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By G. Cameron Deemer
Twenty years ago, pharmacy accidentally shot itself in the foot and made it almost impossible for pharmacists to take their place as deeply collaborating members of the patient care team.
The irony is that this mistake came on the heels of a tremendous success. By the early ’90s, the pharmacy claims process was efficiently digitized. Claims were flowing electronically between pharmacies and PBMs, adjudicated instantly, and results were delivered in seconds to the store. No more paper! The claims networks were highly standardized, making it simple for new entrants in the market to design and certify systems.
By the early ’00s the major PBMs were emboldened to turn the same technology infrastructure into a network for the digitization of the prescription process. And this is where the problem started.
The pharmacy associations were rightly alarmed that they were not leading this initiative; they saw PBM involvement as disintermediating the pharmacist’s relationship with the doctor. In reaction, they also created a digital prescription network. But the real issue wasn’t disintermediation, it was the assumptions underlying the design of the network.
The Clarity of Hindsight
Our collective error was applying the same toolset to prescription delivery that made claims processing such a success. It seemed like the right solution in 2001. At that time, prescriptions were paper based (like claims in the early days), there was a many-to-many problem (just like claims), and unreliable manual delivery and illegible handwriting were key issues (also similar to claims). All those factors led to the obvious conclusion that a claims network would serve well as a prescription network.
But a prescription is not a claim.
- Financial vs. Clinical: A drug claim is a financial instrument, an accounting tool, a request for payment per the terms of a contract between a pharmacy and a PBM, and a promise to pay. A prescription is a clinical order created by a highly trained clinician on behalf of a patient and delivered for fulfillment to another highly skilled clinician.
- Transactional vs. Collaborative: A drug claim is a transaction between two parties (a pharmacy seeking payment and a PBM managing a contract). A prescription is a collaboration of three or more parties (a patient seeking care, a provider who creates the order, a pharmacist who acts on the order, and, in most cases, a payer that establishes payment criteria). It can also involve others (i.e., a specialty drug hub, a case manager, a pharma, or philanthropic organization assisting with payment).
- Simple vs. Complex: A claim is simple, a set of data governed by a contract with a mathematical outcome. A prescription is as complex as the individuality of patients, as complex as the stunning array of conditions from which they suffer, and as complex as the varying methodologies of care teams—infinitely complex.
Treating an electronic prescription as though it were a claim—a paper document to be digitized and handed off from one person to another—effectively limits the pharmacist to acting without clinical context, without collaboration, even without the systems involved recognizing that workflows differ for different drugs. We can do better.
Enabling the pharmacist
The e-prescribing network in place today has had a good run, but it was built on faulty assumptions. It solved for the simple task of sending a message from here to there, but pharmacists need far more than a copy of the script to fully work at the top of their license.
Innovation is coming, however, and I’m encouraged to see industry leaders and state governments pushing for change. For example, California created regulations making it easier for more forward-thinking networks to begin serving pharmacies and prescribers.
Industry is also responding. DrFirst, where I am CEO, operates a platform for sharing vital clinical context, orchestrating inefficient workflows, managing complex processes (like specialty drug ordering and fulfillment), eliminating fraudulent prescriptions, and fostering innovative new collaboration.
Pharmacy deserves a prescription network that enables dedicated, skilled, and knowledgeable clinicians, whether remote or local, to collaboratively apply their minds to each patient’s health conditions and the steps needed to move those patients toward positive outcomes. Two decades ago, we built the network wrong. Now, let’s build it right.
G. Cameron Deemer is CEO of health technology pioneer DrFirst, which developed the first certified solution for electronic prescribing of controlled substances (EPCS). He has worked with electronic prescribing for 32 years, was an original co-chair for the development of the NCPDP SCRIPT standard, was present at the founding of RxHub, helped develop the network that became Surescripts, and has built many of the innovations in this space through 20 years with his colleagues at DrFirst.
