038-05A Streamlining DPH Prescription Process
LEGISLATIVE ANALYST MEMORANDUM
To: Members of the Board of Supervisors
From: Andrew Murray, Office of the Legislative Analyst
Date: May 12, 2005
Re: Employee Suggestion - Streamline Department of Public Health Patient Prescription Ordering, Pick Up, and Payment (OLA#: 038-05A)
Employee Suggestion
As part of the 2005 Board of Supervisors Employee Suggestion Program, an employee advised that patients at San Francisco General Hospital (SFGH) currently must wait in three lines to drop off, pay for, and pick up prescriptions. The employee suggested that the hospital consider implementing a system in which the physician orders the patient’s medication online and the patient pays and picks up the medication in a single line.
Executive Summary
The SFGH pharmacy currently serves approximately 4,300 patients per month, who must typically wait between 2.5 and 4.5 hours to drop off prescriptions and pick them up. This system requires waiting in either two or three lines. There are opportunities to streamline this process to reduce wait times and to improve the customer experience. Whether the benefits of implementing changes outweigh the costs is a policy matter for the Board of Supervisors.
Analysis
Current Process
According to Community Health Network (CHN) Administrator for Pharmacy Services Dr. Sharon Kotabe, roughly 30% (1,300) of the approximately 4,300 patients the pharmacy serves each month have a co-payment requirement. These patients must wait in three lines for prescriptions, one each to order, pay for, and pick up the prescription. The line to pay for the prescription is in a different part of the hospital than the pharmacy. Those that do not have a co-payment requirement must wait in two lines, one to order the prescription and another to pick it up. The typical wait time between when the prescription is ordered and is ready for pick up is two to four hours. The typical total time required to drop off a prescription, make a co-payment (if required), and finally pick up the prescription is 2.5 to 4.5 hours.
Dr. Kotabe notes that most retail pharmacies require two lines. However, the author of the suggestion notes that Kaiser pharmacies have just one line, to pick up and pay for the prescription, because doctors order the prescription online immediately after seeing the patient.
The Department of Public Health has proposed an expansion of co-payment requirements in its FY2005-06 budget that, if adopted, would require 4,000 of the patients the pharmacy serves each month (all patients except those on General Assistance and the homeless) to make co-payments. As such, all 4,000 would be required to wait in the three lines described above, a substantial increase over the 1,300 currently required to wait in three lines.
It should be noted that the need to wait in the co-payment line does not itself increase the total elapsed time from prescription drop off to pick up. The "rate limiting step" between drop off and pick up is the prescription filling process. Nonetheless, shortening or eliminating the co-payment line would benefit patients as it would provide some flexibility in how they spend the time required for prescription filling.
Streamlining Opportunities
Dr. Kotabe identified a number of ways in which SFGH could improve the current pharmacy customer experience. These include:
- Adding a cashier to the outpatient lobby near the pharmacy so that those needing to make co-payments would not have to go to a different part of the hospital;
- Automating the prescription filling process to shorten the time required to fill prescriptions;
- Deploying "navigators" in the outpatient lobby to help direct patients; and
- Adding security to the outpatient lobby, which would enable the front door to be opened, reducing congestion.
In addition, the employee that submitted the suggestion identified the following two opportunities to streamline the process:
- Implementing a system by which doctors could order prescriptions online; and
- Combining the co-payment line and the pick up line into one.
SFGH has already conducted research and planning regarding the implementation of some of these measures. If the proposal to expand co-payment goes through with the FY2005-06 budget, SFGH will add cashiers, although not in the outpatient lobby area. The hospital made some headway in procuring prescription filling automation equipment in FY2004-05, and will try to finalize that process this coming fiscal year. No effort has been made to use navigators, although a patient referral department used to provide a similar service but was eliminated in FY2004-05. Adding security to the outpatient lobby is a high priority, although there are no resources proposed for this in the upcoming fiscal year. There is no plan to implement an online prescription ordering system for outpatient orders, although an inpatient system is planned to be operational by 2008. Depending on the success of that system, it might be possible to modify it for outpatient ordering. Combining the co-payment and pick up lines would require major structural and operational modifications, so it is currently not an option under consideration.
According to Dr. Kotabe, the options above would require the expenditures and result in reduced wait time for patients as illustrated in Table 1, below.
Table 1.Options for Streamlining SFGH Prescription Ordering and Pick Up to Reduce Patient Wait Times | |||
|---|---|---|---|
Option | Required for Implementation | Required Expenditures | Time Savings |
Adding cashier office in the outpatient lobby | Addition of cashier staff and remodel of lobby area | $115,000/year for additional cashiers and $250,000 remodel fees and construction costs | 15 - 30 minutes fewer in line |
Prescription filling automation | Purchase of equipment and remodel of pharmacy | $400,000 equipment cost and $150,000 remodel fees and construction costs | 30 - 45 minutes fewer filling time |
Deploying "navigators" | Addition of staff | $115,000/year for navigator staff | N/A |
Adding security | Addition of security staff | $250,000 for additional security staff | N/A |
Online prescription ordering | Purchase or development of software and additional hardware for physician office areas. Staff to maintain | Estimated $800,000 to $1,200,00 for software, $500,000 for hardware, and $250,000/year for maintenance staff | 25 – 40 minutes fewer in line and an additional 20 minutes fewer filling time |
Combining co-payment and pick up lines | Not feasible without major modifications to physical pharmacy space | N/A | N/A |
Recommendation
The Office of the Legislative Analyst recommends that the Board of Supervisors consider the benefits and costs of implementing streamlining modifications and direct SFGH to implement those the Board deems appropriate.