Clinical services and NHS integration take centre stage as pharmacy IT advances at last.
Information technology is often touted as an enabler — a means of delivering new models of service and improving the efficiency of existing ones — and that has certainly been the case with regards to pharmacy IT in the past few years.
Hub-and-spoke is now a reality for the larger multiples and may be on offer to independent businesses next year. At least two suppliers of dispensary management systems now offer applications that allow paperless dispensing.
Meanwhile, systems suppliers seek to smooth out the bugs and bumps in workflow and join processes together more efficiently. Common standards, protocols and APIs emerge to improve interoperability and with that the full benefits of technology become clearer.
“The goal of PMR systems in pharmacy needs to be focused on freeing up valuable time away from tasks that could be automated by technology,” says Tracey Robertson, product director at Cegedim. “Without this, pharmacy simply won’t have the capacity to focus on services.
“With direct integration into our own Pharmacy Manager system, pharmacy teams are actively alerted to the need or arrival of a service opportunity. A mobile optimised platform ensures service delivery is flexible and the intuitive, intelligent workflows deliver an efficient experience to the pharmacy teams. Automated claiming ensures pharmacies never miss out on essential payments.”
Cegedim argues that the industry should be considering easy access to the wider electronic patient records directly from the PMR system. “This will ultimately safeguard patient care while delivering efficiencies for pharmacy teams,” says Robertson.
For many years the only thing within the NHS that most pharmacy systems connected with was the electronic prescription service. That era is past. As Sima Jassal, clinical director at EMIS, says: “We recognise that clinicians now need a system which goes beyond the existing pharmacy PMR to assist with their expanding role in delivering services.
“During the first half of 2021, EMIS developed interoperability between its PMR, ProScript Connect and PharmOutcomes to support the Community Pharmacist Consultation Service.”
Along with Sonar Informatics, EMIS was commissioned by NHSE to develop a platform to support the new service. The Pharmacy Integration Fund was used to fund IT system licences for contractors. Funding has been extended twice, initially up to September and more recently to April 2022.
However, the decision to pull funding means the specification for the service had to ‘go public’. The NHS CPCS technical tool kit was published in early July, allowing other IT providers to develop their own applications. So far Cegedim (Pharmacy Manager) and Positive Solutions (Analyst) have done so. From November, contractors will be expected to transition to their own contractual arrangements with one of the four assured IT providers.
Invatech says it is also working to deliver a CPCS solution on its Titan dispensary system. Chief executive officer Tariq Muhammad probably reflects the frustration of the wider sector when he says: “The structure was only recently made available. In the meantime, people are being tied into contracts with PharmOutcomes. If we were given the service spec in good time then we could do more…”.
The rollout of CPCS means integration with NHS systems is now a key part of any new service linked application. “Our most recent product to go to market is Hx Consult,” says Mark Merry, head of product management at Positive Solutions. “It is a clinical services platform. It will support the CPCS – that is the first module it will run.
“The CPCS specification allowed us to build the foundations for a consultation platform that will connect to NHS 111, the SCR and the EPS prescription tracker. It allows for post-event messages [to GP systems] using FHIR and MESH, and links to NHS BSA MYS for payments.”
For the geeks, FHIR and MESH are standards adopted by NHS Digital. Fast Healthcare Interoperability Resources (FHIR) is the global industry standard for passing healthcare data between systems, while Message Exchange for Social Care and Health (MESH) is the main secure large file transfer service used across health and social care organisations.
“We have been on a journey with the NHS,” says Merry. “CPCS has set a standard for clinical services and given us an opportunity to break away from PMR solutions.” Hx Consult is a stand-alone solution although it integrates with Positive’s Analyst dispensary system.
“Flu vaccination will be the next service to be added,” he says, “and DMS is on the road map – the specification is ready. The NMS exists in Analyst, but there is no reason why it should not go into Hx Consult.”
Real time intelligence from Cegedim
Pharmacy Intelligence Hub is a new cloud-based digital management tool available to Cegedim’s Pharmacy Manager PMR customer base.
The Pharmacy Intelligence Hub digitally connects a pharmacy head office to its network of individual stores. Real-time metrics provide an instant view of store-level activity, including critical financial performance, stock and order management, and key dispensing statistics. The direct connection to the pharmacy PMR provides management teams with a live digital touch point to their stores and easy access to actionable intelligence, which is presented in one intuitive hub providing a complete picture of store operations.
“Our vision was to deliver an intelligent and powerfully simple digital solution that helps pharmacies to manage all of their critical processes effectively, whilst making their lives easier,” says Cegedim product director Tracey Robertson.
“We have created a digital heartbeat, a real-time connection to pharmacy operations that enhances visibility and improves decision making. This tool enables us to transform Pharmacy Manager with a fully integrated suite of predictive and prescriptive analytics that provide the insight, and more importantly, the foresight needed to allow pharmacies to thrive and survive in the future.”
These services, along with smoking cessation and hypertension case finding (announced as new advanced services in the 2021/22 CPCF settlement), cardiovascular disease, contraception and sore throat monitoring are all included in the Community Pharmacy Standard V2.1. The standard was first published in 2018 and updated in 2021 to allow for new services that community pharmacies are either offering now or may be offering soon.
Published by the Professional Records Standards Body (theprsb.org), an organisation Merry describes as being driven by NHSX, it provides a single standard for what information should be recorded in a community pharmacy for each service. It also defines the subset of information that should be sent to the GP record.
Merry, who is a “massive advocate of common standards”, says CPS V2.1 is “great for suppliers and IT systems because there are less likely to be changes and more opportunities for integration”. The standard supports the pharmacy digital priorities set out by the Community Pharmacy IT Group. Heading the list is interoperability and security (records and standards).
Positive Solutions carried out a consultation with 30 clients across 1,300 sites to ask about their wants and needs. Mobilising services was in the top three, the other two being improved patient communication, and better data and reporting.
As a result, Analyst Quickpick is being rolled out this month (September), which gives users the ability to pick prescriptions using an Android terminal rather that print out tokens.
“It moves us into a paperless environment,” he says. “It saves time and increases safety through the use of product scanning using a hand-held device connected to Analyst. It offers flexible workflow.”
Analyst Handout is another Android-based application on a hand-held terminal that can help promote paperless processes. Well Pharmacy was the first company to use it and, although it has been available for the past year, it has not yet been actively marketed.
Handout works with the shelf management facility in Analyst to record where a dispensed item is stored, allowing speedy retrieval when the patient arrives. It alerts patients through SMS messaging that items are ready for collection and connects with RTEC in the background to check exemption status. “It is one of those products you have to use to experience,” says Mark Merry.
This can happen at Positive’s customer experience centre. “We have built a digital pharmacy, which includes a BD Rowa robot and a trial hub-and-spoke set-up. We had to close it down as soon as it was built because of the Covid pandemic, but it is now open and Covid safe. It allows pharmacists – and their staff if they want to bring them – to role play with the new systems and equipment.”
Titan marches on…
It is only two years since Invatech launched Titan and in that time the company has chalked up some major successes. Its Enterprise model for online providers has mushroomed over the past 12 months. “We are the ‘go to’ company for anyone who has built a system that requires dispensing support,” says Tariq Muhammad.
Echo – now LloydsDirect – was an early major partner. Numan, an online clinic providing pharmacy services in sexual health, has recently gone live. PillTime, an online pharmacy that uses an automated robotic pouch dispensing system for delivering medication to patients at home, and Flo, an app to help women track their fertility, are among others who will be using Titan.
In the community sector Invatech is looking to have 250 independent and small company pharmacies using Titan by the end of the year. “It is a platform to drive change in pharmacy. I like seeing it used in innovative businesses – that is more important than just the number of pharmacies. I’d rather measure the number of prescriptions we handle than the number of sites,” Muhammad says. He estimates 3 per cent of all scripts dispensed in England will be coming though Titan by the end of the year.
The first pharmacy using a Titan system linked to a BD Rowa robot went live in August. “Integration is not just a tick box. We try to understand the business case and create a digital process for the workflow. That means there is two-way traffic – we try and optimise what the robot does,” he says.
“Pharmacies are so chaotic! Robots have provided stock organisation and efficient stock picking, but they are treating the ‘symptoms’. It is better to fix the root cause, which is the lack of workflow and digital processes.”
Proper digital pathway
A proper digital pathway – going paperless and using bar code scanning for all products – has put Titan in a position to apply artificial intelligence (AI) to the dispensing process. An AI app has been registered with the MHRA as a medical device and is being used to build data on how pharmacists carry out their clinical checks.
“With Titan, pharmacists are doing a clinical check at the start of the process in a consistent manner, which means we can apply AI tools,” says Muhammad. “Ultimately, this will release pharmacists from doing monotonous repetitive clinical checks and allow them to focus on the 20 per cent or so of scripts that do require their attention.”
At present the app is only operating in selected pharmacies under controlled conditions, but it will be made available to a wider customer base soon. Muhammad is keen to encourage some debate around the use of AI, especially as its use in pharmacies is not regulated by the GPhC.
“This is new and different, and discussion is needed to see how [the GPhC] wants to respond to this approach. We need to provide things that are safe and effective. The GPhC does not want to stifle innovation, but the regulations need to be up to date and guidance is needed,” he says. “I do not want sub-standard applications causing risk in the wider sector, so we do need standards and the regulations need to be updated – the responsible pharmacist regulations do not sit well with AI.”
FIRST PERSON: case study in automation
Automation is the key to supporting and expanding independent community pharmacies, says Ani Patel, pharmacist and owner at Savages Pharmacy in Essex.
“Savages Pharmacy has been serving the people of Burnham-on-Crouch since 1924. We had already expanded our services in several ways including the introduction of a Post Office bureau and a photo service. Introducing automation to our dispensary practice was a logical step and, after attending the Pharmacy Show in 2019, we decided that the solution most fitting to our needs was the Omnicell VBM.
The decision to automate has resulted in significant benefits for patients, pharmacy staff and healthcare professionals. The speed, precision and wide-ranging abilities of automated dispensing technology means that the pharmacy does not feel stretched and staff no longer feel overburdened. This is especially important given the relentless impact of Covid-19 on pharmacies.
We have seen exponential growth over the last year and we are now comfortable expanding the business, taking on new customers and serving more of the community, thanks to the technology.
Introducing automation produces an auditable trail of the prescription process. This means that at each stage of the process there are multiple levels of logging and tracking users, times, dates and actions. The VBM stores a photograph of every blister tray made up on the system, so we can see what was issued to each patient, avoiding confusion and doubt.
We have had wonderful feedback, word has spread and we have taken on lots of new customers, something we would not have had the capacity to do without the help of automated technology.
Fundamentally, automation can result in:
- Major staff time savings
- A reduction in the risk of errors
- More productive and efficient processes
- A less pressurised work environment for pharmacy staff
- A higher standard of patient care
- Growth for a pharmacy as a business.
Deciding to automate is a big decision that should not be taken lightly due to the financial and operational considerations. When training to use the VBM we soon realised that we had to completely change our way of thinking and operating after years of working the same way. Many staff were concerned that their roles would become redundant with the introduction of automated technology.
In fact, the synergy between knowledgeable staff and pharmacy automation generates a much more productive environment. Staff can now see how valuable the VBM is for their workload and working practices. The ability to work more methodically with a visible data trail and expand the business to help more people has given the team a big morale boost because they feel more fulfilled.
The idea of introducing technology into the workflow of a pharmacy can be daunting. In my experience the whole team must be committed to the vision and on board with the benefits that will be realised because it will take the focus of every staff member to drive progress forwards.
It is not easy to rethink and re-learn your working practices but putting in the effort to do this in order to work in tandem with technological solutions will help keep independent community pharmacies thriving in a space threatened by bigger rival organisations.”
Hub-and-spoke: can it really deliver?
There are some who think that the pharmacy sector has spent so long wrangling over hub-and-spoke that the concept is now out of date.
Hub-and-spoke regulations will be in place by next autumn, says Daniel Lee — and independents will be sufficiently interested in the Leeds hub that his company has under construction to book the facility out, he predicts.
In February, the Medicines and Medical Devices Act 2021 came into law, paving the way for regulations to permit hub-and-spoke dispensing between different retail pharmacy businesses.
Since then, the Department of Health has been having discussions with stakeholders to identify relevant issues, before carrying out a formal, public consultation on the introduction of hub-and-spoke. The consultation is expected before the end of the year, with revised legislation earlier or later in 2022.
“Any delay is not a concern – yet,” says Daniel Lee. “Contractors will hand over the Leeds site to us in late summer 2022. Delays in regulations is part and parcel of moving quickly into a new area of business.”
An impact assessment by the DHSC suggests that three models of hub-and-spoke might be allowed for:
- Large pharmacy chains that already have large automated hubs could expand their capacity, offering chargeable prescription assembly services to independents and small multiples
- Independent and small multiples could co-operate and centralise assembly of medicines in one of their pharmacies or by setting up off-site hub facilities
- New large-scale hub facilities could be developed by wholesalers or new companies, although the hub would need to be a registered pharmacy.
Daniel Lee admits to a vested interest in the regulations being as “light touch” as possible, a view not entirely shared by PSNC. Gordon Hockey, PSNC’s director of operations and support, errs towards regulation being quite restrictive to start with.
PSNC’s key issue is that the model for hub-and-spoke is fair to the sector as a whole. “We say this must be a ‘patient-spoke-hub-spoke-patient’ model,” says Hockey. PSNC does not accept a ‘patient-spoke pharmacy-hub pharmacy-patient’ model as appropriate or fair, since with the electronic prescription service it is, in effect, the supply of dispensed medicines from a distance selling (internet) pharmacy.
For an independent or small multiple looking to engage with hub-and-spoke, the cost of the service is key. “The cost of dispensing an item in a pharmacy is approximately £1.10 per item,” says Lee. “In most pharmacies that is still by and large a manual process. We are seeking to automate the process as much as possible, which will drive down the cost. If a pharmacy can send 70 per cent of its volume to a hub, it means it can be dispensed more cheaply.”
A competitive hub industry means a fundamental change for the sector, he believes. The HubRx Leeds unit will be able to support 200 pharmacies and handle 1.2 million items a month. The indications are that its potential customers will be dispensing slightly more than the 7,000 items per month average. The Leeds facility can serve all of England with scripts delivered back to pharmacies the next day.
“At capacity we know what the cost of dispensing will be and believe we can get it substantially lower than a pharmacy’s current cost. We can save 2-5 per cent on purchase margin and reduce dispensing costs considerably,” says Lee. “If we get the model right to start with, we could see a chain of hubs around the country servicing customers more locally.”
Meanwhile, the NPA has called on the Competition and Markets Authority to look into hub-and-spoke dispensing to ensure that any future legislative changes do not disadvantage independent pharmacies.
Hub-and-spoke can release capacity but only when the solution has been designed to fully optimise the end-to-end prescription journey, says Cegedim. “PMR systems need to offer choice and flexibility in their dispensing workflows and cater for a variety of prescription assembly options,” says Tracey Robertson. “These include store-based dispensing, hub (group owned or third party) or direct fulfilment by wholesaler.”
There is no doubt the technology to deliver hub-and-spoke is there, but that is not the whole story. The DHSC has indicated there will be an impact assessment alongside the upcoming consultation. In the meantime, its views were set out in the impact assessment that came with the Medicines and Medical Devices Act 2021.
Back then, the DHSC said the costs and benefits of hub-and-spoke remain uncertain, and the cost of setting up hub facilities would require a significant number of spokes before savings could be made. It also said that while the regulations would make hub-and-spoke permissible by all pharmacies, no pharmacy would be required to set up, use or offer hub services.
Benefits are expected to include reduced staff time on dispensing at the spoke pharmacy – but the real wrinkle is the statement that “in principle, any gains could be shared between hub operators, spoke operators, patients and the NHS”. If the DHSC sees hub-and-spoke as yet another means of driving down the dispensing fee, then those benefits could evaporate overnight.