How can the pharmacist-at-intake workflow model set you free?
Photo: Carlene Oleksyn
This article was also published in Canadian Health Network
Busting burnout, finding the time for better care and making more money
In the 30 years I’ve worked as a pharmacy owner and as a process analyst/ designer advising independent and corporate pharmacies around the world, the pharmacist-at-intake workflow is the most transformative single advancement I have witnessed.
It creates the capacity for any pharmacy to run a healthy post-pandemic workplace and successfully expand scope, implement new clinical support software, and offer pharmacist-led services at the scale that our country’s overwhelmed primary care system needs.
To be clear, I have no authorship, just awe for this model. My colleagues Chris Juozaitis, co-owner/manager of Howe Sound Pharmacy in Gibsons, BC, together with his partner at the time, and Carlene Oleksyn, owner/manager of Mint Meridian Pharmacy in Stony Plain, AB, came up with the idea separately. Each will tell you they reversed their workflow to put pharmacists at intake simply to spend more time with patients. I can confirm it does that, and more.
The pharmacist-at-intake, also called “P-First” (P1st) workflow, puts pharmacists at seated semi-private intake desks, including a patient chair, and reassigns all tasks that don’t require a pharmacist’s licence to other staff. Time-consuming data entry, insurance adjudication, dispensing, compounding, final package checks and inventory management are not part of a pharmacist’s role in this workflow (just as surgeons don’t mop blood off the operating room floor or organize instruments). Carlene is quick to emphasize teamwork drives this model. Staff have clear roles and receive the training they need to do them. RPhTs work at full scope including all final package checking. The work flows in one direction, and most issues are caught before the wrong medication is packaged and labeled. When combined with prescription synchronization, three minutes of staff time is saved for every refill, inventory is more predictable, and balances-owing are all but eliminated.
Time and motion research shows that the average pharmacist spends only four minutes per hour doing tasks that require a pharmacist’s license (33 minutes per 8 hour shift) .
Pharmacist-at-Intake liberates the other 56 minutes of every hour for every pharmacist, every day to do what ONLY they are qualified to do. It makes pharmacies with regulated techs more efficient – up to a 16X workforce multiplier with no increase in wage costs. No other process increases workforce capacity on this scale. (Almost half that capacity-boost can be captured even before you hire your first RPhT). It doesn’t require software, significant capital expenditures, or permission from regulators, associations or governments.
It just requires pharmacy leaders to make the decision.
That’s what Carlene and Chris did. After more than a decade of working this way, stores have enjoyed above average staff retention and their teams report they are genuinely fulfilled and feel more resilient to stress and burnout than when they worked in the traditional model. Both pharmacies have been consistently profitable despite the emphasis on well-staffed high-touch, patient-facing medication management. I’ll describe the economic mechanics of the workflow later in this article. One of the pharmacies is open 9 to 6, with one evening and a half day on Saturdays. The other is open 9 to 5:30, closed weekends and holidays. Professional visitors often remark at how peaceful each place feels, especially when they learn the volume of prescriptions, assessments and services that are being provided every day. Chris is fond of warning that there are no unicorns and rainbows here. Carlene agrees and says everyone works hard, days are full, surprises happen, but the P1st workflow gives them the time to stay healthy and enjoy their jobs most days.
Both pharmacies use the time created by P1st to give each general pharmacy patient the time they need for proactive care plans, gentle adherence interventions and to give staff time for regular breaks, meals and to absorb the inevitable disruptions from sick leave, vacations and parental leave. It also allows staff members to specialize their practices. Carlene teaches, does research, speaks widely, and enjoys a large, successful travel pharmacy practice. Chris’s team has used it to send pharmacists off-site to visit addictions and renal clinics and LTC facilities. And both pharmacies have steadily grown in Rx count and bottom-line profit despite competition, generic drug price cuts and other external pressures.
Special note – pharmacist-at-intake is not the same as the pharmacist-led clinic or appointment-based models with pharmacists providing care in an office setting. Chris and Carlene’s teams take treatment room appointments all day too, but there is no substitute for pharmacists to be accessible at intake, after they have completed the clinical check and handed the approved prescription to a pharmacy assistant for data entry and dispensing.
The UBC PhINDMORE study of 2,732 Howe Sound Pharmacy patients, published in CPJ in 2014, identified 47% of the 4,019 documented medication management encounters captured by pharmacists at intake, needed additional therapy. These unmet needs would likely have gone undiscovered in the old workflow or even in an appointment scheduled for a specific complaint. And, as patients come to know they always have informal access to their pharmacist, trusting relationships deepen one visit at a time, and drug therapy problems get resolved at the patient’s pace.
A bit on the economic mechanics of the P1st workflow: Current pharmacy service fees generated by a pharmacist working full-time at full scope easily cover any extra labour costs to hire registered techs at the same wage hospitals pay with profit to spare (and the RPhT often gets to save union dues and parking charges). Then doing our job using evidence-based pharmacist-led adherence interventions saves lives and suffering and generates massive, incremental revenue from refilling the other half of all chronic prescriptions that are already written for our existing patients but not refilled (read the literature). For every 100 Rxs you currently fill, there is a potential of 75 additional refills from the same patients. Do the math at say 30% GP for a full year. My colleague Dr. Kevin Walker at The Med List characterized that as “having all the signed cheques in my hand, but only cashing half of them!” (Check out The Med List podcast with Chris and me discussing P1st with Kevin and his partner professor Donna Bartlett)
Try this self-assessment. Estimate the average hours & minutes a staff pharmacist spends during a typical eight-hour shift on these six tasks:
- data entry
- insurance adjudication
- dispensing
- compounding
- final package checking and
- inventory management
How much time do you have left in the day to do tasks that require a pharmacist’s licence?
Chris puts it simply:
“Our workflow was stuck in the 1970s. Just putting some desks and chairs out front, along with clear job descriptions for our pharmacy assistants and registered pharmacy technicians allows our pharmacists and me to practice at the top of our licences every day. We all enjoy more personal satisfaction and my business profitability has increased exponentially. We are a group of ordinary pharmacy professionals thriving in an extraordinary system.”
Some comments:
Ray Arseneau
It is very interesting. Jim Danahy, this design was the subject of the first ever pharmacy practice award that was awarded in the early 90’s in Ontario, subsequently improved upon in another pharmacy but fundamentally based on the French model after a 1986 trip to Paris, a Paris, a pharmacist must be the first to interact with all clients/patients. It is surprising what this type of layout will achieve in patient care and allow multiple levels of discretion and if a bank style roping system and waiting area is developed it becomes like a small clinic office. Glad to hear others have come up with it on their own, but not all are receptive. great stuff
Jim Danahy
Thanks so much for this Ray. Very exciting to hear about the origins. I would love to learn more. Were you involved and/or can you point me to records of the two pioneering Ontario pharmacies you mentioned and which organization presented the practice award in the early 90’s? Also, I can’t seem to find examples or citations of pharmacists at seated intakes or literature on the workflow in France. Are you able to direct me to a source please? Thanks so much! Jim
Kimberley Kallio
I visited a pharmacy in the Kallio district of Helsinki and they took it a step further with all processing on another floor and the pharmacists interacting with patients at pods throughout the space. It was awesome!
Jim Danahy
Fantastic Kimberly! Did you take any photos and would you be willing to share contact information or name of that pharmacy?
Kimberley Kallio
I actually still have the brochure! I can take pics and send to you. Email me!
Robert Rosenblatt
…the P First may be the first step…but the next step will be AI First…yes AI WILL replace the intake Pharmacist without a doubt…the cost savings will be gigantic, plus AI will be just so much more effective in minor analysis…then business , thru technology, will eliminate the Licensed Pharmacy Tech…( and then we will also see the demise of the most unhealthy BULK tablet bottles )..then, thru technology, a Patient need never come into a Pharmacy again…all delivered by self driving cars or drones…. …what will arise as a byproduct may well be specialized NARC dispensaries, catering to the ‘pain’ Patient…all because laws governing control of analgesics will remain stringent…but you can be assured big box stores and corps will not want anything to do with this type of business… …AI will become economically realistic, so every small Pharmacy owner will be early adapters…and thru attrition Pharmacists will disappear from the dispensary… ..Colleges are just arms of business and government, so will pose no obstacle in passing laws governing AI… …PBMs , and Big Boxes and health Insurance conglomerates will rush to take advantage of this niche market …so what will happen when you open your Pharmacy App , will be that of your choice, a beautiful Woman or a handsome grey haired Man who ultimately be the PFirst face of the Dispensary…
Jim Danahy
Robert, Is a pharmacist who engages with every patient at intake and no longer wastes time doing tasks that don’t require a pharmacist’s license, any more susceptible to misuses of new technologies than a pharmacist who chooses to stand at the back of the dispensary toiling in the objectively inferior orthodox pharmacy workflow? As one physician said recently, AI won’t replace healthcare professionals but healthcare professionals who use it will replace those who don’t.
Robert Rosenblatt
…JD…you pose a rhetorical question which I can not answer… …but, in your article , you make an interesting observation that the intake Pharmacist interaction is different than the appointment based private consultation…mutually exclusive? …so then I ask “what is the difference “…
Jim Danahy
Thanks for an astute question Robert. Difference between P1st & appointment model 1) Of course a pharmacist at intake has the option to move into a treatment room for a spontaneous appointment for more privacy, treatment etc 2) The main difference is that in P1st, 100% of incoming patients (including phone,IVR and online refills), have the opportunity to identify additional needs without the time pressure of appointment slots. The pharmacist has both time and opportunity to lean-in while each patient is still seated with them, after the clinical check is done and the Rx is handed off to staff for data entry, adjudication, dispensing and final checking. We know from the literature and billing data that relatively few appointments address multiple complaints. By contrast, the UBC PhINDMORE Study published in CPJ July 2014, that of the 4,000 drug therapy problems that pharmacists seated at intake chose to document, 47% identified additional conditions that needed therapy after the incoming Rx was handed off for filling. So P1st does everything ABM can do and significantly more without the inefficiencies of appointments. And from our team’s observations over 12 years, patients are noticeably more spontaneous and relaxed at intake than in treatment rooms and, we’ve seen they also aren’t shy to ask for appointments when needed. Both patients and staff love it. Thanks for a good question Robert. I hope this was useful.
Robert Rosenblatt
…JD…there is a dichotomy in perspective to my mind with the definition of a Pharmacist…to be sure Pharmacist First , is a tremendous innovation…and your answer superbly addresses the benefits…and I hope the future of the independent Pharmacy’s incorporate this across the board.( but economics will dictate this eventuality)…and as a matter of fact, this shift in focus will be initially enhanced when government empowers Licensed Pharmacy Technicians to sign scripts , so then the Pharmacist First ‘position’ becomes a full time non dispensing function…but , which you are going to say to me ‘it already is “…which comes back to where my point resides…Pharmacy is not synonymous with Pharmacists…as such, assuredly the eventual emphasis will be upon exclusively staffing ‘dispensaries’ with less expensive LPTs…and at that time, each business, will have to rationalize whether the Pharmacist First model can financially ‘ stand alone ‘…in other words, ‘why hire a Pharmacist , when dispensing is the main function ‘…so then the question is how do you make a Pharmacist position , whatever it be , itself financially viable to be relevant…and that eludes to the future of Pharmacy…because , albeit cynical, AI will without a doubt replace a ‘PharmacistFirst’ Pharmacist, or certainly redundant …especially if the focus is simply on drugs…but AI will never replace a medical healthcare Specialist on disease management because ‘people are different’…AI without a doubt can instantly regurgitate every single medical healthcare ‘dot’…but only a trained Disease Management professional can connect these ‘dots’…my point is ‘where in the process’… …so , as far as PharmDs go, are they Healthcare professionals, that in part utilize medicine in their approach to disease management? or are they basically a dispenser of medicine , and subsequent medical information that revolves around prescription medicines?…and that , to my view is the difference in perspective of a Pharmacist First ( ie rx meds )…where clients come in whenever , but specifically for rx drugs , and can get further healthcare information…or , a HealthFirst Appointment/Walkin Wellness Clinic , where disease management is the priority and drug therapy is just an adjunct… …we already see new billing reimbursements for cognitive services with increased scope of practice with minor ailments ( and sure shooting soon major ailments like asthma etc )… …so as of now, the PharmacistFirst is an exceptionally valuable tool , and probably will remain so for many years…but ultimately will be displaced by less expensive and more readily available dispensing Techs…leading to a relatively sole option of becoming a HealthFirst Disease Management Specialists… PS…to get to the future, there has to be a seismic change at the Faculties of Pharmacy, otherwise, there will be no future when 2 out of 10 grads get jobs…but that is a story that is for another philosophical discussion amongst ourselves…
Zach Stevens
As a 23 year employee and 16 year Pharmacy Manager of London Drugs, it’s too bad to see us omitted here. We’ve used consultation booths with pharmacists as first contact for the majority of our stores for over 25 years-a system that I’ve always found works very well, allowing us to maximize clinical services, maximize privacy, and identify issues immediately before the patient walks away. I’ve had the pleasure of visiting howe sound pharmacy and did find that they have taken this workflow model to the next step by further separating the consultation area from the dispensing area.
Robert Rosenblatt
Zach Stevens….i worked LD at the north West corner of Georgia and Granville in 1965…the ‘on the street level’ store was so small that new Rx’s were sent from the cash register upstairs via a vacuum tube…where the Pharmacist up there could easily drink his daily allotment of Cheracol without anyone noticing…so here was the very first separation of the consultation area from the dispensary…kind of trivia…then by 74 there was an underground mall at G&G…and this was the where the dispensary was first reset back from the front counter, to my recollection …I loved it..no customer could ever toss a paper airplane script that far…then ultimately LD opened street level on the south east corner, for the benefit of rioters and those looking for the 5 finger discount… …but LD is a corporate store that for decades has taken their responsibility as a HealthCare provider in an honest manner…but basically when it’s a franchise concept , it’s all about working the employees to the bone… …but Zach, it’s only a matter of time now before a Pharmacist never ever walks into a dispensary again…tell me , how many times did a Patient say to you “you know more than my doctor”…well it’s time for all the new grads to toss the spatula and counting tray and become a total healthcare provider…
Jim Danahy
Love that story Robert! The LD store at W Georgia & Granville is one of the locations where I’ve seen pharmacists practice P1st. Thing is, it can’t be an individual RPh’s prerogative. It is much more dependent on teamwork SOPs than the orthodox workflow. And after all, it is really just hospital pharmacy + a triage desk dropped into community settings.
Jim Danahy
Excellent point about LD Zach! Indeed, London Drugs was a pioneer in building out seated intakes, and I’ve witnessed and experienced pharmacists at London Drugs giving exemplary patient-facing care. I didn’t include them for two reasons, first I don’t have their data, and second, the wonderful and incredibly humble executive who built the LD met with Chris and me and confided that the company built the furniture but never changed the company’s standard of workflow to remove data entry , adjudication, dispensing, compounding, package checking and inventory management from every pharmacist’s job description for ever — so it became optional.
No pharmacist at either of the case study pharmacies has entered data or touched a pill in over a decade.
