by John King, CEO of OmniSYS
The path to provider status for retail pharmacists is becoming clearer by the day. In fact, one positive outcome of the COVID-19 pandemic is that it has accelerated the resolution of issues surrounding scope of practice and reimbursement for pharmacy-based clinical services, at both the federal and state levels. And while all the details are not yet finalized, it’s hard to imagine a post-pandemic world where pharmacy’s role will be scaled back to a scope of practice that doesn’t account for basic clinical services such as expanded immunizations and point of care testing for flu, strep and future viruses like SARS CoV-2.
So now that the proverbial genie is out of the bottle, what will it take from an IT perspective to enable pharmacists as providers of medical services?
In a nutshell, pharmacists will be required to address and meet the same care objectives as everyone else in the medical system. They will need solutions in place that help them understand their patients holistically in order to drive certain quality and value metrics which healthcare buyers expect. They will need tools that help them efficiently and accurately document clinical encounters so that they can communicate their findings across the continuity of care. And finally, they will need technology that understands the language and practice of ICD-10 and CPT coding so that they can submit medical claims. Said more plainly, pharmacies will need a billing-enabled electronic health record (EHR).
There are many elements to an EHR. However, let’s look at three core aspects that pharmacists will need in order to practice at the top of their license.
Clinical Documentation That’s Easy to Use
Working in a retail pharmacy is completely different than practicing in a clinic or a medical office. If an EHR is going to be successful in the pharmacy, it must be fast, efficient and easy to use. Because the scope of practice is limited for a pharmacist, the documentation system should be streamlined for only those encounter types performed in the pharmacy. In the past, attempts to introduce customized or ‘dumbed down’ physician EHR’s into the retail setting failed due to cumbersome workflow, extraneous functionality and non-intuitive user design.
A workable solution for retail pharmacy must be built with the pharmacy and pharmacist in mind. It should provide structured documentation templates that guide the pharmacist through the encounter types covered under their scope of practice, and which ensure that all required data elements are captured. This process needs to be simple and intuitive, making clinical workflow easy and efficient.
Integrated Revenue Cycle Management
Spoiler alert… billing for clinical services in the pharmacy is complex! The two principal issues that a pharmacy EHR must resolve are 1.) dual benefit design and 2.) automated medical claims management.
First let’s address the issue of dual benefit coverage. In most cases, the outcome of a properly documented encounter should result in a valid medical claim. The concept of which is foreign to many pharmacies, as most organizations have little experience or capability of billing medical payers. As if this wasn’t challenging enough, some payers create additional complexity by defining certain immunizations and clinical services under the pharmacy benefit. Thus, the right technology will need to support a common pathway for the documentation and billing of encounters, regardless of the plan design. Ideally, this pathway should leverage the NCPDP standards making interoperability with existing pharmacy management systems and workflows a cinch.
Now to the second issue, automated medical claims management. The outcome of a successfully documented encounter should result in a claim that is built using the right billing codes to ensure proper reimbursement. This claim in turn should be electronically submitted to either the PBM, or more commonly, the medical payer. While the PBM billing pathway is already established via the NCPDP standards, the key to a successful clinical practice is finding an EHR which is integrated with, or can interface to, an MBM (medical benefit management) provider who specializes in medical billing and who can electronically submit and remit claims to the medical payer. Either way, a successful pharmacy EHR should make the workflow and subsequent billing, regardless of plan design, transparent to the pharmacist.
Communication is Key
As a provider of care, pharmacists rightly take their place as a member of the broader medical team. And in doing so, they must ensure that their findings and insights are shared with the various stakeholders across the continuity of care. The right technology should make this easy to do and a natural outcome of the care delivery process. Examples of key recipients are other providers, payers, public health reporting and state IIS registries.
There are many valid technical means to solve information sharing, everything from automated faxing to the utilization of the HL7 FHIR interface format. Obviously, the more automated the better. A common industry standard, which any valid EHR should support, is the Pharmacist eCare Plan (PeCP) which allows for pharmacist-level monitoring and reporting of medication adherence, health assessments, conveyance of lab results, payment opportunities and other activities related to a patient’s plan of care.
In the end, good technology is designed to automate workflow and hopefully reduce costs. As an outcome of any pharmacy encounter, care plans should automatically be shared with other provider’s electronic health records and appropriate results sent to state and public health reporting entities. This capability should be core to the pharmacy EHR.
The Pathway is Clear and its Paved with Technology
Provider status for pharmacists is finally here, and it’s about time! As one of the largest and most trusted medical professions, pharmacists offer convenient access to quality, affordable care. With the right technology in place, pharmacists can efficiently practice at the top of their licenses, be reimbursed for the services they provide and share their valuable insights to the broader medical community. The good news is that this technology exists and is available to pharmacies today. Working together, technology vendors and retail pharmacists can begin building the infrastructure to making every retail pharmacy a health hub for their community.