman they had used for past implementations and she was able to do our recordings for us.
Interacting with the System
As mentioned, the system works both over the phone and through the Internet. The system can provide some very basic information in the form of email messages or voice messages including the time when filled prescriptions will be ready for pick up and whether a prescription needs to be approved by the physician. It will also query the patient, if a prescription isn’t refillable, as to whether they want to contact their provider directly or have the pharmacy contact the provider.
One of the advantages of this system is that it is somewhat independent of the general pharmacy workflow. The IVR system assigns a number to each prescription and the interface matches that prescription number to the order in the pharmacy. This interface also includes a pharmacy identifier number so we know which ambulatory pharmacy the prescription is being requested for. If the identifier does not match the pharmacy where the order was originally received, a message is sent back to the patient indicating that a new pharmacy has been requested as the pick up location. It will ask the patient whether this is the intention or if it was a mistake. If the patient requests a pharmacy outside our network, the message will indicate this as well.
Once a patient enters a prescription number either through the Web or over the phone, a message is sent to our transaction system that checks the availability of refills. If available, a message comes back to the patient indicating the time it will be ready for pick up. If there are no refills left on the prescription and the patient requests that the pharmacy contact the physician to request a new refill, a message is sent to the patient requesting a 24-hour window to allow the pharmacy enough time to contact the physician.
On our end, a technician will go through the queue of orders by number and fill them in the traditional manner. Often there are several orders in the queue each morning, particularly in our busier pharmacies, so we make sure to process these quickly each day.
Avoid System Disruptions
The system has a constant monitoring capability wherein if something goes wrong—be it a network or telecomm issue, or even if a server needs to be reset—a message is sent to two designated staff members who will contact the vendor to resolve the issue. The vendor can solve many such issues remotely, which brings up a valuable point. It is essential that a message tree be established to identify reaction responsibilities in case of a breakdown. It is important to emphasize training in this area so that designated staff members are comfortable with basic troubleshooting (ie, does the issue require vendor support, or should it be directed to our internal IT department?) and can determine how best to enable a resolution.
While the entire system has never gone down, we have experienced occasional service outages at individual pharmacies. It is important to remember that the system depends on a clear interface with our transaction system, so if there are any disruptions to that system, such as an upgrade or interruption in service, the IVR system will be disrupted as well. So any changes made to either the IVR system or any of its attendant systems need to be double checked for compatibility. While downtime on the IVR system is not beneficial, we can always revert to person-to-person phone interaction as a back-up.
Benefits and Lessons Learned
Among our ambulatory pharmacy staff, we did not eliminate any positions as a result of implementing IVR to handle prescription refills. However, recouping staff time has allowed us to further develop other outpatient services such as our medication therapy management (MTM) program. Freeing up skilled technicians to coordinate with pharmacists to arrange patient appointments and follow up on medication education was a very valuable side effect of IVR implementation.
Keep in mind that depending on the system you select, functionality will vary, but some IVR systems have extensive order input and management capabilities, so you need to ensure your internal systems and processes can interact with IVR. The system’s interaction with attendant systems (such as transaction and fulfillment software) will dictate much of what IVR can do for you, so it is vital to ensure parallel interfacing capabilities between all interdependent systems prior to system selection. While we did not face many challenges in instituting this system throughout our network of ambulatory pharmacies, it is worth paying attention to each individual interface at each pharmacy.
Fundamentally, this is a patient-pharmacist interaction proxy, so perhaps the most essential element to consider when researching IVR is how best to gain buy-in from both your patients and your staff. Obviously much of this will involve giving advance notice to both parties via staff meetings and information placed in existing customer prescription materials. Clearly identifying the advantages of an IVR system will help ease its transition into usage. I also highly recommend that you look at your existing call volume prior to implementation. Depending on your patient population, certain outpatient pharmacies can experience hundreds of calls per day. Therefore, establishing what the IVR system can handle in terms of your average patient calls per day can give you a leg up on the process before it goes into place allowing you to allocate your resources accordingly.
Future System Use
Now that we have been working with this system for four years, there certainly are functions that we would like to see including the ability to automatically send text messages to patient cell phones when updates to prescription information is available. Furthermore, our IVR system does not currently interface with our organization’s electronic medical record system, so there is a separate system involved when patients are communicating directly with physicians. It would be ideal if all medication requests, even those filtered through a physician, could flow through the IVR queue keeping all refill requests in a single location. Aside from this, IVR is a worthwhile solution for any hospital that is experiencing a heavy call load to outpatient pharmacies.
The function of IVR in overall medication adherence is just a piece of the larger picture. Ultimately, inpatient therapy often must be assisted or maintained by medication regimen adherence upon discharge. To nurture proper education on medication use once a patient has left the hospital, we assembled a team of pharmacists and technicians that focus on education and medication reconciliation at the point of discharge. IVR can be an helpful tool in the effort to keep patients compliant with their medications by making automated reminder calls to patients who have not picked up their refills after a specified period of time.
Outpatient pharmacists have a different view of patient care than their inpatient counterparts and thus are well equipped to provide education on medications that need to be taken at home. Sometimes, patient care can take on an out-of-sight, out-of-mind mentality, so recognizing that adherence to prescriptions and proper patient education will reduce patient readmissions and alleviate further burdens to the health-care system is a valuable exercise.
Michael Kelly, RPh, MBA, is the ambulatory pharmacy service director for the University of Utah Hospitals and Clinics. Michael received a BS in pharmacy from the University of Utah and an MBA from the University of Phoenix. Michael is responsible for the operation of fifteen ambulatory pharmacies as well as the management of specialty pharmacy clinical services and medication therapy management services in several of University of Utah pharmacies.
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