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Staying On Track

Complying with government regulations doesn’t have to be confusing

Rethinking Robotics How investing in automation can free you to focus on patient care

The Specialty Opportunity Tips on starting a specialty care program in your retail pharmacy

VOL. 3 ISS. 4 | DEC 2014 | pbahealth.com/elements

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The business magazine for independent pharmacy

STAFF & CONTACTS Matthew Shamet - Publisher and Editorial Director Kirsten Hudson - Editor Kellie Paxton – Graphic Designer Chloe Holt – Contributing Writer Kathleen Barbosa – Contributing Writer Molly Norburg – Editorial Intern Interested in advertising? elements@pbahealth.com

Contents Departments 23 SPOTLIGHT:


Elements Magazine is Now Online Find more tips and advice for your business on our new website. 6 TRENDS:

Going Local D&H Drugstore stocks quality local products to create a unique front-end experience. 8 RETAIL:

Staying On Track Complying with government regulations doesn’t have to be confusing. 11 SOLUTIONS:

Rethinking Robotics Learn how investing in automation can free you to focus on patient care.


A Few Minutes with a Community Pharmacist We talked with Melissa Gilkison, Pharm.D., about her experience using CPR. 26 MONEY:

Business Loans How to build the foundation for a successful loan application.


Smoking Cessation How pharmacists can help put an end to smoking. 34 NOTES:

What’s Trending? Five up-and-coming trends for independent pharmacies in 2015.

Feature: The Specialty Opportunity


Starting a specialty care program in your retail pharmacy.

Explore exclusive online content to improve your business at www.pbahealth.com/elements.

5 Preventative Care Ideas that Boost Profits

By practicing preventative care in your pharmacy, you can help patients stay healthy, expand your services and increase profits. Find the article at www.pbahealth.com/5-preventive-care-ideas-that-boost-profits.

ELEMENTS is published quarterly by PBA Health. Copyright© 2014 PBA Health. All rights reserved. Neither this publication nor any part of it may be reproduced without written permission by PBA Health.



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Elements Magazine is Now Online Find more tips and advice for your business on our new website We’re online! You can now read more from Elements magazine anytime at pbahealth.com/elements. Our new website includes all of the business tips, success stories and expert advice you’ve come to expect from Elements magazine, plus much more. Here are a few more reasons to visit our new website.

Read exclusive content You’ll find tons of articles not published in the magazine on the new website. Articles are broken down by topic, so it’s easy to find what you’re looking for. Want to know more about marketing? Read all of our pharmacy marketing articles in one place. You can also explore articles on business, retail, technology and more. Find back issues Our new website makes it easier to revisit old issues of Elements. If you missed the last issue, or if you’re searching for a specific article, you can now look at back issues of Elements on our easy-to-read flipbook. Sign up for our e-newsletter Don’t forget to sign up for our weekly e-newsletter while you’re exploring the new website. The Elements e-newsletter includes a quick dose of the best articles from that week, including exclusive online content. And, it’s all for free!

Subscribe to the print edition Do the other pharmacists, employees and staff at your pharmacy want to receive Elements magazine? Anyone can easily subscribe to the print edition of the magazine on our new website. Just fill in your information and hit submit. Subscribing is free! Find us on social media Keep up with Elements magazine on Facebook and Twitter. You can share your favorite articles or just see what’s new. Find us on Facebook at facebook.com/elements-magazinepharmacy or on Twitter with our handle @elementsmag. View on your phone You can even access Elements magazine on the go. Our website is mobile responsive, so you can view it on your tablet or smartphone. If you’re busy or away from your computer, all of the pharmacy success stories, business tips and expert industry advice you want will be right at your fingertips.

Talk to us Tell us about the ideas, solutions and services that are working for your pharmacy by emailing elements@pbahealth.com. You just might be featured in the next magazine. You can also ask questions, give feedback, or tell us what topics you want to know more about. We look forward to hearing from you!

Get daily news updates on issues that matter to your pharmacy by following Elements magazine on Facebook at www.facebook.com and on Twitter at www.twitter.com.

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Going Local D&H Drugstore stocks quality local products to create a unique front-end experience By Molly Norburg

Your next business opportunity might be hiding right down the street. The buy local trend has gained popularity in recent years and it has created an opportunity for independent community pharmacies to participate. Stocking locally-made products in your front end can differentiate you from the competition, provide more value for customers and show support for the community. At D&H Drugstore, which has two locations in Columbia, Mo., stocking local products is a business model that has been successful, said Brenda Smith, front-end manager at D&H Drugstore. “We’re always trying to improve and do something more innovative,” Smith said. “As an independent community pharmacy, you have to do things to differentiate yourself from the mass-market pharmacies. We really strive to set ourselves apart.” What customers want Customer service is the motivating factor for stocking local products at D&H Drugstore. It’s about offering more value and personal engagement for the consumer. “We strive here on our customer service, and so it’s exciting to be out on the floor talking to our customers, helping them find the perfect gift or the perfect item that they’re looking for,” Smith said. Customers of the pharmacy play a big role in determining what local products make it to the frontend floor. Some of the most popular items include baby bibs, Hippie Chow (a type of granola), fused glass or custom cards from local artists and skin products made with goat’s milk. D&H Drugstore constantly refines its local inventory by gathering input from customers on the


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products it stocks. Forms at each checkout counter give customers the opportunity to provide feedback and suggest new products. The staff also personally asks customers what products they do and don’t like. “Just being in communication with the customers, you learn what to look for,” Smith said. “I’m more hands-on. I don’t just order stuff in and then look at what’s selling. I’m a real people person. So, I really do enjoy trying to find those special niches and products that are a good fit for our business.” Finding what works By offering a balance of mass-market products and local treasures, D&H Drugstore has created a profitable front end that appeals to all types of customers. “Sure, on some of those mass-market items, you can get a better price to bring in and sell retail, but people tend to be willing to pay a little bit more for an item that’s homemade,” Smith said. One way to keep profit margins steady is by capping the cost of local products. “I strive to keep our price point down for the consumer. No more than $20 tops,” Smith said. “That’s been a good selling point for us.” But the benefits of stocking local products extend beyond financial interests. In addition to improving customer relations, it can also strengthen your image as a supporter of the community. At D&H Drugstore, the consumer response to local products has been overwhelmingly positive, which has also generated excellent word-of-mouth marketing. “People really want to support local products in the community,” Smith said. “Customers will actually remark


to us, ‘I am so glad that you have local products in here.’” Stocking these items also presents an opportunity to network with other local businesses. And these connections are often mutually beneficial. “I try to work alongside other businesses, especially if they carry similar products,” Smith said. “I try not to carry anything that someone down the street has.” This collaborative approach fosters better relationships with local business owners, and helps Smith make unique buying choices. “That’s the kind of thing I try to build: a relationship and rapport with other businesses,” she said. “If I decide to bring in a product, I also talk to any other store that has it to see if that would be okay. I don’t want to tread on toes, and I want to set us apart.”

Uncovering unique products In addition to customer suggestions and samples sent by local artisans themselves, Smith finds a lot of the local products the pharmacy stocks while on the road. “My husband and I will just get in the car and go,” she said. “I love going to neighboring towns or even states. I always search out independent pharmacies to see what kind of things they’re selling.” This front-end model with a focus on quality, local products has worked well for D&H Drugstore. “People really like to support other local people,” Smith said. “I would recommend it highly to other independent community pharmacies.”

“Sure, on some of those mass-market items, you can get a better price to bring in and sell retail, but people tend to be willing to pay a little bit more for an item that’s homemade.”

D&H Drugstore, which has two locations in Columbia, Mo., stocks local and handmade products in its front end to create more value for customers.

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Staying On Track Compliance doesn’t have to be confusing By Chloe Holt

Do you have a compliance system in place in your pharmacy? If not, you’re potentially at risk for huge audit fines or even, in extreme situations, civil and criminal fines. Complying with all of the regulations that govern the business operations of your pharmacy can be tricky. The regulations themselves come from multiple organizations—the federal government, Medicare, State Boards of Pharmacy—and the penalties that enforce them continue to evolve and increase each year. This audit phenomenon is fairly new in pharmacy. “Back in the 70s and 80s, even into the 90s, audits were not in pharmacists’ vocabulary,” said Tim Gregorius, vice president of operations at PRS Pharmacy Services.


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“Then, you could have survived for a long time never caring about being audited. That’s no longer true today. It is now a reality of doing business.” In 2015, experts agree that every pharmacy should be prepared for an audit. Because of this, daily compliance is more important than ever. Discover why you need to pay attention to compliance, and how building a culture of compliance can make all the difference in your pharmacy. Compliance confusion It’s easy to see why compliance is difficult for pharmacists. “There’s no single source of information for regulations and compliance,” Gregorius said. “It’s hard to


even understand all the ABCs of what you need to comply with and what regulations you need to be meeting. And because of that confusion, most pharmacies believe they are compliant even though they’re not familiar with the details.” That mistake, however, can be costly, as auditors won’t be forgiving. “When it comes to HIPAA, for example, the Office for Civil Rights has said that ignorance of the requirements of the law, or of the law itself, is going to be dealt with severely. They’re going to go with the maximum fine they can possibly levy for someone who’s ignorant of the law,” said Joshua Potter, director of compliance at PRS Pharmacy Services. “There are still a lot of business owners who think that if they hand out a notice of privacy document and whisper in a consultation area, that they’re HIPAAcompliant and that’s just not true today,” he said. A culture of compliance As the role of the pharmacist expands today, it’s difficult to make compliance a priority. “Pharmacists are focused on patient care. They make sure medicines get out safely and that patients are being dealt with appropriately,” Potter said. “They don’t necessarily always have time to focus on compliance.” While it’s true that compliance may require a lot of work upfront, beyond that, it’s not as difficult as it seems. “You need to make sure you set up a whole culture of compliance. Once everybody is trained appropriately and your policies and procedures are written well enough, you don’t really need to be doing anything different on a dayto-day basis,” Potter said. “Once you have everything in place, being compliant is very easy.” This means, as a start, you should put a system into place and educate your employees to ensure that your records, forms and documents are always accessible, upto-date and used when needed. And while it may seem more cost-efficient to manage compliance on your own, your time is valuable. There are options available to help you manage compliance, so that you can devote your time to other aspects of your business. You might consider partnering with a company that offers a compliance solution, such as ComplianceTrack from PRS Pharmacy Services, which consolidates all compliance standards into one program for pharmacies.

“We’ve tried to take the confusion out of compliance and make it simple and effective in real time. We know the battles that go on at the pharmacy counter and we’ve really tried to look at that and make our ComplianceTrack service work for pharmacists,” Gregorius said. “We look at it as an insurance policy for their pharmacy.” With a little diligence, compliance can be easy to manage, and you can get back to what’s most important—your patients.

3 Regulations You Should Know Looking to 2015, Joshua Potter, director of compliance at PRS Pharmacy Services, identified three regulations you should always be aware of, and what can’t be overlooked as you work to comply. 1. HIPAA One of the important things to understand about HIPAA training is that your training has to be based on your policies and procedures, not on the regulation itself, Potter said. If auditors find that your training and your policies don’t mesh together, that’s going to be a ding. 2. Fraud, Waste and Abuse When it comes to Fraud, Waste and Abuse, it’s important to have your pharmacy’s Code of Conduct and Code of Ethics in place, and to know if your third party plan requires you to be compliant with the Compliance Program Guidelines, Chapter 9 of the Medicare Prescription Drug Manual. 3. Exclusion Verifications Any pharmacy that’s involved in receiving any sort of public funds, whether it’s Medicaid or Medicare, needs to make sure they’re checking their employees on the Office of Inspector General (OIG) and System for Award Management (SAMS) exclusion databases on a monthly basis. If they find that any employees are on that list, they need to remove them from being involved in any provision of care services.

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Rethinking Robotics Learn how investing in automation can free you to focus on patient care By Kathleen Barbosa

Between filling scripts, counseling patients and providing additional services, independent community pharmacies often have more tasks than they can complete. But there are tools that can help your business by taking some of the work out of your hands—literally. Adding robotics to your pharmacy is an investment worth considering. While pharmacy robots are nothing new, the reasons to add automation to your business have only increased. Patients now look to pharmacists for more than filling their prescriptions. Pharmacists today give immunizations; they counsel, recommend over-the-counter products and provide health screenings. As the role of the pharmacist evolves, so must your business. “If you look across the spectrum of businesses in general— not just pharmacies— you see the importance of finding ways to automate, so people can focus on higher-level tasks,” said Mike Coughlin, president and CEO of ScriptPro, a company that develops robotics-based pharmacy management, workflow and telepharmacy systems. According to the 2014 NCPA Digest, only 25 percent of independent pharmacies have an automated dispensing system. If you’re operating without automation, maybe it’s time to take a look at your pharmacy and see if your

business could benefit from investing in a robot. “If you’re not willing to take a hard look at how you run your business and make investments, then you’re not protecting your business and it will probably come back to haunt you,” Coughlin said. Triggering events Every pharmacy that believes in its future needs to invest in automation, Coughlin said, but how do you know when it’s the right time? There’s an easy way to find out. You’ll know you’re ready if you experience what Coughlin calls a “triggering event.” Key triggering events for pharmacies include incidents like an increase in customer complaints due to long wait times, lost business because of inefficiencies in your system or key employees quitting. If a competing pharmacy closes and you know their patients will be coming to you, that’s also a triggering event. Another gauge you can use to evaluate if you’re ready to add a robot is prescription volume. A significant increase in volume, or if you’re filling more than 150 prescriptions a day, indicates that you should consider investing in a robot. Perhaps the most important triggering event is a dispensing error. Coughlin said he has had customers

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install a robot because they made a dispensing error and were looking for a way to ensure it would never happen again. When a robot fills a prescription, it does everything from selecting the bottle to placing the label without human assistance. This virtually eliminates the chance for error in the dispensing process. Initial challenges Whether it’s the hefty start-up cost or the lack of floor space, there are many concerns that might cause a pharmacy to hesitate before installing a robot, but Coughlin said the most common cause is simply inertia. It can be hard to change the system you’re used to,

whether that’s manual dispensing or filling scripts with the assistance of a counting machine. But adjusting to a robotics system is worth the effort. It can boost your pharmacy’s efficiency and help you combat declining reimbursements and rising employment costs. “When you’re running a business, you can either view challenges as things that are going to wreck your business or you can view challenges as opportunities to figure out a better way to run your business,” Coughlin said. “Those people who have viewed challenges as opportunities and figured out a better way to run their businesses have been successful. Those who have just kept doing what they’ve always done are finding that they’re getting worse and worse results.”

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Before you buy If you think it’s time to consider adding a robot to your pharmacy, the first thing you need to do is look around at the various sizes, functions and prices of the systems available. Coughlin suggests visiting pharmacies to ask current robotics customers about the quality of the machine. How easy is it to use? And, in particular, how easy is it to change the drugs dispensed? Also, ask about the quality and timeliness of the service and customer support they receive. Pharmacies currently using a robot will also be able to give you a better idea about how different companies handle updates to their machines. Some robots become obsolete quickly. Others can be retrofitted with new hardware and software, so you can keep your robot up-todate without purchasing a whole new system. When looking at different systems, Coughlin warns that, like with most things, you can always get something cheaper, but paying a little more for a higher quality machine that won’t become obsolete might be worth it in the long run. Concerns about paying for the machine can often be addressed through financial modeling and analysis that take into consideration the financial returns of an automated system in comparison to your current system.

And, it improves workflow. “There’s a certain amount of chaos in a pharmacy that doesn’t have automation,” he said. “You’ve got pharmacists and techs running around, picking things up, getting interrupted and coming back and starting over. There are stock bottles, counting trays and labels sitting on the counter. The telephone is ringing. There are patients waiting, some of whom are getting impatient.” “You put a robot in that same environment and all of a sudden the work just flows through quicker. Nobody has to tell the robot what to do. It automatically does the job.” Looking forward Adding automation will create time for you and your staff to focus on what’s important—your patients. With a robot handling a good portion of the work, pharmacists and staff will have more time to go in the aisles and interact with patients. Focusing on patient care can translate to better medication outcomes and adherence, which results in healthier patients and, potentially, better Star Ratings for your pharmacy. As pharmacies focus on serving their patients, they’ll be looked at as more of a source of health knowledge and less as a dispensary. “The pharmacy operators that are going to be successful in the future are going to be viewing it that way,” Coughlin said. “They’re not going to be seeing their role as glorified inventory control clerks, but as providers of knowledge.” And robotics can help pharmacies in that role. Coughlin said current developments in robotics include improving adherence through different packaging methods, like the use of pouches that encourage compliance. “What that robot is doing isn’t going to go out of style,” Coughlin said. “It’s here to stay.”

“If you look across the spectrum of businesses in general—not just pharmacies—you see the importance of finding ways to automate, so people can focus on higher-level tasks.”

Integrating pharmacy Coughlin said there are several reasons to make your pharmacy’s next hire a robot. “It’s cheaper, faster and more reliably accurate to have a robot counting pills into a bottle and putting a label on it than it is to hire a person to come in and do that,” Coughlin said. “The robot is there 24/7. It doesn’t call in sick. It doesn’t take lunch breaks. It isn’t going to be interrupted.”


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The Specialty Opportunity Starting a specialty care program in your retail pharmacy By Kirsten Hudson

Specialty patients are already in your community. Isn’t it time to start providing their care? PBMs, pharmaceutical manufacturers, health plans and specialty pharmacies are all starting to focus on specialty care. It’s easy to see why. The specialty market is booming. Specialty is the fastest-growing segment of the pharmacy industry. More than 40 percent of the drugs currently under development are specialty drugs, according to the National Center for Policy Analysis. They’re also some of the most expensive. Specialty medications make up less than 1 percent of prescriptions dispensed, but account for 27.7 percent of total pharmacy spending in the U.S., according to the 2013 Express Scripts Drug Trend Report. So far few independent pharmacies have entered into this niche area, but the time to do so is now. Market dynamics are all pointing to specialty pharmacy as a profit driver for independents.


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“The increasing pressures of low profitability on generics and patent expirations on brand drugs, coupled with the pipeline of FDA approvals heavily-focused on specialty, means independents must focus on generating revenues in more ways than just filling prescriptions,” said Rinku A. Patel, Pharm.D., R.Ph., founder and CEO of KloudScript, Inc., a company that provides a turnkey specialty solution for independent pharmacies. “This is the time for independents to innovate, adapt or become extinct.” Competition for servicing specialty patients is only increasing. Mandatory mail order has already started to steer patients taking specialty medications away from retail pharmacies, according to the 2014 NCPA Digest. “Competition is fierce as everyone runs to get a piece of the pie,” Patel said. “But my firm belief is that the provider with the best quality of care and the most efficient service model will have great opportunities to participate.” “It’s important for independents to start building experience in the specialty space now,” she said. “The pharmacy industry is evolving and independents need to provide specialty care services before becoming completely excluded from this space.”

“Three or four years ago, specialty at retail was not a viable service model in the eyes of industry stakeholders,” Patel said. “But look at what we have today. Larger chains are seeing the value of specialty at retail and even some payers are recognizing the need to simplify care and improve access for specialty patients.” And who better to provide care for the specialty patients in their communities than independent pharmacists? Specialty patients are dealing with not only the physical, but also the emotional issues that result from their conditions. Patients with chronic conditions like cancer, Crohn’s disease, Hepatitis C, HIV/AIDs, multiple sclerosis, psoriasis, rheumatoid arthritis and osteoporosis can benefit from the personalized attention of their local pharmacy. “When specialty pharmacies first emerged, the goal was to have a close-knit patientpharmacist relationship to result in better support and clinical care for the patient,” Patel said. “As the specialty boom has taken over, unfortunately, most specialty pharmacies have adopted the mail order model where that close-knit relationship isn’t feasible. This is where independent pharmacies can make the biggest difference.” The independent community pharmacies that have started providing specialty services have already improved patients’ lives. “Every day I hear stories about the impact our pharmacy providers have on patients and caregivers receiving specialty care,” Patel said. “Like how specialty

“We have to help make the specialty experience special again for the patients who are experiencing these excruciating and life-altering chronic conditions.”

Simplifying care Health care is one area where consumers tend to rely on the resources within their community. They seek care from their local providers and pharmacists when they’re ill. As specialty pharmacy grows, it’s important to make specialty care local.

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care transformed the life of a young man covered in 80 percent psoriasis, or how the patient who was terrified of self-injection overcame her fears with the help of the face-to-face training provided by a pharmacist.” “We have to help make the specialty experience special again for the patients who are experiencing these excruciating and life-altering chronic conditions,” she said. Starting out Specialty pharmacy is still a new area for many independent pharmacies, but it’s the field of the future. “Twenty years ago no pharmacist working in a retail environment thought they would be administering immunizations and now those very individuals are delivering flu shots,” Patel said. “The question pharmacy owners need to ask themselves is, ‘If I don’t get into specialty today, what will the impact be on my business in three to five years?’” Even though specialty drugs have lower profit margins due to their high cost, they have much higher dollar profitability compared to generics or non-specialty brand drugs—and they offer new ways to drive revenue. “The challenge for independent pharmacies today is the need to diversify their businesses so that they’re not just relying on brand and generic prescriptions to generate revenue,” Patel said. Specialty pharmacy does just that. Independent community pharmacies can grow revenue simply by taking care of all of their specialty patients’ prescription and health care-related needs in one place. “Independents have started to provide a lot more clinical services over the past 10, 20, 30 years,” Patel said. “Immunizations, medication synchronization, MTM and consultations related to diabetes education, to name a few. These types of clinical services have been very valuable.” The clinical services independent pharmacies are already providing can easily transition to improving care for specialty patients—and increasing business. Patients who have diseases that require specialty


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drugs may also need to get vaccinated to prevent complications, or they may need over-the-counter drugs to manage side effects. “This all leads to a diversification of revenue sources,” Patel said. It’s also important to synchronize all of a patient’s specialty and non-specialty medications. “This is a competitive advantage for independents because many times patients are getting specialty medications from their specialty pharmacy and the rest of their medications locally. This is an opportunity to provide better care under one pharmacy,” Patel said. Obstacles to expect Independent pharmacies face many challenges when it comes to specialty pharmacy. The special handling of the drugs, the extensive patient care and the high costs involved all represent obstacles to success. “Specialty pharmacy requires extensive infrastructure and operational demands that independents are not used to,” Patel said. The first challenge is the investment. “One of the biggest challenges I see for independents is that they believe they can start doing specialty without much investment of resources,” Patel said. “Just like when they bought their pharmacy, there has to be an infusion of capital and resources. It requires time and money before they see a return-on-investment.” In other words, pharmacies can’t expect to turn into a specialty pharmacy overnight. “Specialty operations are complex and require the integration of sales, marketing, and operational and clinical strategies,” Patel said. You can’t look at specialty simply as a dispensing service for your pharmacy. “You have to walk, talk and act like a specialty care provider,” Patel said. “Many times I talk to owners and they look at specialty only from the lens of ‘dispensing specialty drugs.’ This can get them to fill a script or two for patients who accidentally walk into their pharmacies. However, it will not allow them to have a sustainable specialty care program that integrates well with the rest of their business and creates opportunities

What is KloudScript, Inc.? Rinku A. Patel, Pharm.D., R.Ph., CEO and founder of KloudScript, Inc., breaks down what KloudScript does and how pharmacies looking to get into specialty can benefit from its services. Tell us about Kloudscript. What is it? What does it do? Independent community pharmacies need a staged approach to provide specialty care in a retail setting. KloudScript, in partnership with the independent pharmacy, provides the exact same services to industry stakeholders as specialty pharmacies. KloudScript provides strategic and administrative functions, and the pharmacy is responsible for what it does best—providing patient care and medications. What are some of KloudScript’s best features? As part of the development and launch of KloudScript, I have participated in many focus groups and market research activities with various industry experts and independent pharmacy owners throughout the country. The one phrase that keeps resonating when I solicit feedback from owners is that it’s a “no-brainer” to participate in the KloudScript alliance to enable specialty care at retail. The best feature of KloudScript is that it eliminates the obstacle of intense capital requirements and knowledge deficit. Our management team has solid experience and our infrastructure, including a technology solution, provides economies of scale and scope for our independent pharmacy partners to be able to enter the specialty market. Having the quality and consistency of care experience, with a broad geographic footprint to address the needs of payers and pharma, is also a unique and substantial attribute. How does KloudScript help pharmacies create a specialty program? KloudScript provides the framework to set up a specialty care program. There are some implementation requirements on the part of the pharmacy, such as staff members’ time for training and execution of the day-to-day operations. However, with the training and support provided by KloudScript, independent pharmacies can implement a specialty solution within a

reasonable timeframe, given staff resources are focused and dedicated to the specialty care program and to the implementation process. How would a pharmacy benefit from using KloudScript for its specialty program? In order to be successful, a pharmacy will need to commit to quality and performance and live it on a dayto day basis. KloudScript provides the entire framework and a patient care management system to execute the specialty care program. However, our partnership with the independents is strictly based on providing service at a level and quality that is above the expectations of industry stakeholders including patients, prescribers, payers and pharma. Why is it important for pharmacies to partner with a company like Kloudscript instead of trying to do specialty on their own? A successful specialty care solution requires integration of strategic and operational components. Using software, consulting advice, or outsourcing your backoffice functions can get you to a certain level, but it will not give you a long-term viable solution of sustainable growth because of the scale required to attract the attention of pharma and payers. Owners have to ask themselves if they want a solution that just takes care of “accidental specialty” that ends up in their pharmacies, or if they want a solution that will not only help them retain the “accidental specialty” scripts, but more importantly build and grow the specialty business over a period of time. KloudScript’s solution is a turnkey integrated approach. As we grow, more and more industry stakeholders will benefit from our solution because it’s aligned with the needs of the patients and our pharmacy partners, as well the prescriber, pharma and payer community. How can a pharmacy find out more about KloudScript? Please send a request to sales@kloudscript.net. We do webinars occasionally to help owners understand our solution. They can request participation by emailing us.

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for growth long-term.” Specialty pharmacy also requires additional knowledge and capabilities related to specialty services, such as helping patients find financial assistance for their costly medications. “The patient journey in the world of specialty is different,” Patel said. “There’s confusion over co-pays, prior authorizations, delays, lost shipments and more.” “Pharmacy staff will have to help with issues like funding support,” Patel said. “It’s also important for the owner to understand the strategic aspects and critical success factors of the specialty business.” Pharmacies looking to get into specialty will also need to work through issues like simply accessing the drugs their patients need. It’s not as simple as ordering traditional brand and generic pharmaceuticals. “Specialty pharmacies have evolved over the years to develop services that cater to payers and pharma,” Patel said. “This leads to semi-exclusive networks of specialty pharmacies in a payer contract that prevent retailers from participating. There’s also the problem of retailers not being able to access the drugs they need because they’re tied down in a closed or limited channel.” Competition is huge in specialty right now and independents will need to partner with a company that provides support for these strategic and administrative burdens in order to succeed, Patel said.

“There’s a notion that prescribers don’t want to collaborate with pharmacists,” Patel said. “This may be true to some extent on non-specialty medications because the complexity of care isn’t high and the prescriber community may not require additional support from the pharmacists. However, when it comes to specialty, prescribers and pharmacists do collaborate on a regular basis to provide care for specialty patients.” Many specialists even rely heavily on specialty pharmacists to assist with managing adherence and refill compliance, as well as educating and training patients on the administration of specialty medications. “All of this is achieved if pharmacists take the time to build relationships with prescribers in their community,” Patel said. Engaging with organizations in your community can also benefit your pharmacy when it comes to specialty. The support groups and organizations dedicated to the specialty disease states you service are good sources to know. “Independents are already more community and patient-centric than other businesses,” Patel said. “By forming relationships with the support groups in the community, and doing direct-to-patient marketing of their specialty services, independents can build bridges that remotely-operating pharmacies can’t, at least with respect to the patient-pharmacist relationship.”

Building relationships Because specialty patients need regular monitoring, pharmacies and physicians must work closely together to properly care for the patient.

Taking the right steps Creating a specialty program in your retail pharmacy requires a lot of work, and it’s important to know where to start.

Specialty pharmacy in numbers


Percentage of prescriptions dispensed that are specialty medications



Percentage of FDA approvals for new drugs that are specialty products

Number of specialty drugs currently in development

Sources: 2013 Express Scripts Drug Trend Report, 2014 Catamaran Trend Report, 2014 Prime Therapeutics Trend Report


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To develop a specialty program, you need to first look at the disease states you want to target. “If you’re in an area where there’s a high concentration of geriatric patients, then it doesn’t make sense to introduce a therapeutic category that primarily affects young people,” Patel said. “It would also make sense to start your specialty service integration initially with therapies that are primarily reimbursed under the pharmacy benefits,” she said. “It will take time and experience to come to a stage of being able to handle medical billing processes.” Pharmacies also need to take into consideration the operational and clinical complexity of the drugs within the therapeutic category they choose to target. “If all of the drugs in a given category of interest are infused products, then it doesn’t make sense to attempt that therapeutic category right out of the gate,” Patel said. “It also doesn’t make sense to select a category in which a greater percent of the products are only distributed through closed or limited distribution channels that you don’t have access to. It is critical to build experience and demonstrate your services by targeting therapeutic categories with the most success factors leaning towards you.” It all comes down to doing research ahead of time to define how you can integrate specialty into your current business plan. “Choosing a few therapies of interest is a good start, but you also need to do financial and market analysis to determine a sales strategy,” Patel said. A sales strategy could be marketing to prescribers initially to let them know you offer specialty services, and then focusing on marketing to payers in later stages, for example. As the specialty industry has grown, the challenges for specialty patients—and the retail pharmacies looking to serve them—have escalated, Patel said. “A properly developed specialty care program with protocol that connects everything from sales and marketing to dispensing and clinical operations is essential for long-term success,” Patel said. “The mistakes I see independents make are either investing in the wrong resources or getting frustrated with road blocks and aborting their efforts altogether.”

A better experience Retail pharmacies are where the patients are. Close patient-pharmacist proximity makes specialty care less confusing and more accessible. Empowering patients, so they’re able to choose the pharmacy where they receive their specialty drugs, is an important dynamic. Local care is the way of the future. “It has the ability to provide better pharmacoeconomic outcomes for not just patients but all of the stakeholders involved,” Patel said. “Independent pharmacies must spend more time managing the patient and not just the prescription,” Patel said. “The retail pharmacy industry is moving toward becoming more patient-centric as opposed to just prescription-centric.” “Imagine the difference you can make for specialty patients walking into your independent pharmacy,” Patel said. “Your pharmacists know them by first name, and probably even know their entire life stories. The passion independent pharmacies have for their patients is what can help redefine the specialty experience.”

About the Expert Rinku A. Patel, Pharm.D., R.Ph., is the founder and CEO of KloudScript, Inc., a company that provides a turnkey solution for independent pharmacies to enter the specialty space. Dr. Patel is dedicated to enabling independently owned retail pharmacies to provide better care to patients using specialty medications. She’s an expert in helping independent pharmacies succeed in specialty. She has worked in various roles in the field, including pharma relations and business development, specialty operations and clinical services development. But she’s most passionate about using technology to create solutions that tie business needs and clinical care into a meaningful resource for pharmacies, pharma and payers to ultimately improve care for patients.

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A Few Minutes with a Community Pharmacist Melissa Gilkison, Pharm.D., never expected to use her CPR training. But when a man collapsed in an aisle of the Price Chopper, a regional grocery store chain, where she was working, she sprang to action. “I had just opened the pharmacy, like any normal day, and about five minutes later one of the employees came over and asked if I knew CPR,” said Gilkison, director of long term care with AuBurn Pharmacies, which has a location inside the Overland Park, Kan., Price Chopper. “She told me, ‘There’s a man down over there,’ and I ran over.” When Gilkison arrived, an elderly man lay on his back in the aisle, suffering from what appeared to be a heart attack. He was pale, had no pulse and wasn’t breathing. “There was someone doing chest compressions that wasn’t CPR-certified when I arrived, and they kind of backed off and I took over and started CPR,” she said.

We talked with Melissa Gilkison, Pharm.D., about her experience using CPR and the important role pharmacists play today as health care professionals.

Did you think you would ever use your CPR training before this? Oh no. I was hoping I would never have to. I just happened to be the one there. I think anybody else would have done it in the same situation. There just

Melissa Gilkison, Pharm.D., understands the importance of CPR training, especially after she had to use her training. “Someone had already called 911, so I did compressions for about five minutes until the paramedics got there.” Unfortunately, the man later died at the hospital. But without Gilkison, who was the only person in the store trained in CPR, he may never have had any chance at all. “She had just renewed her CPR certification less than a month before this happened, never knowing she would need it so much,” said Michael Burns, R.Ph., president and CEO of AuBurn Pharmacies. “As pharmacists, we truly are the front line in health care and situations like this prove it.”

was no one else in the store with the training. I just happened to be that person that day. Do you think this experience has brought awareness in the community to the importance of CPR training? Yes. People in the Kansas City area have become more aware. Neighbors, friends and customers have all talked to me about it. Everyone has mentioned that they were surprised that I was the only one in the store who was

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CPR-certified. There were probably 20 to 30 people in the store at the time. I’ve had people tell me they have kids at home and now want to get CPR-certified. They’ve asked me questions about whether they can get certified, even if they’re not in a health care field. I said anybody could do it. I’ve had a lot of good feedback from people about it, and it has motivated them to get CPR-certified now. I’ve told them to ask their employers and maybe they’ll start offering training. I think people were probably surprised that pharmacists have to be CPR-certified in order to give immunizations. CPR-certification is important, but when EMT showed up, obviously I was out of there. Those people do it for a living every day. But it’s one more thing that we have under our belts, and it’s good to have.

How long have you been CPR-certified? I’ve been CPR-certified since I was a lifeguard in high school. I just renew. When I started pharmacy school, I got CPR-certified, and then I’ve continued with it so I can give immunizations, but I’ve been CPR-certified since I was probably 17 years old. Are independent pharmacists becoming more clinically focused today than in the past? Definitely. CPR-certification is one of those things that does keep us up-to-date as pharmacists and it does make us more of hands-on medical professionals, whereas before we weren’t at all. Being able to give immunizations was a big step in the right direction for pharmacists. If we never would have gotten approval to give immunizations, I don’t know if I would have kept my CPR-certification up or not. I can’t say that I would or wouldn’t have. I’ve got kids, so maybe I would have. I’ve been CPR-certified for years because I was a lifeguard, but that doesn’t mean I would have kept it up if I didn’t have to. I only do it when I have to renew every two years.

“As pharmacists, we truly are the front line in health care and situations like this prove it.”

Is it important for independent pharmacists to get CPR training? Yes, especially if you’re in a retail setting. People are going to go to you. Someone ran to me—the pharmacist—and asked if I was CPR-certified, not knowing if I was or not. You’re the only health care professional in that kind of setting. Just because we don’t have a lot of hands-on experience, doesn’t mean we can’t help. Even in a hospital setting, the pharmacist may be talking to a patient and something could happen. So yes, it’s incredibly important.


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What other additional training is important for pharmacists to have? It depends on your specialty. There are lots of things you can train yourself in, depending on what kind of practice you’re in. There are classes; there are CEs; there are all kinds of different trainings you can do to


When a customer collapsed in the grocery store where Melissa Gilkison, Pharm.D., was working, she performed CPR until the paramedics arrived.

become certified in specific areas. We have a couple of people in our company who are trained to help diabetic patients, and that’s a big part of retail and independent settings. Fitting diabetic shoes and helping patients find the right walkers, things like that are very important. Do you think the role of the pharmacist is changing? Definitely. With the direction health care and insurance is going, with doctors and doctors’ offices so busy dealing with how they’re going to get paid, a lot of the training for the patients falls on the pharmacist. Our patients trust us more and more every day. We hear

all the time, ‘My doctor didn’t explain any of this to me; I don’t really understand it; You guys know better anyways, so I just waited to ask you.’ And that’s a good feeling. When they leave their doctor’s office confused and they know they can go ask their pharmacist, that’s great. Or, if they don’t get a lot of time at the doctor, they know their pharmacist will spend time with them. So, I think doctors’ offices are, unfortunately, having to focus on whose insurance they carry and how they’re getting paid and how much time they have with each patient, which is less and less. So, our role is definitely becoming more important in educating patients.

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Business Loans How to build the foundation for a successful loan application

Every business needs extra funds at some point. Whether you’re hoping to remodel your store, expand to a new location or ensure that you’re prepared for cash flow timing problems, you’ll likely need a loan to get started. And to secure a loan, you’ll need to work with your banker. Your relationship with your banker is essential to the loan application process, said Justin Squires, senior vice president and small business banking manager at Bank of America. The more your banker understands about you and your pharmacy business, the more productive the process will be. Applying for a line of credit The first type of financing you’ll likely apply for is a line of credit. No matter what stage of business you’re at, a line of credit is a valuable tool and a security measure. It will ultimately help strengthen your application for long-term loans. “We’re always looking to have the maximum number of ways that a business can access credit and cash. We want to have you more liquid and less leveraged,” Squires said of the process at Bank of America. A line of credit is healthy for your business operations and helps establish trust between you and your banker. Defining your goals If you’re expanding or remodeling, Squires said that the key to a successful loan application is starting the process with a strong business plan and clear


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objectives. “The main thing that we always look at is the purpose. We want to match up the credit request and the purpose with the overall goal of the business and what they’re trying to achieve,” he said. It’s important to let your banker know your immediate and future goals, what stage of business you’re in and how this loan will help you. The more your banker understands about your business, the easier it is to identify how the bank can help. Helping your business Ultimately, banks want to help you achieve your business goals. Squires said that he sees his role— and all bankers’ roles—in helping pharmacies and small businesses finance their growth as a way of contributing to a strong and healthy economy. “The more we can contribute to that owner for that business, the more that we play a part in making things better,” Squires said. “If I can improve a business owner’s cash flow, and I increase that cash flow so that they grow and hire another employee, when they hire another employee, they’re helping their community. And when you multiply that out, now you’re helping the economy.” A strong relationship between you and your banker will cultivate growth for your pharmacy and your community. “Create that partnership,” Squires said, “and it could be that impactful and powerful.”


Smoking Cessation How pharmacists can help put a stop to smoking

With more than 16 million Americans suffering today from a disease caused by smoking, you probably often have patients filling prescriptions for smoking-related illnesses in your pharmacy. Tobacco use is the leading preventable cause of death in the U.S., according to the Centers for Disease Control and Prevention (CDC). With regular access to patients, independent community pharmacists are in a prime position to help patients quit smoking and improve their health. “Pharmacists have a unique opportunity to help smokers quit because they are a trusted and accessible source of information and assistance on health issues,” said Stephen Babb, M.P.H., a public health analyst and spokesperson with the CDC’s Office on Smoking and Health. Smoking is an issue pharmacists can help with today. According to the 2014 U.S. Surgeon General’s Report on Smoking and Health, “The current rate of progress in tobacco control is not fast enough, and much more needs to be done to end the tobacco epidemic.” This year marked the 50th anniversary of the first Surgeon General’s report on smoking and health, which was released in 1964. Despite 50 years of campaigns,

more than 42 million people in the U.S. continue to smoke cigarettes today. “If smoking persists at the current rate among young adults in this country, 5.6 million of today’s Americans younger than 18 years of age are projected to die prematurely from a smoking-related illness,” the report stated. Recent events, like CVS Health discontinuing the sale of tobacco products, have brought attention back to the issue of tobacco use and smoking. Many independent community pharmacies already don’t sell tobacco products, and as leaders in their communities they can play a key role in combating tobacco use and helping patients quit smoking for good. Smoking cessation and business Helping your patients live smoke-free isn’t just a public health service; it’s also an opportunity to increase business. Through the sale of cessation prescriptions and front-end products, like nicotine gum, lozenges and patches, you can provide a needed service—and earn revenue. Providing nicotine counseling or even starting a

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Smoking by the numbers

complete smoking cessation program are additional ways to get patients into your pharmacy. “If you can’t get the patients into your pharmacy, then you don’t have any business,” said Fred Mayer, R.Ph., M.P.H., president of Pharmacy Planning Services, Inc., a non-profit corporation offering various health awareness programs to promote public health and education. As a public health advocate and activist, Mayer has worked for more than 50 years to help people stop smoking and to end tobacco sales in pharmacies. He helped start the Great American Smokeout, an annual smoking cessation event now handled by the American Cancer Society, and he started one of the first smoking cessation campaigns in the U.S. at Sausalito Pharmacy, the independent pharmacy he owned in the 1960s. “In those days, doctors were recommending Lucky Strike cigarettes to patients because they made you calm and they said they’d help you lose weight,” Mayer said. “I had a lot of patients coming in with lung problems; I had patients coming in with a cough and a cold; I had people who were dying, but they didn’t know it. So, I decided to get rid of cigarettes in my store and start smoking cessation,” he said. “I went to all the doctors in my community and said, ‘Want to get your patients who have high blood pressure, cholesterol problems, diabetes, asthma and COPD to stop smoking? Send them to Sausalito Pharmacy.’” Mayer said he helped more than 350 patients quit smoking. Today, only 17 percent of independent community pharmacies offer smoking cessation programs, according to the 2014 NCPA Digest conducted by the National Community Pharmacists Association. While, that’s up from 12 percent in 2011, it’s still a relatively small number. Mayer recommends that pharmacists obtain smoking cessation certification and then work to develop a simple smoking cessation program in their pharmacies. “Pharmacists are the most available and accessible, but the most underutilized of all health care professionals,”


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480,000 – Deaths per year in the U.S. due to cigarette smoking

69 – Percent of adult smokers in the

U.S. who want to stop smoking

50 – Million adults in the U.S. who are

former smokers

Sources: Centers for Disease Control and Prevention, The American Lung Association

he said. “You’re underutilized; you’re trained, and you can do smoking cessation.” Helping patients quit Many people want to quit smoking. In fact, 69 percent of adult smokers want to stop smoking and 43 percent have made a quit attempt in the past year, according to the CDC. They just don’t know how to quit for good. That’s where pharmacists can make a difference. “Pharmacists are well-positioned to personalize the health effects of smoking by educating customers that specific health conditions they are experiencing are caused or exacerbated by smoking,” said Babb of the CDC. “One specific area where pharmacists can make a big difference is in ensuring that patients use cessation medications correctly,” Babb said. “Using medications correctly is an important factor in successful cessation.” Often, you can also help your patients simply by advising them to quit smoking and then providing them with information. It’s a good idea to ask questions about tobacco use when you create profiles of new patients and then to follow up with them. “Pharmacists can leverage their relationships and credibility with regular customers to motivate them to quit, and to help them to quit successfully when they

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are ready to do so,” Babb said. “Pharmacists’ ongoing contact with customers also allows them to follow up with smokers over time to check how their quit attempt is going and to provide additional help if necessary.” The CDC recently created a website full of resources for pharmacists to help their patients stop smoking. The website (www.cdc.gov/tobacco/campaign/tips/partners/ health/pharmacist) includes handouts for patients, posters you can download and hang in your pharmacy,

frequently asked questions for health care providers, a video on how to conduct a tobacco intervention and additional resources for referring patients. “Pharmacists’ role in helping smokers quit is only likely to grow as more smokers who were previously uninsured or underinsured gain cessation coverage and as many pharmacies begin to take on more health care functions,” Babb said.

The 5-Step Tobacco Intervention Follow these easy steps to conduct a brief tobacco intervention with your patients.

1. Ask about tobacco use Make asking about tobacco use standard procedure in your pharmacy. Always ask new patients, “Do you currently smoke or use other forms of tobacco?” 2. Advise the patient to quit If the patient uses tobacco, your next step is to advise the patient to quit. You can say, “Quitting tobacco is one of the best things you can do for your health. I strongly encourage you to quit.”

3. Assess readiness to quit Next, get a feel for how the patient feels about quitting by asking, “Are you interested in quitting tobacco?”

4. Assist the patient in quitting If patients are ready to quit, provide brief counseling and obtain a prescription from the patient’s doctor (if appropriate.) Refer patients to other support resources that can complement your care, such as quitlines, like 1-800-QUIT-NOW; websites like smokefree.gov and betobaccofree.gov; or group counseling. If patients aren’t ready to quit, strongly encourage them to consider quitting by using personalized motivational messages. Let them know you’re there to help when they’re ready.

5. Arrange for follow up Follow up regularly with patients who are trying to quit. Make a note to check in with them whenever they come in to pick up a refill. Source: Adapted from “The Brief Tobacco Intervention” from the Centers for Disease Control and Prevention

Resources Agency for Healthcare Resource and Quality www.ahrq.gov/path/tobacco.htm Tips for pharmacists on how to offer brief tobacco counseling. Centers for Disease Control and Prevention www.cdc.gov/tobacco/campaign/tips/partners/health/pharmacist Download handouts and posters, watch videos and get tips specifically for pharmacists to help patients quit smoking. Smoking Cessation Leadership Center http://smokingcessationleadership.ucsf.edu/Resources.htm Tools and resources to help pharmacists and other health professionals with tobacco intervention.

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What’s Trending? Five up-and-coming trends for independent pharmacies in 2015 Get ready to think differently about your business in 2015. The health care industry is evolving and your independent community pharmacy must, too. If you understand the trends of tomorrow, then you can adapt to make them work for your business and your community today. These five emerging trends are ones to watch out for—and implement—in the New Year.

Star Ratings for pharmacies, only for health plans. But the plans can assess how their network pharmacies meet CMS-defined quality measures. Completing your MTM cases can help improve adherence levels and medication safety, which is what the Star Ratings are based on. As a result, maintaining high ratings can potentially improve pharmacy reimbursement and network participation.

back. And it’s not just front-end data. Knowing your patients—their disease states, potential drug interactions, adherence rates, gaps in therapy and high-risk medications—will be important in 2015. You’ll need to know your performance numbers in order to meet the expectations of health plans, PBMs and CMS, and also to ensure network participation and continued access to patients.

Natural products for front end The “going green” movement is coming to pharmacies. Diversify the offerings in your front end in 2015 by stocking natural vitamins, supplements and health and beauty products. Fifteen percent of consumers say they’ll use more natural and organic products in the next 12 months, according to a 2014 report by IRI, a market research company. If you’re not stocking a varied selection of natural health, beauty and personal care products, you could be missing out on front-end sales.

Specialty pharmacy The specialty market is booming right now, and it’s an area your pharmacy can access. Help make health care local again for the patients in your community. Patients who are living with chronic conditions that require specialty medications can benefit from a specialty care program at your pharmacy. (To find out more about how to start a specialty care program, check out page 16.)

Disease state management services As pharmacy grows more clinically focused, now’s the time to consider niche areas your pharmacy can specialize in. The most common disease state management services independent community pharmacies currently provide are immunizations, blood pressure monitoring and diabetes training, according to the 2014 NCPA Digest conducted by the National Community Pharmacists Association. Some niche areas to look into for 2015 include smoking cessation, lipid monitoring, asthma management, weight management, osteoporosis services, HIV/AIDS, anticoagulation monitoring and pet medicines.



Medication therapy management Signing up for and completing your assigned medication therapy management (MTM) cases will be increasingly important in 2015. The Centers for Medicare and Medicaid Services (CMS) don’t currently issue


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Big data Whether it’s analyzing loyalty card transactions, coupon redemption at point-ofsale or prescription purchases, understanding data about your patients is essential to success. Like many retailers, national chain pharmacies and big box stores are already collecting and analyzing as much data as they can to increase sales and keep customers coming



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Elements Magazine - Vol.3 Iss.4 Dec 2015  

Elements Magazine - Vol.3 Iss.4 Dec 2015  

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