The average physician receives 10 to 25 prescription refill requests per day, contributing to the growing administrative burden placed on doctors. This reduces time with patients and can cause burnout — especially in a safety net comprised of resource-constrained, understaffed institutions. In the post-Medicaid expansion era, safety-net providers could help alleviate this burden, expand capacity, and make care more timely and efficient by using automated tools.
Enter healthfinch, a Madison, Wisconsin-based technology company named for the family of birds that led Charles Darwin to formulate the principles of the theory of evolution. The company designed a practice automation platform — colorfully named “Charlie” — to make each refill faster and easier and to delegate elements of the process to other clinical staff. Processing refills is an ideal task for automation because it consists of repeatable steps: monitoring recent lab values, checking for duplicate requests, and reviewing a patient’s other active medications for contraindications. Charlie runs each request through those steps and applies hundreds of evidence-based protocols to flag items requiring further review. The platform also has a feature, known as “care gaps functionality,” that identifies overdue and upcoming lab tests and office visits. By the time the refill request lands in the queue of a nurse, medical assistant, or physician for approval, much of the preorder work has been completed, and follow-up actions are clearly identified. Streamlining workflows can save health care providers valuable time so they can focus on patient care.
Assessing the Impact at Two Health Centers
I am an independent evaluation consultant, and CHCF asked me to evaluate the effectiveness of Charlie in safety-net settings. With support from CHCF, healthfinch and I collaborated with two Federally Qualified Health Centers, Alliance Medical Center (AMC) in Sonoma County and QueensCare Health Centers (QHC) in Los Angeles County. About two-thirds of their patient populations are Medi-Cal beneficiaries, and each center uses a cloud-based version of the Epic electronic health record (EHR) system supported and hosted by OCHIN, a nonprofit health IT provider.
The two sites had different goals and priorities, which was evident in their baseline efficiency metrics, protocols for refill staffing, and the volume and complexity of their refill burdens. At AMC, nurses complete most refills, and the staff focused on improving relevant efficiency metrics. The staff of clinical pharmacists at QHC had a different goal for Charlie — to increase standardization of refill protocols and processes.
Both health centers saw positive changes, including more refills completed the same day, a larger share of refills filled by non-physicians, and more provider hours saved by delegation of tasks. Both also experienced high provider and staff satisfaction with Charlie, successful implementation of both medication protocols and standardized workflows, and better refill authorization decisions.
“For clinics like us, which experience challenges with refills, Charlie has been a great tool and product,” said a registered nurse at AMC. “Sometimes the numbers may not reflect it, but from a workflow and patient safety perspective, it’s a whole different ball game.” A clinical pharmacist said that healthfinch allowed her staff to “trust the system a bit more.”
Four Key Implementation Lessons
This evaluation offered us the chance to closely observe a technology implementation process from start to finish and to learn broader lessons for safety-net providers implementing technology solutions. Although the Charlie evaluation sites were clinics, these findings apply to other care settings.
Customization is key. Healthfinch allowed the clinics to customize their refill protocols. For example, they could set default refill quantities or determine which medications are eligible for refill by non-providers — choices that reflected their staff capacities, patient populations, and organizational cultures. QHC delegates refills to its clinical pharmacists, while AMC sends a greater percentage of refills back to the prescriber to be completed. Takeaway: To increase the likelihood of adoption by staff, look for solutions that can be customized to accommodate existing workflows and staffing structures, rather than the other way around.
Not every product works for every patient. Charlie generally worked well at both clinics. However, for care of medically complex patients — a level of intensity that does not fit neatly into Charlie’s automated protocols — staff must do manual chart review before authorizing refills. To take full advantage of Charlie’s ability to identify overdue and upcoming lab tests and office visits, clinics need the help of sufficient staff, such as care coordinators who can schedule needed services. Moreover, Charlie’s ability to spot care gaps can be effective only if those patients follow recommendations and show up for scheduled services. Takeaway: When using a tech solution, apply a realistic understanding of how your patient mix may affect its performance and impact.
Value is in the eye of the beholder. Any solution within Charlie may add greater value for one clinic and less value for another. Before Charlie, 80% of QHC prescriptions were filled by non-physician providers, mostly clinical pharmacists. For them, Charlie served to enhance efficiency and evidence-based consistency in the refill process. At AMC, where the emphasis was on boosting the percentage of same-day and non-physician refills, Charlie increased same-day refills by 11 percentage points and delegated refills by four percentage points. Takeaway: At the start, determine how a given solution can add the most value and then ensure the vendor is measuring data and reporting back against those goals.
High-tech solutions require high-touch support. Both health centers benefited from in-person training and support from healthfinch and from assigning internal champions to oversee implementation. Healthfinch staff focused on helping clinics adjust to workflow changes, which can generate resistance. Healthfinch helps clients dig into quality metrics, and it offers ongoing support for changing refill needs, such as protocol adjustments. Takeaway: Empower champions within the provider organization to advocate for solutions to problems and make sure they are implemented. Vendors should be vetted for their ability to provide effective support over the long haul as the facility’s needs evolve and team members change.
Safety-net providers can make good use of this type of technology. Our evaluation of the two clinics documented clinical efficiency improvements across various refill management measures as well as better ongoing experiences for Charlie users. We also documented positive trends and feedback from staff about Charlie’s features that address care gaps. These have the potential to streamline patient care.
Charlie’s success with these two health centers required strong staff commitment to the product, clear and measurable goals, and a willingness to standardize workflows and protocols. If they follow these lessons, other safety-net providers are likely to achieve success when using similar platforms.
Seth Emont is a research and evaluation consultant and principal of White Mountain Research Associates in Walpole, New Hampshire. With over 30 years of experience in the field, Seth has led evaluation efforts that span across innovation in health and health care delivery, clinical quality improvement, social networks, human capital, self-management support, patient- and family-centered care, advocacy and policy change, community health, childhood obesity, end-of-life care, tobacco control, substance use, and eHealth.
Previously, Seth was a senior program officer in the research & evaluation division of the Robert Wood Johnson Foundation in Princeton, NJ. He received a PhD in epidemiology from the State University of New York at Buffalo, a master’s degree in psychology from Bucknell University, and a bachelor’s degree in natural sciences from Michigan State University.