WORKFLOW & SOPJulie Wolfe Lancaster Cancer Center, PaSarah Stadt, CPhTCancer Specialists of North Florida, FL Carol Hemersbach, CPhT, BSHCA, Arizona Oncology, Az

Moderator:Bob Orzechowski MBA, SPHR, SHRM-SCP Lancaster Cancer Center, Pa

ØSummarize key points of comparison between medically integrated dispensaries of varying sizes and scope and how their workflows differ

ØIdentify elements of medically integrated dispensary workflow that can be improved by incorporating elements of other workflow models

ØIdentify key roles that ensure accountability and an efficient workflow

OBJECTIVES

CANCER SPECIALISTS OF NORTH FLORIDASarah Stadt, CPhT

• 8 sites in Jacksonville-area• Each site has at least 1 IV tech & all sites dispense oral medications • Central location has:

• 3 retail technicians • 1 intern (focuses on adherence calls)• 1 PA specialist • At least 2 pharmacists (total of 6 pharmacists including PRNs)

• Utilize Pioneer and OncoEMR• 37 prescribers • Approximately 130 scripts filled daily (including supportive meds)• ACHC accredited• Currently completing URAC application

CANCER SPECIALISTS OF NORTH FLORIDA GENERAL PRACTICE INFORMATION

• From 8am - 10:30am techs process, fill, and package a daily run to be sent to each site via courier

• We have 3 stations that techs rotate between weekly:1. Data station 2. Phone calls/emails3. Filling/mail

• The techs process every prescription filled on site or in the central pharmacy

• Each technician has an assigned inventory section and miscellaneous duties (ordering supplies, packaging controlled hardcopies, etc.)

• Every site has individual inventory responsibilities as well (newer process)

CANCER SPECIALISTS OF NORTH FLORIDA TECHNICIAN WORKFLOW

Start of Morning• Unpack delivery totes• Fill pending order items• Fill outstanding site orders and transfer • Place remaining drug on shelf• Fill any cooler orders• Print morning queue• Fill morning queue• Tag site sheets• Place bags in cubbies• Check the check queue (workflow - Rx

queue waiting for check in drop down)• Fill any remaining items due in check queue• Call out bags placed in bins

CANCER SPECIALISTS OF NORTH FLORIDA FILLING TECHNICIAN MORNING WORKFLOW

• Unpack any returned totes currently on hand

• Match up ALL c2 hardcopies with completed scripts (add scripts to totes)

• Make copies of site sheet• Place 1 sheet in tote and keep one• Close up totes, label, and zip tie• Take totes to front lobby (reception)• Provide reception with site counts • Scan labels into will-call bins• File away orders and site sheets• Return all drug bottles to shelf• Return any prescriptions in return totesMorning Run Complete

• All site orders pulled• Fast mover drugs refilled (i.e. Ondansetron, Emend, etc.) and double checked for need to order• Vials/tops refilled • Printer labels/paper refilled• Prescription bags refilled• Counters/trays wiped with alcohol (beginning and end of shift and as needed for dust and sulfa

drugs)• Empty prescriptions from basket into the site bins and sticker sheets (double check for

refrigerated items)• All bins unpacked• Coolers put away• Trash/boxes taken out• Lobby cleaned (counter, seating area, and credit card machine cleaned with Sani-Wipe)• Chemo pad changed • Other supplies refilled (i.e. paper towels, staples, soap, etc.)

CANCER SPECIALISTS OF NORTH FLORIDA FILLING TECHNICIAN END OF DAY DUTIES

CANCER SPECIALISTS OF NORTH FLORIDA STANDARD OPERATING PROCEDURES

Adding a New Patient Processing Prescriptions

• If rx was e-script, use the add (+) button within Pioneer to begin process

• If walk-in or fax, create patient profile before processing script

• The following must be added to patient profile in Pioneer, access G4 and EMR for information

1. SSN2. Allergies3. Site in Alternate ID Field

• Verify you have selected the correct patient

• Process the prescription ensuring you select the correct medication and strength

• Send prior authorizations to the PA specialist immediately to ensure it is done quickly

• If co-pay is more than $150, notify the patient to see if we need to put them in touch with a social worker

ARIZONA ONCOLOGYCarol Hemersbach, CPhT, BSHCA

• 12 MID sites across Arizona

• 8 out of 12 sites have 1 MID tech• Other 4 have 1 IV tech at each site that dispense oral medications

• We have 2 pharmacists (1 in Phoenix & 1 in Tucson) • Each site dispenses oral chemo meds as well as supportive meds

• Utilize IKM, IKM G2, and OncoEMR

• 61 prescribers

• ~ 36 scripts filled daily

• Participate in OCM

ARIZONA ONCOLOGY GENERAL PRACTICE INFORMATION

• Provider e-prescribes Rx to QS1• Rx reviewed by MID tech• Tech determines insurance and if able to fill• PQI review and supportive meds recommended to provider

1. Techs have PQI notebooks printed from NCODA website • Techs notify the provider of any recommended additional supportive meds needed

2. Provider (MD/NP/RN) complete chemo education and nurse navigators provide follow-up calls for OCM patients

• PA/FA completed by MID tech even if we are not able to fill (exception at some Phoenix sites where a separate person completes this step)

• Once PA/FA is obtained, MID tech will reprocess Rx to see what copay will be and explain to patient

• If not able to afford, tech seeks FA and then order drug for next day• Rx is voided and reprocessed when drug comes in

ARIZONA ONCOLOGYTECHNICIAN WORKFLOW

• Patient is notified Rx is ready• If needed we will ship to patient per PBM contractual requirements

• If Rx needs to be sent out, MID tech responsible for triaging out to proper pharmacy and patient notified

• Tech responsible for follow up and documentation in EMR

• End of day Rx picked up or shipped out need to be checked out of pharmacy software as posted

• If patient does not pick up, phone calls are made if not picked up in 2-3 days and also after 7 days

• If the Rx is not picked up after 7 days, the Rx is voided and drug returned to stock

• Track FedEx shipments next day and print signature from FedEx web site

ARIZONA ONCOLOGY TECHNICIAN WORKFLOW CONT.

• All medication orders submitted to supplier for next day delivery to site

• Supplies, paper, vials, label paper, bags, etc. refilled as needed

• Counter trays wiped down with alcohol after each use typically • We have 2 trays: one for chemo and one for supportive meds

• Post end of day pick ups/copays

ARIZONA ONCOLOGYFILLING TECHNICIAN END OF DAY DUTIES

• Float techs needed • Additional MID techs for busier sites• Too many EMR systems in the Phoenix-area which causes additional

training and confusion with documentation • Numerous wholesalers

• We currently have 3 wholesalers who we order from depending on pricing or rebate opportunities

• More space for techs to work out of• Capture rate

• Refill leakage via MA’s and RN’s

• Clinical improvements and documentation

ARIZONA ONCOLOGYWORKFLOW IMPROVEMENTS

Adding a New Patient• If Rx was e-scribed

• Double click on patient in queue• Then click new to begin adding patient to QS1

• If walk-in or fax• Create patient profile before processing script

• The following must be added to patient profile in QS1, access Centricity and IMK, IMK G2, or OncoEMR to obtain the following:

1. SSN (if applicable)2. Allergies3. Diagnosis4. Insurance information5. MRN

ARIZONA ONCOLOGYSTANDARD OPERATING PROCEDURES

Processing prescriptions• Verify you have selected the correct patient• Process the prescription ensuring you select the correct med and strength

• Some sites verify last progress note to verify patient is to continue medication

• Complete prior authorizations immediately and notify patient of possible delay

• Notify patient of copay to see if they are able to afford • If not, seek financial assistance through foundations or manufacture

ARIZONA ONCOLOGY STANDARD OPERATING PROCEDURES CONT.

• The roles and responsibilities vary from site to site • Our sites function differently per direction of the provider• The primary role is to process oral oncology medications and their

supportive care meds, increasing the ability to procure oral oncoloytics for cancer patients

• The MID tech should be able to accomplish the goals in the workflow process

• Efficient workflow1. Oral oncology knowledge2. Financial assistance knowledge3. Prior authorization knowledge (the ability to answer PA questions by utilizing the patients

record in the EMR)4. Multitasking5. Ability to be empathetic to patients with cancer

ARIZONA ONCOLOGY KEY ROLES/RESPONSIBILITIES

LANCASTER CANCER CENTERJulie Wolfe

• 40 years of serving patients• 2 physicians (1 MD & 1 DO)• 3 large health systems in Lancaster-area

• LCC is only private independent oncology practice in the area

• Dispensary has been around for 8+ years• 2 full time and 1 part time technician

• Onsite CLIA high complexity certified lab• Infusion room with ISO certified ante room

LANCASTER CANCER CENTER SOP/WORKFLOW BASICS

LANCASTER CANCER CENTER WORKFLOW PROCESS

Technician responsibilities• Once the Rx is written by the physician, the technician runs the scripts to learn if we can dispense the drug

• If it is a new patient, all demographics, insurance, and allergy info is entered into our pharmacy management software

Prior Authorization Specialist• If PA is denied, the prior authorization specialist appeals the decision and pursues a peer-to-peer in an attempt to get the drug covered

• The prior authorization specialist alerts the technician(s) at every decision tree branch

• Once approved, the Rx returns to the technician and the Rx is re-run• Route 1 = Using in-house pharmacy

• Check patient’s co-pay• The financial counselor researches availability of any assistance

• Route 2 = Sent to specialty pharmacy (SP)• If to SP, our RN sends the Rx electronically• Onco EMR reveals a successful transmission• Technician then voids our in-house Rx

• After either of these routes• The patient is contacted by the technician and scheduled for oral chemo teaching• RN teaches patient and then the drug is dispensed if possible, or we give the patient the telephone # to the SP• After the drug is dispensed or received by the patient at their home, the RN initiates contact with the patient regularly and documents every encounter in our EMR

• Patient is scheduled for F/U appointment as appropriate

LANCASTER CANCER CENTER ROLES AND RESPONSIBILITIES

1. Human Resources – Work environment expectations, general admin (ACHC standard - STD-DRX4-2H)

2. Regulatory Compliance – HIPAA, infectious and communicable diseases, compliance program

3. Patient Care and Services – Clinical, fiscal, communication and counseling, documentation of care

4. Practice Operations – Prescription delivery services, supply management, equipment maintenance and cleaning

5. Controlled Substances

6. Business Continuity – Continuity and recovery (ACHC standard - STD-DRX7-4C)

7. General and Administrative - Record retention, safety, OSHA

8. Quality Assurance and Performance Improvement – Patient satisfaction, performance committee roles, monitor quality & performance, improvement goals and plans, plan implementation (ACHC standard - STD-DRX6-3C)

LANCASTER CANCER CENTER SOP TABLE OF CONTENTS

• Oral chemo adherence flow sheet built into OncoEMR• Schedule teaching in EMR after drug approved• 2 nurses check chemo Rx before dispensed• Dispensing staff documents every oral chemo pickup• Phone calls made to patients regularly (new starts and existing patients)

JULIE WOLFE IMPROVING ADHERENCE MEASURES

COMPARISONCANCER SPECIALISTS OF

NORTH FLORIDA(SARAH)

ARIZONA ONCOLOGY (CAROL)

LANCASTER CANCER CENTER (JULIE)

OCM PRACTICE X X X

FINANCIAL ASSISTANCE X X X

PRIOR AUTH DONE ON SITE X X X

QS1 SOFTWARE X X

KNOWLEDGE OF ORAL ONCOLYTICS AND SUPPORTIVE CARE DRUGS

X X X

SHIP MEDICATIONS X X

PHARMACIST X X

SINGLE SITE X

IV TECH AND PHARM TECH X X

FILL CONTROLLED SUBSTANCES

X X

THANK YOU!QUESTIONS?