Putting pharmacists in specialist outpatient clinics: a pilot approach to integrate services under one roof

Abstract

Patient journey with multiple stopovers has long been recognized as suboptimal and attempts to co-locate pharmacists with physicians have been explored in various healthcare systems to integrate processes and improve patient experience. This prospective study aims to evaluate and compare process efficiency between a decentralized prescription review workflow (intervention) and conventional prescription filling workflow (control). Both workflows were concurrently assessed in selected specialist outpatient clinics. Outcome measure was end-to-end prescription processing time between intervention and control workflows. A total of 1117 complete prescription time–motion data entered analysis. There was significant reduction in patients’ waiting time of approximately 25% (803.6 ± 409.0 s vs 618.6 ± 468.3 s, p < 0.001). For patients undergoing intervention workflow, instant collection of medication was achieved 96% of the time. However, reduction in dispensing time spent in intervention arm was not observed compared to control workflow. The findings may support further modification and implementation of the decentralized workflow in other healthcare institutions in order to realize team-based patient-centered care that ensures timely supply of medications that are optimized for the purpose of treatment.

Introduction

Traditionally, outpatient clinics operate separately from pharmacies. Typically, patient sees doctor in the clinic, pays for consultation and investigation, then proceeds to pharmacy to fill prescription, and pays for a second time. The number of stops may be more if the visit involves third party payer or if there are appointments with other healthcare professionals within the same day. Such patient journey has long been recognized as suboptimal,^1,2 and attempts to co-locate pharmacists with physicians have been explored at various healthcare systems to integrate processes and make the patient experience more seamless, with less duplication of services, less stopovers, and single point of payment. ³

A practice model that puts pharmacists in the clinic may present promising opportunity for delivery of value-added, patient-centered services. ⁴ For instance, with pharmacies usually being the last point of contact in the past, drug-related issues were often detected long after patients had left the clinic. As a result, locating and contacting the doctors for interventions could be challenging at times. Prescription reworks were not uncommon, affecting up to 12% of the total daily prescription load. If such problems can be detected and corrected earlier while patients are still in the clinic, a direct, team-based discussion may ensue and timely interventions may be made.

In line with the continuing trend for patient-centered care in Singapore, we decided to examine the potential benefits for putting pharmacists in specialist outpatient clinics for prescription review, and conducted a workflow efficiency study. By bringing forward the prescription review process, the pilot aims to reduce physical waiting time our patients spend in our pharmacy through early initiation of concurrent medication packing before their arrival. A single, consolidated payment that includes all clinic services rendered and medications dispensed can be made at the clinic cashier, before the patient proceeds to pharmacy for medications collection. Through this study, we hope to identify gaps in our proposed systems and processes, anticipate institution-specific issues and further modify the workflow prior to hospital-wide implementation in the near future.

Study details

This prospective, single-center, cohort study was conducted at Alexandra Hospital, a 330-bed acute care hospital in Singapore, over four months from June to September 2017. The planning and implementation of intervention workflow adopted a team-based approach, including early involvement of clinic operations colleagues and fellow nurses. Implementation plans, project team structure, Gantt chart, and timeline were discussed in detail before presenting to the hospital’s Medical Board for approval in May 2017. Upon approval, briefings were carried out for all pharmacy and clinic staff. With involvement from fellow clinic operations colleagues and physicians, the pilot intervention workflow was rolled out on 12 June 2017.

The workflow consisted of three specific components: (1) early interface between patients and pharmacists – by doing basic medication reconciliation and counselling for patients at the clinic, patients could better understand their own medications and conditions, thereby increasing the accuracy of order taking and reducing the need for reworks downstream; (2) one-queue-one-payment – apart from enhancing clinical experience, this streamlined administrative experience by introducing a single consolidated payment for both consultation and medications; (3) early initiation of parallel medication packing – the outpatient pharmacy staff would be triggered remotely to prepare patients’ medications in parallel sequence while patients were making payment at the clinic. This helped to speed up the processing and allowed the patients to “pick-and-go” at the pharmacy upon their arrival.

The intervention workflow was implemented in an outpatient general medicine clinic with disciplines including dermatology, psychiatry, internal medicine, geriatric medicine, and infectious diseases. Control (standard workflow) continued in other clinics including staff clinic, family medicine, renal medicine, endocrinology, urology and surgical disciplines. Prescriptions from acute care clinic were not included in this study. A comparison of the workflows can be found in Figure 1.

Figure 1.

Comparison of conventional and improvised medication supply workflows.

Primary outcome measure of workflow efficiency was characterized by end-to-end prescription processing time. Standardized data collection slips were used for a time–motion study in gathering data for primary outcome measure. Pharmacy staff would note down the time stamp at the start of each prescription processing step, which time taken could then be calculated from. Secondary process indicators tracked for intervention arm included proportion of prescriptions ready for instant collection at pharmacy, and reworks contributed by bill reversals and inventory issues.

For our outcome measure, 385 prescriptions were required for each workflow at 95% confidence level and 5% margin of error. Total prescription processing time between the two workflows was compiled in seconds and compared using independent sample T-test. A p value of <0.05 was considered statistically significant. All statistical analyses were performed with STATA version 13.1 (StataCorp LP, College Station, TX).

By the end of data collection, a total of 1443 prescriptions undergoing both intervention and control workflows were randomly tracked. Of these, there were 1117 complete sets of time–motion data (537 in the control arm and 580 in the intervention arm) entering analysis; 326 prescriptions were excluded from analysis due to incomplete data recorded. Data imputation was not performed in this study.

As shown in Table 1, our findings showed significant reduction in patients’ waiting time by approximately 25% (803.6 ± 409.0 s vs 618.6 ± 468.3 s, p < 0.001), primarily contributed by the parallel packing process in the outpatient pharmacy.

Table 1.

Time–motion study comparing control and intervention workflows.

Processing task	Control timing (s)	Intervention timing (s)	p value
Reception	83.0 ± 63.3	396.4 ± 344.4	-
Checking	137.0 ± 108.3
Typing	72.8 ± 52.6
Packing	287.6 ± 290.8
Dispensing	227.3 ± 265.3	222.3 ± 286.6
Total prescription processing time	803.6 ± 409.0	618.6 ± 468.3	0.000

For patients undergoing intervention workflow, instant collection of medication on arrival was achieved 96% of the time. Throughout the study period in the intervention arm, a total of 14 bill reversals were recorded, constituting 2.4% of prescription load. Nine cases of inventory inaccuracies within the pharmacy dispensing system were reported, constituting 1.6% of the prescription load.

Discussions

This study reports the findings in workflow efficiency for a specialist outpatient clinic using an integrated decentralized pharmacy workflow compared with an existing standard workflow. Our results suggest that the integrated decentralized workflow may shorten end-to-end prescription processing time and may result in positive impact on the majority of patients’ perceived waiting time.

A parallel process of packing medications while the patient made their way to collect from pharmacy reduced the patients’ waiting time at the pharmacy. Besides, timely intervention and team-based care could be delivered by clinic pharmacists when the review process was brought forward, allowing earlier detection of drug-related problems. With most of the transactions being performed in the clinic, we also managed to reduce the patient traffic and crowd at the pharmacy during peak hours.

However, during the implementation, we also observed several challenges. Firstly, the intervention workflow combined reception, typing, and checking (tasks originally requiring three persons to perform) to a single pharmacist. While the streamlining of processes reduced wastage and shortened overall prescription processing time, the risk of errors increased. Secondly, despite having drug image database on hand, it was noted that medication counselling and education could not be effectively carried out by clinic pharmacist without physical medications. This was evident in the time–motion study that the dispensing time taken for intervention arm remained similar to the control arm instead of an expected reduction as the patient would just “pick-and-go.”

A post-mortem meeting was carried out among various stakeholders involved in this project. Challenges were discussed at length and future modifications to workflow were proposed and debated. For example, in order to mitigate the increased risk of errors from the clinic pharmacists, a pharmacy technician may be partnered with every two clinic pharmacists. In this workflow modification, a clinic pharmacy technician will establish the medication order from the patients and transcribe their prescriptions into electronic entries in the pharmacy dispensing system. Following this, clinic pharmacists will take over and review the prescriptions, and perform checks on transcription performed earlier by the pharmacy technician. This breaking down of tasks does not only alleviate some workload from the clinic pharmacists, but also creates an additional layer of checks at the same time.

Besides, from our results, we also noted that education and counselling performed at the clinic by pharmacist did not significantly reduce the time needed for dispensing at the pharmacy. This could be due to several reasons. Counselling at the clinic was usually performed without physical medication. Pharmacists could only show drug image during the clinic counselling. Moreover, some patients might request for additional instructions to be written on the physical medications at the pharmacy. With these findings, we intend to remove the counselling function from clinic pharmacists in future implementation and focus the education effort at the point of physical dispensing. Additionally, we also recognized the importance of an updated and comprehensive drug image database. The database in our hospital will be further enhanced to meet the operational needs of the clinic pharmacists in the future.

Conclusion

As a comprehensive effort to evaluate the workflow that decentralizes pharmacist’s prescription review to the clinic, the results of this study can provide some insights into the advantages and challenges associated with the proposed integrated, decentralized workflow. The findings may support further modification and implementation of the decentralized workflow in other healthcare institutions in order to realize team-based patient-centered care that ensures timely supply of medications that are optimized for the purpose of treatment.