US Pharm. 2013;38(8):43-50.
health care technologies are often blamed for rising health care costs,
but they can also be part of the solution as the nation strives to
create a value-based health care system. The next generation of mobile
and telehealth technologies for chronic disease management holds great
promise in terms of improving the quality and lowering the cost of care,
while also creating significant business opportunities for community
pharmacies. As pharmacies strive to become more comprehensive wellness
centers, these technologies create opportunities to expand service
offerings, engage patients in their care, and ultimately define a
greater role in the evolving health care delivery system.
The United States is under growing pressure to create a
value-based health care system in the face of escalating health care
costs and shrinking budgets. One significant driver of cost has been the
rising prevalence of chronic diseases, especially cardiovascular
disease, diabetes, and asthma. Nearly half of all American adults have
at least one chronic disease, and more than 75% of Medicare spending is
dedicated to their care.1,2
The burden of these diseases often falls on underserved
populations. The safety-net delivery system usually lacks the financial
resources, human resources, and information technology infrastructure
needed to properly manage chronic diseases, while these patients face
additional challenges in their lives over literacy and language barriers
and housing instability.
Innovative health care technologies are often blamed for
the rising cost of health care, but they can also play a critical role
in the quest for value-based health care, offering the potential to
lower costs, improve access, and enhance clinical outcomes. In 2012,
NEHI, with support from the California HealthCare Foundation, conducted a
research project to identify the next generation of chronic disease
management technologies, paying special attention to the needs of the
underserved. NEHI, formerly known as the New England Healthcare Institute,
is a national health policy institute focused on enabling innovation to
improve health care quality and lower health care costs.3
As these technologies continue to gain popularity, they
are not only transforming the health care delivery system and how
patients and providers interact, but they are also offering a new
business opportunity for the community pharmacy world. Many of the
emerging technologies and services identified by NEHI can be sold by
community pharmacies and used to complement existing service offerings
by pharmacists and retail clinics. This article will explore several of
the technologies with promise for improving the quality and reducing the
cost of care for chronic disease patients and show how these
technologies have been used in community pharmacies to date.
NEHI’s Technology Project
In NEHI’s 2012 report, Getting to Value: Eleven Chronic Disease Technologies to Watch,3
a robust and replicable methodology was designed to identify, assess,
and aid the adoption of transformative technologies for chronic disease
care. The scan process began by identifying a diverse list of over 80
technologies, which was winnowed down to 11 through a process that
identified those technologies with the highest potential for clinical
benefit, cost savings, and adoption. Extensive research was conducted to
create profiles for each of the 11 technologies.
Additional research in the form of literature reviews and
primary interviews with technology developers and medication adherence
experts was conducted to assess the emergence of these technologies in
the community pharmacy world. Because these partnerships are in their
infancy, research was predominantly comprised of the insights gleaned
from these primary interviews.
Snapshot of Technologies: A subset of
the 11 technologies that NEHI identified has already found its way into
community pharmacies, including virtual visits and medication adherence
tools. There is a logical business case for pharmacies to sell many of
the others, including home telehealth, mobile diabetes management tools,
mobile asthma management tools, and mobile cardiovascular tools. FIGURE 1 shows how these technologies were classified.3
Home Telehealth: These technologies
are remote monitoring devices that allow patients to actively track and
manage their chronic diseases by wirelessly transmitting physiological
data from their homes to physicians’ offices and, in turn, receive
health coaching. Recent estimates suggest a sizable portion of the
chronic disease population may benefit. One study estimates that about
50% of its total patient population could be cared for with home
telemedicine technologies.4 Despite their potential, adoption
rates remain relatively small when considering the immense target
population of chronic disease patients.
Several significant barriers have slowed adoption,
including the cost of these devices, which can reach as much as several
thousand dollars per unit. Reimbursement remains another challenge, as
many third-party insurers still do not cover the cost of these tools.
Providers are increasingly adopting home telehealth technology, although
physician and patient behavior remains a challenge as well. Finally,
legal and licensure barriers across state lines remain a significant
challenge for telehealth technologies in general.3
Virtual Visits: These technologies
facilitate real-time interactions between patients and providers. Unlike
home telehealth, these platforms do not require a hub device; instead,
virtual visit technology can be accessed from smartphones, personal
computers, and kiosks. These technologies offer the potential to ease
access challenges for patients while allowing providers to intervene
before costly complications ensue. A recent survey revealed that nearly
75% of patients are interested in interacting with providers online,
while only 25% are willing to pay extra to do so.5
Barriers to adoption for virtual visit technologies
include the fact that these technologies present a difficult business
model requiring an organization—like a drug store—to offer the service,
and they often are not a direct-to-consumer product. The use of these
technologies also requires a shift in behavior for providers and
patients as they need to become comfortable with remote consultations.
Mobile Diabetes Management Tools: These
tools represent the next generation of diabetes management and use
wireless devices to collect and log blood glucose readings, provide
alerts, and interpret data over time. Results from a manufacturer study
showed that patients who received automated, real-time educational and
behavioral messaging in response to blood glucose values exhibited a
1.9% decline in A1C compared to 0.7% for the usual care group after 1
year.6 A single percentage point drop in A1C level can reduce the risk of heart, kidney, and eye disease by up to 40%.7
Widespread adoption is dependent on the reimbursement
model. If these new devices are not covered by insurance, it is unlikely
patients will purchase these technologies out-of-pocket, if the less
sophisticated alternatives are covered. Another barrier is that many of
these tools still require patients to take an active role in data
transmission, either by manually entering data into a platform or
plugging in their device. Finally, for these technologies to realize
their true potential, they must be compatible with existing blood
glucose monitors and the growing health information technology
infrastructure in the delivery system.
Medication Adherence Tools: These tools leverage
cell phones to alert patients and caregivers when to take their
medications. Many patients do not take their chronic disease medications
as prescribed—up to half of all patients in the U.S. do not take their
medications as prescribed by their doctors, and NEHI research suggests that poor medication adherence represents $290 billion in wasteful spending annually.8
Often the elderly and the underserved are impacted by poor
medication adherence. Many of these technologies use smartphone
applications, which could be costly and confusing for the elderly or
those not technologically savvy. Reimbursement is another significant
barrier for widespread adoption. If these technologies are not covered
by third-party insurers, patients are unlikely to pick up the added
Mobile Asthma Management Tools: These
tools use GPS technology to log when and where asthma attacks occur and
provide feedback to patients on how to make appropriate lifestyle
changes. These tools have been shown to have a number of positive
clinical outcomes, such as helping patients get their asthma symptoms
under control, improving the effectiveness of inhaler therapy, and
decreasing flare-ups, which results in fewer hospitalizations and trips
to the emergency department or physician’s office for uncontrolled
asthma. One study showed that many patients were able to get their
symptoms under control after being given baseline data collected from a
rescue inhaler with a GPS attachment.9,10
Additional research is needed to accurately quantify the
clinical and financial benefits. The cost of these devices also poses a
barrier to expanded adoption. Most of these technologies require
smartphones or add-on devices that may be cost-prohibitive to many
patients. Without insurance coverage, it is unlikely that patients will
purchase them out-of-pocket, especially the underserved and the elderly.
Mobile Cardiovascular Tools: These
tools enable patients with cardiovascular disease to monitor and share
their vital signs with caregivers and providers using wireless
technology. Often patients with cardiovascular disease will not
recognize or will ignore symptoms, leading to costly interventions,
sometimes resulting in mortality. These tools allow patients to manage
their disease and identify clinical aberrations before they become
serious problems. The clinical benefit of specific mobile cardiovascular
tools has not been robustly quantified to date, though controlled blood
pressure can lower the risk for stroke and heart attack.
Similar to many of these other technologies, one of the
greatest challenges is the reimbursement model. Without the financial
and clinical evidence to justify reimbursement, third-party payers are
unlikely to cover these technologies. Additional studies are needed to
clearly define the appropriate use of these technologies and to verify
the clinical and financial benefits.
Opportunities for Community Pharmacies
Community pharmacies continue to seek opportunities to
expand service offerings, engage patients in their care, and ultimately
define a greater role in the evolving health care delivery system. There
has been a shift in the mission of many of these retailers from being
solely a drug store to a more comprehensive wellness center. Over the
last few years, most of the large pharmacy chains have experimented with
new technologies as a means to bring them closer to this goal.
Rite Aid NowClinic: In September 2011, Rite
Aid partnered with OptumHealth and American Well to create NowClinic, a
virtual visit technology that customers can use to engage with nurses
and physicians.11 As part of Rite Aid’s larger strategy of
rebranding their stores as wellness centers rather than pharmacies and
to avoid the significant start-up costs that have plagued the expansion
of retail clinics, Rite Aid invested in virtual visit technology to
connect patients to nurses and physicians remotely. Rite Aid piloted
these in-store kiosks in the Detroit area, a market where residents
often have difficulty accessing health care due to low incomes and low
availability of primary care physicians in the area.
The services offered at NowClinic are similar to those
that would be offered in retail clinics and include treatment for
allergies, bladder infections, bronchitis, pink eye, sore throat, and
other minor illnesses.11 Customers can have a free online
consultation with a nurse or select optional upgrades for a 10-minute
virtual visit with a physician for $45 and purchase additional time in
5-minute increments payable by credit card. The customer is responsible
for submitting claims to the insurer for reimbursement, if covered.
Depending on the consultation, the nurse or physician can advise the
patient whether an in-person visit with a doctor is necessary, have a
certified pharmacist deliver vaccines, or have the pharmacist fill a
prescription. Rite Aid’s in-store NowClinics are available in four
states (Michigan, Maryland, Massachusetts, and Pennsylvania) and can
also be accessed through an online portal.11
Walgreens Pill Reminder Application: Over
the last several years, Walgreens has been one of the industry leaders
in terms of offering convenient mobile applications that promote
medication adherence, including their Pill Reminder and Refill by Scan
applications.12 Pill Reminder is a free mobile application
that allows customers to easily track drug schedules and receive alerts
to remind them to take their medications. These reminders can easily be
set by scanning a prescription barcode and selecting preferences.
Customers can add additional prescriptions, vitamins, and other
supplements to a single reminder.
Refill by Scan is another convenient and free mobile
application that allows patients to order refills simply by scanning a
prescription barcode with a smartphone.12 Many of the other large retail pharmacy chains, including CVS and Rite Aid, offer similar applications.
Community pharmacies have a long history of marketing
various consumer health devices and providing counseling on their use.
This remains true today. Recently, pharmacies have been much quicker to
embrace mobile health and telehealth technologies than physician
practices and hospital systems. Retail pharmacy chains now routinely
offer smartphone applications for medication alerts and refill
reminders, just as they earlier offered customer Web portals.
Improving Care Coordination Through the Exchange of Health Information: There
is enormous opportunity for the pharmacy sector to consider leveraging
the wealth of information already at their fingertips to advance health
policy goals. These emerging smartphone applications and existing Web
portals create a number of opportunities to promote medication
management and adherence goals. If a patient fills all of his or her
prescriptions at a single pharmacy chain, that person has access to his
or her prescription history, creating a real time medication list,
something that remains elusive in health care.
There is also an opportunity for the pharmacy sector to
consider how to leverage its existing investment in accessible
medication records to achieve Meaningful Use goals (i.e., the set of
standards from the Centers for Medicare and Medicaid Services [CMS] that
governs the use of electronic health records and allows eligible
providers and hospitals to earn incentive payments by meeting specific
criteria).3 The information housed in these already existing
systems could be beneficial not only to pharmacists and patients, but
also to physician teams, hospital discharge planners, and other
clinicians in improving coordinated care of patients’ pharmaceutical
Expanding Service Offerings to Improve Access: Community
pharmacies could also be in line to sell many of the peripheral devices
profiled in NEHI’s report, including the next generation of asthma,
diabetes, and cardiovascular tools.3 Most, if not all,
pharmacies are actively expanding their clinical services, including
additional counseling services for patients and medication review by
pharmacists. The question for community pharmacies is how to leverage
these new technologies to expand their clinical offerings to patients.
Rite Aid’s NowClinic is one example of how large pharmacy chains are
entering into this new world of technology and expanded service
Rite Aid’s choice to leverage virtual visit technology is a
strategy that in many ways bypasses the retail clinics staffed by nurse
practitioners that major retailers have invested in across the country.
On the other hand, community pharmacies that have already made major
investments in retail clinics could find additional value in actively
marketing some of the other peripheral devices profiled in NEHI’s
report.3 Major chains such as Walgreens and CVS have begun an
expansion into services that include limited prescribing, lab orders,
and more extensive chronic care case management, where these are
permitted by state regulation.11
Defining a New Role in an Era of Accountable Care:
An accountable care organization (ACO) is a group of health care
providers formed to provide coordinated, high-quality care to Medicare
patients. As the pharmacy sector considers its role in the world of ACOs
and other forms of global payments, pharmacies will need to weigh how
these new devices and applications can help them achieve their
performance goals.3 ACO and other payment innovations tie
payment heavily to the achievement of population health goals in major
chronic disease areas like diabetes, heart disease, and asthma—disease
states that are major targets of the new mobile and telehealth
technologies. Community pharmacy chains are actively considering their
place in new ACO structures, as demonstrated by the recent approval by
CMS of three Walgreens-affiliated Pioneer ACOs in New Jersey, Texas, and
How will pharmacies use and effectively price these
technologies for patients to help them achieve larger population health
The continued transformation of the community pharmacy
world will depend upon the flexibility of practice regulation at the
state level and specifically on whether pharmacists and nurse
practitioners will be allowed to provide more “top of the license”
services. Historically, physicians have been reluctant to delegate tasks
to pharmacists, although such delegation happens routinely in highly
integrated health care systems and emerging models of practice. A common
criticism of the retail clinics by physicians has been that they will
divert patients from their primary care provider and fragment patient
care. The emergence of ACOs with their distinct population health goals
and emphasis on coordination across the care continuum may alter these
historic battle lines. If so, community pharmacies may find a growing
incentive to market, service, and promote innovative mobile and home
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8. NEHI. Thinking Outside the Pillbox: A System-Wide Approach to Improving Patient Medication Adherence for Chronic Disease. Cambridge, MA: NEHI; August 2009.
9. Newman J. High-tech inhaler from Madison company would help doctors track asthma attacks. Wisconsin State Journal.
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Accessed March 13, 2013.
11. Dolan PL. Rite Aid clinics place new twist on “doc-in-a-box.” American Medical News. February 6, 2012. www.ama-assn.org/amednews/2012/02/06/bil20206.htm. Accessed March 13, 2013.
12. Better health through mobile—Walgreens introduces new pharmacy tools to help smartphone users manage prescription needs. Walgreens News. March 9, 2012. http://news.walgreens.com/article_print.cfm?article_id=5560. Accessed March 13, 2013.
13. Walgreens forms accountable care organizations (ACO)
to deliver seamless, coordinated care to improve patient health, lower
costs and close critical gaps in care for Medicare patients. Walgreens News. January 10, 2013. http://news.walgreens.com/press+releases/general+news/aco.htm. Accessed July 1, 2013.
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