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MODULE 23: THE HSSP AS A SYSTEM-WIDE ASSET
Section 1: Integration with Hospitals, IDNs, and Clinics
A deep dive into the operational, clinical, and data integration of an HSSP. We’ll explore how the pharmacy plugs into the EMR, shares data with providers, and becomes a seamless part of the Integrated Delivery Network’s (IDN) care continuum.
SECTION 23.1
Integration with Hospitals, IDNs, and Clinics
The HSSP as the Central Nervous System of Specialty Care.
23.1.1 The “Why”: Beyond “Meds in a Box”
Welcome to one of the most important modules in this entire program. If you grasp the concepts in this section, you will understand the fundamental “why” behind the existence and explosive growth of Health-System Specialty Pharmacies (HSSPs). For decades, specialty pharmacy was an external, siloed entity. A provider in a hospital-owned clinic would diagnose a patient, fill out a complex form, and fax it into a “black hole”—an external, mail-order specialty pharmacy owned by a PBM or large corporation. Weeks could pass with no communication. Was the referral received? Was the prior authorization approved? Did the patient get the drug? Did they know how to take it? Nobody knew.
This model is the very definition of fragmented care. It creates massive gaps in data, communication, and clinical oversight. The provider is blind, the pharmacist is disconnected, and the patient is lost in the middle. The external pharmacy’s primary function is logistical: to ship a (very expensive) box from Point A to Point B. Your experience in community pharmacy has shown you the frustration of this model. A patient comes to your counter, desperate for their Humira, only for you to tell them, “I’m sorry, this has to be filled by a specialty pharmacy.” You are as much a victim of the silo as the patient.
The Health-System Specialty Pharmacy is the antidote to this fragmentation. Its value proposition is not simply “we can also ship that box.” Its value proposition is total integration. The HSSP’s premise is that by embedding the specialty pharmacy *within* the health system, it can leverage the system’s existing infrastructure—the Electronic Medical Record (EMR), the provider relationships, and the clinical data—to create a seamless, transparent, and clinically superior patient experience. This section is a deep dive into the “how.” We will explore the three pillars of integration: data, operational, and clinical. This is how an HSSP stops being a simple “dispensary” and becomes the true central nervous system for specialty medication management across the entire health enterprise.
Pharmacist Analogy: The Internal Specialist vs. The External Consultant
Think about how physicians work within your hospital. When a hospitalist on the medicine floor needs help managing a complex heart failure patient, they have two choices.
The External Consultant: They could refer the patient to a cardiologist across town. That cardiologist would require a faxed referral, a packet of records, and would see the patient in 2-4 weeks. They would make recommendations in their own separate EMR, which would eventually be faxed back to the hospitalist, long after the patient’s acute needs have changed. This is a transactional, fragmented relationship. This is the external specialty pharmacy model.
The Internal Specialist: The hospitalist places an “Internal Consult to Cardiology” in the EMR. The in-house cardiologist gets a notification, opens the same EMR chart, and sees the patient’s entire history—labs, notes, imaging, and vitals, all in real-time. They walk up to the floor, see the patient that day, and write their recommendations directly in the shared EMR chart for the *entire team* to see instantly. This is a collaborative, integrated relationship.
The HSSP is the Internal Specialist. Your power comes not from being a different pharmacist, but from being the right pharmacist, in the right place, with the right data, at the right time. This integration is your ultimate competitive and clinical advantage.
23.1.2 The Digital Backbone: EMR Integration as the Central Nervous System
The single most valuable asset of an HSSP is not its inventory, its cleanroom, or its location. It is its unfettered, real-time access to the health system’s Electronic Medical Record (EMR). This is the digital backbone of all three forms of integration. In your community practice, you were lucky to get a diagnosis code on a prescription. As an HSSP pharmacist, you have the entire clinical narrative.
When a referral for Skyrizi hits your queue, you don’t just see a prescription. You see:
- The gastroenterologist’s latest colonoscopy report and clinical note.
- The patient’s full problem list, including comorbidities like CHF or hepatitis.
- A complete medication list, including prescriptions from other providers.
- A full allergy profile, including reaction histories.
- All recent and pending lab results (e.g., baseline TB test, LFTs, CBC).
- The patient’s upcoming appointment schedule.
- The provider’s full contact information, including their EMR “in-basket” messaging address.
This complete data access transforms your role from a reactive dispenser to a proactive clinical manager. But not all “integration” is created equal. True integration is a spectrum, and as an HSSP leader, you must constantly advocate for moving your pharmacy to the highest level possible.
Masterclass Table: The Levels of EMR & Dispensing System Integration
| Integration Level | Description | HSSP Capability (What you can do) | Primary Weakness |
|---|---|---|---|
| Level 0: No Integration (“The Black Hole”) | The HSSP operates on a completely separate, standalone pharmacy system (e.g., CPR+) with no EMR access. This is the external SP model. | Fill prescriptions received via fax. Call providers for all information. Hope for the best. | Clinically blind. Operationally catastrophic. No way to prove value. This model is non-functional for an HSSP. |
| Level 1: Read-Only Access (“The Window”) | The HSSP team has view-only logins to the EMR (e.g., Epic Hyperspace), but the pharmacy dispensing system is still separate. | Look up clinical data. You can see labs, notes, and allergies. This allows you to perform a safe clinical review and gather justification for PAs. | No “write” access. You cannot write notes in the EMR. You cannot message providers. Data must be manually re-entered into your pharmacy system (high error risk). |
| Level 2: Interfaced / Bi-Directional (“The Bridge”) | The EMR (e.g., Epic) and the HSSP’s dispensing software (e.g., Therigy, WellSky) are connected via an HL7 interface. | Data flows automatically. New e-prescriptions route to a digital queue. Patient demographics, allergies, and lab results populate in the pharmacy system. Dispense info *may* flow back to the EMR MAR. | Often clunky and not real-time. Interfaces break. You still work in two different systems, “swivel-chairing” between them. Writing notes is difficult. |
| Level 3: Full Integration (“The Native”) | The HSSP’s dispensing module lives inside the EMR. The primary example is Epic Willow Ambulatory. | One Patient, One Record, One System.
|
Cost and complexity. This is the most expensive and resource-intensive model to build and maintain. However, its value is unmatched. |
The “Fake Integration” Trap
A common pitfall is what’s known as “swivel-chair” integration. This is when an HSSP has two separate systems (EMR and dispensing) and claims they are “integrated” because a staff member sits with two monitors and manually types information from one screen into the other. This is not integration. This is manual data entry. It is slow, inefficient, and creates an enormous risk of transcription errors (e.g., typing the wrong dose, wrong directions). True integration means data flows electronically, without human hands typing it. As an HSSP leader, you must fight for true, interfaced (Level 2) or fully integrated (Level 3) systems.
23.1.3 Operational Integration: The “How” of Patient & Data Flow
Data integration is the *what*; operational integration is the *how*. It’s the real-world workflow of how a patient referral moves from a provider’s brain to a dispensed medication at the patient’s door. A poorly designed workflow will create bottlenecks, frustrate providers, and delay care, even with the best EMR system. A brilliant workflow, however, feels “invisible” and seamless to the clinic and the patient. Your goal is to build an invisible, frictionless process.
The core of operational integration is the HSSP Patient Referral Workflow. This workflow is built, managed, and optimized by the pharmacy team, and it all begins with the provider’s e-prescription.
Visualizing the HSSP Referral Workflow
Let’s map the ideal workflow in a fully integrated (Level 3) system. Notice how every step is a digital handoff, not a fax or a phone call.
Step 1: The Referral (Provider Action)
A provider in a specialty clinic (e.g., Rheumatology) sees a patient and e-prescribes a new-start Humira. The prescription is routed electronically to the HSSP’s EMR Work Queue (e.g., an Epic “In-Basket” pool) instead of to an external pharmacy.
Step 2: Triage & Data Capture (HSSP Liaison Action)
An HSSP Pharmacy Liaison (a specialized technician or pharmacist) monitors this queue in real-time. They “pick” the referral, which opens the patient’s full EMR chart. They review the note, confirm demographics, and check for any obvious missing information. They create the “Specialty Pharmacy Encounter” in the EMR.
Step 3: Benefits Investigation & Prior Authorization (HSSP BI Team)
The encounter is routed to the Benefits Investigation (BI) team. They run a test claim to determine coverage. If a Prior Authorization (PA) is needed, they initiate it immediately. Crucially, they pull the clinical notes and labs needed for justification *directly from the EMR*. They don’t need to call the clinic and ask for “chart notes.”
Step 4: Clinical Review (HSSP Pharmacist Action)
While the PA is pending, the encounter routes to the Pharmacist’s clinical queue. The pharmacist performs a full clinical review within the EMR. They check for DDIs, confirm baseline labs (TB, LFTs) are done, check for contraindications (e.g., active infection), and verify the dose. They then write a Clinical Note in the EMR documenting their approval.
Step 5: Financial Clearance & Patient Contact (HSSP Liaison Action)
The PA is approved. The BI team re-runs the claim. The copay is $250. The team identifies a manufacturer copay card and a foundation grant, applies them, and brings the patient’s cost to $0. The Liaison calls the patient: “Hi, I’m from the hospital’s specialty pharmacy team. Your Humira is approved and your copay is $0. I’ve scheduled your one-on-one injection training with our pharmacist.”
Step 6: Dispense & Follow-Up (HSSP Pharmacy Team)
The order moves to the dispensing queue. The drug is filled, billed, and either delivered to the patient’s home or sent to the clinic for pickup (“meds-to-beds” for outpatients). The pharmacist counsels the patient. A follow-up adherence call is automatically scheduled in the EMR for 7 days post-dispense. The entire process is documented in the shared chart.
23.1.4 Clinical Integration (Part 1): The Embedded Pharmacist & Liaison Model
This is the “boots-on-the-ground” component of integration. Data and operational workflows are the foundation, but clinical integration is what builds trust, improves outcomes, and makes the HSSP truly indispensable. The most effective HSSPs do not hide in a basement pharmacy. They are visible, proactive partners who are physically and functionally part of the clinical teams they serve.
The pinnacle of this model is the embedded HSSP pharmacist or liaison. This is a member of your pharmacy team (often a pharmacist or a highly skilled technician/liaison) who physically sits in the specialty clinic (e.g., the Oncology center, the GI clinic, the Transplant clinic) several days a week. They become a core part of that clinic’s team.
A Day in the Life: The Embedded HSSP GI Liaison
To understand the power of this model, let’s follow “Sarah,” an HSSP Pharmacy Liaison, during her day embedded in the hospital’s Gastroenterology clinic.
- 8:00 AM: Clinic Huddle. Sarah joins the GI clinic’s morning huddle with the MDs, NPs, and MAs. The lead NP says, “We have a new-start Crohn’s patient in Room 3 who is very anxious, and a patient in Room 5 who is failing Humira and we need to switch to Entyvio.” Sarah takes notes. She is already planning the PAs and patient education.
- 9:00 AM: The “Warm Handoff.” The NP sees the new-start patient in Room 3. At the end of the visit, the NP says, “I’m prescribing you Skyrizi. It’s a complex medication, so I’m going to introduce you to Sarah. She is our pharmacy expert on my team, and she will handle *everything* for you—the insurance, the financial aid, and teaching you how to use it.”
- 9:15 AM: Bedside Benefits & Education. Sarah sits with the patient *in the exam room*. She pulls up their insurance on her laptop and explains the PA process. She sets expectations (“This may take 3-5 days, but I will call you every 48 hours with an update”). She answers initial questions. The patient leaves with a single point of contact and a face with a name. They are not calling a 1-800 number.
- 10:30 AM: Provider Consultation. The MD from the huddle catches Sarah at her desk. “Hey, that patient in Room 5, the Humira failure—what do you think is faster to get, Entyvio or Stelara? Their insurance is Aetna.” Sarah does a quick “benefits check” on the spot. “Aetna prefers Stelara and has a simpler PA. Let’s go with that. I’ll get the PA started.” She just saved the clinic hours of work and the patient weeks of delay.
- 1:00 PM: EMR Triage. Sarah works her HSSP “In-Basket” queue. She sees all the *other* GI clinic prescriptions. She initiates PAs, gathers clinical data from the EMR, and routes the clean, clinically-vetted referrals to the central pharmacy for fulfillment.
- 3:00 PM: Closing the Loop. She gets an alert: a PA for a patient from two days ago was approved. She messages the patient via the EMR portal (“Good news! Your Xeljanz is approved!”) and sends the prescription to the dispensing queue. She also sends a quick EMR message to the provider: “FYI – Mrs. Smith’s Xeljanz PA was approved, and we are scheduling delivery. She is all set.”
Masterclass Table: Embedded vs. Centralized HSSP Models
| Model | Description | Pros (Advantages) | Cons (Disadvantages) |
|---|---|---|---|
| Embedded Model | HSSP pharmacists and/or liaisons are physically co-located within the specialty clinics they serve. | ||
| Centralized Model | All HSSP staff (pharmacists, liaisons, BI team) are located in one central pharmacy hub, managing referrals digitally via EMR queues. | ||
| Hybrid Model (The Best) | A “hub-and-spoke” model. Liaisons are embedded in high-volume clinics (Onc, GI, Rheum) to capture patients, while the centralized team (pharmacists, BI, dispensing) manages the complex fulfillment. | This is the optimal approach. It combines the “high-touch” capture of the embedded model with the “high-tech” efficiency of the centralized model. The liaison acts as the “concierge” and single point of contact, while the central hub does the heavy lifting. | |
23.1.5 Clinical Integration (Part 2): Collaborative Practice Agreements (CPAs)
If the embedded pharmacist is the highest *service* level of integration, the Collaborative Practice Agreement (CPA) is the highest *clinical* level of integration. This is where the HSSP pharmacist transcends the traditional role of “dispenser” and becomes a true “provider” and clinical partner, sharing responsibility for patient outcomes.
A CPA is a formal, written agreement between a pharmacist (or group of pharmacists) and a provider (or group of providers) that allows the pharmacist to initiate, modify, or discontinue medication therapy and order/interpret laboratory tests, all under a pre-defined protocol. This is the HSSP pharmacist practicing at the absolute top of their license.
In your community practice, you are an expert at identifying problems (e.g., “This dose is too high,” “This patient needs a lab test”). Under a CPA, you don’t just *identify* the problem—you *fix it* yourself, and then you document what you did. This is a game-changer for clinic efficiency and patient safety.
Masterclass Tutorial: Building a CPA for Hepatitis C
Let’s design an HSSP-driven CPA protocol for Hepatitis C (HCV) management. This is a perfect example of a protocol-driven, “curative” disease state that is ideal for pharmacist management.
Example CPA Protocol: HSSP Pharmacist-Led Hepatitis C Management
- The Trigger: A Primary Care Provider (PCP) or GI provider identifies a patient with a positive HCV antibody test. The provider places an EMR referral: “Consult HSSP Pharmacist – HCV Management.”
-
Pharmacist Action (Per CPA): Initiate Baseline Workup.
- The HSSP pharmacist receives the consult. Under the CPA, the pharmacist orders and reviews the required baseline labs:
- HCV RNA Viral Load (to confirm active infection)
- HCV Genotype
- Liver Panel (LFTs), CBC, INR
- FibroSure or FibroScan (to assess for cirrhosis)
- Hepatitis A and B serologies
-
Pharmacist Action (Per CPA): Select & Prescribe Therapy.
- The pharmacist reviews all lab results *in the EMR*.
- Patient has: Genotype 1b, no cirrhosis, treatment-naive.
- Pharmacist (Per CPA): Selects the appropriate, guideline-driven, and payer-preferred agent (e.g., MAVYRET 3 tabs PO daily x 8 weeks).
- The pharmacist generates the prescription under the CPA, which is co-signed by the delegating provider.
-
HSSP Internal Action: Secure Access.
- The HSSP’s BI team (now working on their own pharmacist’s order) completes the PA and financial assistance.
-
Pharmacist Action (Per CPA): Patient Education & Monitoring.
- The pharmacist dispenses the 8-week supply.
- The pharmacist performs the full education and counseling session.
- Per protocol, the pharmacist orders follow-up labs (e.g., 4-week LFTs/CBC) and a 12-week post-treatment Viral Load (SVR-12) to confirm cure.
-
Pharmacist Action (Per CPA): Document Cure.
- The SVR-12 lab result comes back: “Not Detected.”
- The pharmacist writes the final clinical note in the EMR: “Patient has successfully completed MAVYRET therapy and has achieved SVR-12, indicating a cure for Hepatitis C. Case closed.”
The Result: The patient was cured. The provider placed *one* consult, and the HSSP pharmacist team handled the *entire* clinical and operational process. This is the definition of integrated, top-of-license care.
CPA Pitfalls: Meticulous Documentation is Non-Negotiable
A Collaborative Practice Agreement is not a “blank check.” It is a formal, legal delegation of authority. This authority can be revoked instantly if it is misused or, more commonly, poorly documented. If you do not document it, it did not happen. Every action taken under a CPA—every lab ordered, every dose change, every patient assessment—must be documented in a formal, professional, and timely clinical note within the EMR. This documentation is your legal and professional justification for your actions. It proves your value, ensures continuity of care, and is the first thing an auditor will review. A successful CPA program is built on a foundation of obsessive-compulsive documentation.
23.1.6 The Data Goldmine (Part 1): Leveraging EMR Data for Proactive Clinical Interventions
Now we circle back to the EMR, the digital backbone. We’ve established that having “read-only” access (Level 1) is good, and having “read-write” access (Level 3) is best. But *how* do you leverage that access to do more than just fill a prescription? You use the data to become a proactive clinical safety net for the entire health system.
Your EMR access allows you to monitor not just the patient’s fill history, but their entire clinical journey. This enables you to catch and prevent adverse events in a way no external pharmacy *ever* could. You are no longer just monitoring for adherence; you are monitoring for safety and efficacy.
The HSSP Mindset Shift: From Reactive Dispensing to Proactive Monitoring
External Pharmacy (Reactive): “The patient’s refill for their TNF-inhibitor is due. I will fill it and ship it.” (The pharmacist has no idea the patient was just admitted to the hospital for a severe infection).
HSSP (Proactive): “The patient’s refill is due. I see in the EMR they were admitted to our ED 2 days ago with a 102.5°F fever and a high white count. I am holding this refill. I am messaging the provider and the inpatient team to alert them that the patient is on a biologic and that the next dose should be held pending infection workup.”
This single, proactive intervention—made possible *only* by EMR integration—prevents a catastrophic adverse event (giving an immunosuppressant during an active infection) and potentially saves the health system hundreds of thousands of dollars from a complicated, prolonged hospital stay. This is the unambiguous value of an HSSP.
Masterclass Table: The EMR Data-to-Intervention Playbook
| EMR Data Point | The “Signal” (What it means) | The Proactive HSSP Pharmacist Intervention |
|---|---|---|
| A patient on Rinvoq (upadacitinib) has new LFTs result in the EMR, showing LFTs > 3x ULN. | This is a sign of drug-induced liver injury, a black-box warning for JAK inhibitors. The provider may not have seen this lab yet. | HOLD the next refill. CALL the patient to assess for symptoms (jaundice, nausea). MESSAGE the provider immediately: “Dr. Smith, I saw Mrs. Jones’s new LFTs. Her ALT is 180. Per package insert, I am holding her Rinvoq. Please advise.” |
| A patient on Gilenya (fingolimod) for MS has an EMR note from a cardiologist for “new-onset bradycardia.” | Gilenya’s first dose causes bradycardia, but this is new. The cardiologist may not know the patient is on Gilenya. | MESSAGE both the neurologist and the cardiologist: “FYI, this patient is on Gilenya, which has a known side effect of bradycardia. This may be contributing to their new-onset symptoms. Please review.” |
| This is the NUMBER ONE black-box warning for JAK inhibitors. This is a critical safety signal. | IMMEDIATELY HOLD all future refills. MESSAGE the provider: “Per black-box warning, Xeljanz is contraindicated in patients with a new PE. We are holding all future fills and recommend permanently discontinuing.” | |
| A patient on Otezla (apremilast) has a new prescription in the EMR for Carbamazepine from an outside neurologist. | Carbamazepine is a strong CYP3A4 inducer. Otezla is a 3A4 substrate. This will cause a sub-therapeutic Otezla level. | |
| A patient on Hepatitis C therapy (e.g., MAVYRET) misses their 4-week follow-up lab appointment. | This is an adherence/efficacy monitoring failure. We don’t know if the drug is working or if it’s safe. | CALL the patient: “Hi, this is your HSSP pharmacist. I see you missed your 4-week lab draw. This is critical for us to monitor. I’ve placed a new order for you at the lab. Can you go tomorrow?” |
23.1.7 The Data Goldmine (Part 2): Reporting, Outcomes, and Proving Value
The clinical interventions in the last section were on the individual patient level. The second, and equally important, use of this data goldmine is on the population level. By being integrated into the EMR, your HSSP is uniquely positioned to collect, aggregate, and report on clinical outcomes in a way no external pharmacy can. You don’t have to ask for data; you own it.
This aggregated data is the language you use to speak to hospital leadership, to payers, and to manufacturers. It is how you prove your value in concrete, financial, and clinical terms. An external pharmacy can report on its *time-to-fill* and *copay collection*. An HSSP can report on its *disease cure rates* and *hospital admission avoidance*. These are not in the same league.
Building Your HSSP Clinical Dashboard
This data becomes the basis for your HSSP’s “report card” to the health system C-Suite. This is the dashboard that justifies your existence and secures future investment.
Hepatitis C (HCV)
98.9%
SVR-12 (Cure Rate)
(n=412 patients treated)
Rheumatoid Arthritis
94.2%
PDC (Adherence Rate)
(vs. 78% external SP average)
New Start Oncology
2.1 Days
Average Time-to-Therapy
(vs. 11.4 days external SP)
Leveraging Outcomes Data
This dashboard becomes your ultimate tool:
- For Health System Leadership (The C-Suite): “Our HSSP isn’t a cost center; it’s a value generator. We are curing 99% of our Hep C patients and getting our cancer patients on therapy 5x faster than the alternative. This is a critical asset for our IDN’s quality scores.”
- For Payer Contracting: “We don’t just want to be *in* your network; we want to be your *exclusive* specialty provider for your members at our institution. Our EMR-verified data shows our adherence and outcomes are 20% higher than the network average. Partnering with us will lower your total cost of care.”
- For Manufacturer Partnerships: “Our integrated system can track a patient from prescription to outcome. We can provide you with anonymized, real-world evidence (RWE) on your drug’s performance and adherence in our system, data you cannot get from any external PBM pharmacy.”
The Payer Negotiation Playbook: Speaking Their Language
When you talk to a payer (like Aetna or Cigna), they don’t care about your dispensing fee. They care about total cost of care. Your integration is your key.
Your Pitch: “You are currently paying for 100 MS patients at our hospital. 50 of them go to your external specialty pharmacy, and 50 come to our HSSP. Our EMR data shows that our HSSP-managed patients had 40% fewer MS-related ER visits and 30% fewer hospital admissions over the last 24 months. Why? Because our embedded pharmacists are monitoring their adherence, catching side effects, and preventing relapses. The ‘cheaper’ external pharmacy is costing you *more* in medical spend. Give us exclusivity for our patients, and we will save you $1.2 million a year in avoidable hospital costs.”
This is how an integrated HSSP proves its value and wins contracts.
23.1.8 The IDN Ecosystem: The HSSP as a System-Wide Asset
Now let’s zoom out to the 30,000-foot view. Most HSSPs exist within a larger Integrated Delivery Network (IDN). An IDN is a health system that tries to provide a full continuum of care—from primary care, to specialty clinics, to hospitals, to home health, to its own health plan—all under one corporate umbrella. Think of systems like Kaiser Permanente, Geisinger, UPMC, or Intermountain Healthcare.
The ultimate goal of an IDN is to manage the health of a population and control the total cost of care. To do this, they are guided by the “Triple Aim” (now often the Quadruple Aim):
- Better Health: Improve the health outcomes of their patient population.
- Better Care: Improve the patient experience (satisfaction, access, quality).
- Lower Costs: Reduce the per-capita cost of healthcare.
- (Quadruple Aim adds: Improving the provider/staff experience).
The integrated HSSP is one of the most powerful tools an IDN has to achieve these goals, especially for the 5% of patients (on specialty drugs) who drive 50% of the total drug spend.
Masterclass Table: How the Integrated HSSP Drives the IDN’s “Triple Aim”
| The IDN Goal | The Problem with External Specialty Pharmacies | The Integrated HSSP Solution & Strategy |
|---|---|---|
| 1. Better Health (Clinical Outcomes) | No data sharing. External SP is blind to lab results, side effects, or hospitalizations. They just ship the drug. This leads to non-adherence, treatment failures, and adverse events. | Clinical & Data Integration. HSSP pharmacists use EMR data to proactively monitor safety, adherence, and efficacy. They manage side effects in real-time and use CPAs to optimize therapy, leading to higher cure rates (Hep C) and lower relapse rates (MS). |
| 2. Better Care (Patient Experience) | The “black hole.” Patients are confused. They have one number for their doctor and another 1-800 number for a pharmacy that doesn’t know them. Delays are common and communication is poor. | Operational & Clinical Integration. The “warm handoff.” The patient meets their HSSP liaison in the clinic. They have *one* trusted team. The HSSP pharmacist is a visible, accessible part of their care, leading to massive gains in patient satisfaction. |
| 3. Lower Costs (Total Cost of Care) | An unmanaged, non-adherent patient is an expensive patient. They end up in the ER or admitted to the hospital—the most expensive sites of care. The external SP model is blind to this and cannot prevent it. | Data & Financial Integration. The HSSP lowers total cost in two ways:
1) Clinically: Proactive monitoring prevents ER visits and readmissions. 2) Financially: The HSSP leverages 340B pricing (see Section 23.2) and captures pharmacy revenue that was “leaking” out, keeping it inside the IDN. |
23.1.9 Interoperability: The FHIR Standard and the Future of Integration
This is a masterclass-level topic that will prepare you for the future of health-system pharmacy. For decades, the “integration” we’ve discussed (Level 2) has been powered by a standard called HL7 (Health Level Seven). You can think of HL7 as the “digital fax machine” of healthcare.
- HL7: It’s a rigid, message-based standard. An “event” (like a patient discharge, or a new lab result) triggers a “message” that gets pushed from one system to another. It’s one-way and hard to query. You can’t just “ask” an HL7 system for a specific piece of data; you have to wait for it to be pushed to you.
The future of integration, and the standard that will power the next generation of HSSP tools, is FHIR (Fast Healthcare Interoperability Resources). You must know this term. You can think of FHIR as the modern API (Application Programming Interface) for healthcare.
- FHIR: It’s a web-based standard that breaks data down into “resources” (e.g., “Patient,” “Medication,” “Observation”). Instead of clunky messages, it allows one system to make a direct, real-time “query” to another, just like a website pulling data from a server.
Why FHIR is a Game-Changer for HSSPs
FHIR allows for the creation of “apps” that can plug directly into any EMR or pharmacy system. Imagine a future state, even if your dispensing system is *not* Epic Willow (Level 2):
A provider is in a patient’s chart in Epic. They click a “Specialty Pharmacy” button on the sidebar. A FHIR-based app opens *inside their Epic window*. This app makes a real-time call to your HSSP’s dispensing system and displays:
“Patient: John Smith
Medication: Cosentyx
PA Status: Approved (Expires 12/31/2026)
Copay: $0.00 (Copay card on file)
Last Fill: 10/15/2025
Next Fill: 11/12/2025 (Scheduled)
Last Pharmacist Note: ‘Counseled pt on 10/15, no side effects reported.'”
This is the “holy grail” of interoperability. The provider gets all the information they need, in real-time, without ever leaving their EMR, and without you having to be on a fully integrated (Level 3) system. Understanding and advocating for FHIR-based solutions will be a key part of your role as an HSSP leader.
23.1.10 Tying It All Together: A Case Study of Total Integration
Let’s walk through a complex, real-world case from start to finish to see how all three pillars of integration (Data, Operational, Clinical) work together to create a perfect patient experience.
The Patient: “Mrs. Chen”
- Diagnosis: Newly diagnosed HER2+ breast cancer.
- Plan:
- IV “Buy-and-Bill”: Herceptin (trastuzumab), given in the hospital’s ambulatory infusion center.
- Oral “Pharmacy Benefit”: Xeloda (capecitabine), to be taken at home.
- Supportive Care: Zofran (ondansetron) for nausea.
The Integrated HSSP Workflow in Action
- [OPERATIONAL]: The Referral. The oncologist (Dr. Lee) places all three orders in the EMR (Epic). The Herceptin order routes to the Infusion Center’s queue. The Xeloda and Zofran orders route to the HSSP’s “Willow Ambulatory” work queue.
- [DATA]: Triage. The HSSP Liaison (Sarah, from our “Day in the Life”) picks up the Xeloda referral. She immediately has full data access. She reviews Dr. Lee’s note, the pathology report confirming HER2+ status, and the patient’s baseline labs (CBC, LFTs, CrCl). She sees the linked Herceptin order and the patient’s “Chemo Cycle 1, Day 1” appointment scheduled for next Monday.
- [CLINICAL]: Clinical Review. The referral routes to the HSSP Oncology Pharmacist (Tom). Tom reviews the full regimen. He uses his data integration to verify the Xeloda dose based on the patient’s CrCl and BSA. He sees the plan is for a 14-days-on, 7-days-off cycle. He notes that the Zofran is ordered “TID PRN” but knows from experience that “scheduled” dosing for the first few days is better.
- [OPERATIONAL]: Financial Clearance. The BI team begins the PA for Xeloda. They attach Dr. Lee’s EMR note and the path report directly to the PA submission. The PA is approved in 24 hours. The test claim shows a $500 copay. The team immediately enrolls Mrs. Chen in the Xeloda manufacturer copay program and a hospital foundation fund, bringing her cost to $0.
- [CLINICAL]: Proactive Intervention. Tom, the pharmacist, sends an EMR in-basket message to Dr. Lee: “Dr. Lee, I’m verifying the Xeloda for Mrs. Chen. Dosing is correct. I recommend we change the Zofran to ‘8 mg PO TID *Scheduled* for Days 1-3’ to better prevent CINV, then PRN. I’ve pended the order for your signature if you agree. We have cleared her Xeloda, and her copay is $0. We will dispense a 14-day supply to align with Cycle 1.”
- [OPERATIONAL]: The “Meds-to-Beds” Handoff. Dr. Lee signs the pended order. The HSSP team prepares the Xeloda and the *newly-optimized* Zofran order. They coordinate with the Infusion Center. On Monday, when Mrs. Chen arrives for her Herceptin infusion, the HSSP pharmacist (Tom) meets her at the infusion chair.
- [CLINICAL]: The Perfect Discharge. Tom performs the full Xeloda counseling at the chairside. He hands her the “Meds-to-Beds” fill of Xeloda and Zofran. He gives her a printed calendar showing her “on-off” days. She leaves the hospital with her IV drug infused and her oral drugs in her hand. She has met *one* pharmacy team, at *one* location, all part of her trusted hospital.
- [DATA]: Follow-Up. Tom documents his counseling in a formal EMR clinical note, visible to Dr. Lee. He schedules two follow-up calls in his EMR queue: a “Day 3” call (to check on nausea) and a “Day 7” call (to screen for hand-foot syndrome).
This entire, complex process was managed by the HSSP as a single, seamless event. The provider was supported, the patient was never confused, and safety was maximized. This is the power of integration.
23.1.11 The Human Element: Building Trust with Providers and Clinics
You can build the most advanced, expensive, and perfectly integrated EMR workflow in the world, but it is utterly useless if the providers and clinic staff refuse to use it. Technology is only the tool. Trust is the currency. Clinical integration is built on a foundation of human relationships.
You must remember that from a clinic’s perspective, “specialty pharmacy” has historically been a source of pain. They are conditioned to expect delays, endless faxes, and angry patient phone calls. When your new HSSP opens, they will view you with that same skepticism. “You’re just *another* pharmacy,” they’ll think. “It’s easier for me to keep faxing to Accredo. At least I know their fax number.”
Your first and most important job is to prove you are different. You are not “another pharmacy”; you are their pharmacist. You are part of their team.
How to Build Trust and Become the “Path of Least Resistance”
- 1. Show Up. You cannot build trust from a basement office. Put on your white coat and walk up to the clinics. Introduce yourself to the clinic managers, the MAs, and the nurses. Ask them, “What is your biggest pharmacy headache right now?” And then, *fix it*.
- 2. Be a Problem-Solver, Not a Problem-Creator. Your community pharmacy training taught you to *find* problems. Your HSSP training must teach you to *solve* them.
- Bad: “This prescription is wrong. I’m denying it.”
- Good: “This prescription needs a dose adjustment for renal function. I’m calling the provider to recommend the new dose.”
- Best (Integrated): “I saw this prescription needed a renal dose adjustment. I’ve already pended the new, correct order in the EMR for the provider to sign. It’s all set.”
- 3. Provide “White Glove” Service to the *Clinic Staff*. Your most important customer is often not the provider, but the Medical Assistant (MA) or Nurse Navigator who handles their referrals. *They* are the ones who decide where a prescription goes. Make their lives easier than any external pharmacy. Give them your direct EMR message address or desk phone. When they contact you, give them an immediate, accurate answer.
- 4. Be a “Black Hole” Antidote. The #1 complaint about external SPs is the lack of communication. You must do the opposite. Over-communicate (politely). Use the EMR. Send short, professional messages: “Got the referral.” “PA submitted.” “PA approved.” “Patient contacted.” “Drug shipped.” The clinic staff will feel a profound sense of relief, and they will never want to use another pharmacy again.
The “Get to Yes” Playbook
Your job is to make the *right thing* the *easy thing*. The goal of the HSSP is to “Get to Yes” for the patient and provider. This means your team must be relentless. When a PA is denied, you don’t just send a fax to the provider saying “Denied.” You immediately start the appeal. You write the first draft of the appeal letter. You call the provider’s MA and say, “The PA was denied for ‘step-therapy.’ I’ve drafted an appeal letter highlighting the patient’s contraindication to the preferred agent, and I’ve attached the EMR notes. Can you get Dr. Lee to sign it so I can submit it?” You are doing 90% of the work, making it easy for them to do the last 10%. That is how you win their loyalty forever.
23.1.12 Section Summary & Key Takeaways
Integration is the defining characteristic and strategic imperative of a successful Health-System Specialty Pharmacy. Without it, you are merely an external pharmacy located inside a hospital. *With* it, you become an indispensable clinical partner, a data-driven quality engine, and a powerful financial asset to the entire Integrated Delivery Network.
- The Three Pillars: Your integration strategy must be built on Data (EMR access), Operations (seamless workflows), and Clinical (embedded staff and CPAs).
- The EMR is Everything: Your level of EMR integration (from Read-Only to Fully Integrated) will define your pharmacy’s capabilities. A “Level 3” (e.g., Epic Willow) integrated system is the gold standard.
- Data is Your Superpower: Use EMR access to move from reactive dispensing to proactive clinical monitoring. This is your single greatest safety advantage.
- Prove Your Value: Use your EMR data to track and report on population-level outcomes (cure rates, adherence, admission avoidance). This is the language of the C-Suite and payers.
- Trust is the Currency: Technology is useless if providers don’t trust you. Be visible, be a problem-solver, and make your HSSP the absolute “path of least resistance” for clinics and patients.
