How things are changing !

Years ago.. back in the ’80’s.. I was one of 5-6 national moderator of a Pharmacy Bulletin Board called Helix.. I think that it was sponsored by Glaxo.. and it was based out of the St Louis College of Pharmacy.. This is back when we were dealing with state of the art 14.4 or 28.8 dial up modems.. that is how long ago it was.. Glaxo brought the national moderators and a small group of others in pharmacy to St Louis for a weekend “think tank”. At that think tank, I was befriended by a professor at U of KY and in talking to him.. he asked that I put in writing where I though pharmacy/medicine was going.. below – FUTURE MEDICAL CARE  – is what I came up with…  that was maybe 25  +/- yrs ago.  At that time.. not all pharmacies had computers… cell phones weighed POUNDS and were in cases.. referred to as a “football”.. dial up modems may have gotten up to 96K baud… but could have been only 56k baud.. I remember buying a “state of the art ” 96K baud modem for $1000…  cable TV was for those “out in the country” that were too far from major cities to get “over-the-air” signal.. the word “internet” was only known/used to/by techie types.. there were no “blogs”… there was no GOOGLE .. as compared to today.. we were in a technology “stone age”… Today I ran across this article in DRUG STORE NEWS.. which reminded me of this article that I had written.. and this “clinic on the spot” may be step before we get to what I had foreseen 25 + yrs ago… by the patient doing it in their home.. using what is commonly known today as SKYPE

http://www.drugstorenews.com/article/cleveland-clinic-healthspot-expand-healthcare-access-walk-kiosks?

SRAcrystalballFuture Medical Care ?

The year is 2005 and as John Smith awakens one morning, during the night the nuisance cough that he had the day before has developed into much worse symptoms. To find a treatment for his condition he goes to one of the cable video/keyboard outlets in his home. In the year 2000, the cable, television, telephone and Internet superhighway merged into one common communication source.

John logs onto the HealthNet diagnostic system. This system was mandated under OBRA ‘99 which required that all medical care be provided by health care cooperatives (HCC) under a capitate payment system. Congress deemed that this would get our medical system away from its preoccupation of managing costs to promoting wellness and truly trying to manage care and focus on positive medical outcomes. This legislation also mandated universal coverage so that no one could be denied coverage. This universal coverage was paid for by a complex set of rules combining employer mandatory contributions and payroll taxes. Medicare and Medicaid have been merged into the universal program. To maintain some sort of competitive, OBRA ‘99 mandated that at least two HCC’s in each county or designated area containing at least 50,000 people.

John willingly uses the automated system because his HCC provides financial incentives to do so. All of John’s medical history is stored on a national data base which documents all medical incidents and all therapies prescribed. This national database came on-line in 2002 after being mandated by OBRA ‘99. The next phase is scheduled to come on-line in 2008 when everyone will have a medical I.D. card which will duplicate the patient’s medical records on a credit care size “smart card” that the patient will carry and present when seeking out medical services. Currently the medical I.D. card that John has contains pertinent medical coverage and personal information.

Once on the system, John is queried to determine if there is a need to see a medical specialist. John’s initial symptoms falls within the guidelines for the automation medication protocol to be used. Because John has used the diagnostic computer system, all medications will be paid for at 100%, even if OTC’s are indicated, provided they are obtained from a participating vendor.

In this particular situation, protocol indicates that an OTC is the appropriate therapy. John is provided, via the printer attached to the cable system, a printout with directions on how to take the OTC medications, precautions and side effects. John also receives a list of participating vendors, locations and authorization code for payment. John is also provided a list of non-participating vendors based on geographic location and the current retail price at the particular stores.

The list of participating stores are those that have agreed to accept the HCC’s allowable reimbursement and will direct bill for products. The list is extensive, including convenient stores, grocery stores, mass merchandisers and others.
John decides to go to a participating vendor and retrieves the particular product from the shelf and proceeds to the checkout where he presents his insurance card which is scanned along with the product. Since there is authorization on file for John to get this product at no charge, the transaction is finished.

During therapy all patients are required to report back to the system on a daily basis to assess progress or sooner if symptoms worsen. In John’s particular situation, his condition worsen somewhat, so according to protocol additional medication is called for, this time one or more legend drugs are indicated. John is provided with a list of participating drug distribution depots for him to chose from.

Most of the drug distribution depots are previous chain drug store outlets, which are now jointly owned and operated by the HCC’s and the four remaining drug manufacturers. They are operated on a 24/hr/day 7 days/wk 365 days/yr basis, and are geographically located so that there is one to handle approximately a five mile or less radius. The system is so designed to allow that 80% +/- of the prescriptions are filled by a totally automated process, the balance is filled by a semi-automated process by certified technicians. All medications are prepackaged in the days supply as dictated by protocol for the particular drug. Hand held scanners and bar coding on the prepackaged bottle and labels makes the process virtually error free and the HCC’s have introduced and passed legislation that all pharmacy operations are no longer controlled at the state level but is under the auspices of the FDA. Subsequence federal rules no longer requires a pharmacist be present when a prescription is provided. OBRA ‘90 has been modified to allow all necessary consultation to be done via a TeleVideo conference, via the cable system, with regional/national information centers which are manned mostly by pharmacists.

Once the depot is chosen, the appropriate orders are electronically sent to the chosen depot’s automated dispensing system. John is provided printed information concerning the medication on the printers attached to his cable system (the principle of any cheap ID card printer work). If at any time John has a question concerning the medication, he can have a TeleVideo conference with a pharmacist at the drug information center.

John is still required to check in with the system on a daily basis or if symptoms worsen. Unfortunately, John’s condition does not improve after 3 days of therapy, so protocol requires, that given John’s symptoms, he is to have certain lab tests done and be seen by a primary healthcare professional in person. John is provided, via his cable screen, the participating labs where the test can be performed. Once John chooses the lab of his choice, a electronic order for the specific tests is sent to the lab. Because John’s condition is not life threatening, he is given the option to arrange for the first available appointment with the first available professional or the first with a specific professional. John chooses to see a particular professional that he has used before, so this particular professional’s appointment schedule appears on John’s screen with the available time slots shown. John chooses the appointment time that is convenient for him.

Due to the capitation payment system, all health care service have been consolidated into large group practices each containing 30 to 50 physicians with the necessary ancillary support personnel and ancillary services. Typically all clinics are located next to or are part of the HCC’s hospital and out patient surgery centers.

When John shows up to the health clinic for his appointment, he is first assigned to see a patient manager (PM). Most PM’s are credentialed Pharmacists, Physician Assistants or Advanced Nurse Practitioners. In most clinics the PM is the first person a patient sees in a non-life threatening situation. The PM’s have prescriptive authority granted from either the physician group or the HCC, this allows the PM to work between the Office manager and the physician and performing mostly a triage function. The PM is also responsible for monitoring patients with chronic conditions, patient education and treating minor conditions. The PM, in this encounter, is a credentialed pharmacist who reviews John’s records and the recent lab report. The determination is made that the antibiotic that John is taking was, according to the labs, not the correct one and the PM, under written protocol, changes the antibiotic order to correspond to the one indicated by the labs as most appropriate.

The new medication order is electronically transmitted to the automated drug filling system at the drug distribution depot. John is provided a PIL (patient information leaflet) by the PM and he/she answers any questions that John has concerning his therapy.  John always has the option of having a TeleVideo conference with a pharmacist at the drug information center.

While John’s records are being reviewed by the PM, it is pinpointed by the computer that he has been less than consistent in taking/refilling his anti-hypertension medication. The computer records indicate that John has failed to respond to reminders sent via email.

The PM takes this opportunity to encourage John to be compliant with his therapy and reminds him that unless his refill records improve that the HCC will increase the percent co-pays that he will be responsible for in treating complications resulting from his lack of being compliant.

The PM suggests to John that he considers automated refills, this would cause the drug distribution system to automatically refill chronic medications and have them mailed to either his home or office. The PM reminds John that if his condition is not being controlled by his next visit, that the HCC will require that he uses a medication bottle cap monitor that will electronically record the date and time of each time that the bottle is opened and that John will be required to “plug in” this cap into his cable com port weekly to monitor his compliance.

The PM points out that John’s failure to be compliant will require that he have a one year SUBQ medication implant be done and that John will be financially responsible for the cost difference between the normal cost of the oral medication and this implant and that the HCC has the authority to directly debit this expense from either his paycheck or checking account.

After seven days of therapy, John’s symptoms disappeared and is no longer required to check in with the HealthNet system on a daily basis. Due to the various financial incentives that the HCC has in place, John has elected to have his medication sent to him automatically and to be compliant with his therapy.

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