Section 1: PMS/Dispensing, CRM, and Workflow Platforms

28.1.1 The “Why”: Beyond the Filling Task

As an experienced pharmacist, your entire career has been built around a core piece of technology: the Pharmacy Management System (PMS). In the community setting, you are a master of this system. You know its keystrokes, its shortcuts, and its limitations. You’ve used systems like EnterpriseRx, Rx30, Pioneer, or Computer-Rx to manage a process that is fundamentally transactional: a prescription arrives, you verify it, it’s filled, it’s billed, and the patient picks it up. Your PMS is designed to perform this task with incredible speed and safety, millions of times a day.

You must now fundamentally reset your expectations. A standard retail PMS is to a specialty pharmacy what a simple cash register is to a modern e-commerce enterprise. It’s a single, vital component, but it is wildly insufficient for the job at hand.

Why? Because specialty pharmacy is not a transactional business; it is a longitudinal service. You are not managing a prescription; you are managing a patient’s entire therapeutic journey, often for months or years. This journey is not a simple line but a complex, branching, and data-heavy process that involves a dozen different stakeholders. It includes:

• Complex Intake: Receiving a 30-page referral packet with lab values, chart notes, and a diagnosis code, not just an e-prescription.
• Benefits Investigation (BI): Spending hours, not seconds, determining if the $10,000/month drug is covered under the medical benefit or the pharmacy benefit.
• Prior Authorization (PA): Actively managing the PA process, submitting clinical data to the payer, and tracking appeals.
• Financial Assistance: Proactively enrolling the patient in copay cards and manufacturer free-drug programs *before* the first fill.
• Clinical Management: Scheduling monthly adherence calls, monitoring for side effects, and reporting outcomes to the prescriber.
• Logistics: Managing cold chain shipping, coordinating deliveries with the patient, and tracking proof of delivery.
• Data Reporting: Compiling complex data on adherence rates, turnaround times, and clinical outcomes for payers, manufacturers, and accreditation bodies.

Your retail PMS was not built to do any of this. Attempting to run a specialty pharmacy on a retail PMS is like trying to fly a 747 using the dashboard from a 1995 Toyota Camry. You simply don’t have the instruments to see, manage, or document the process.

This section is a deep dive into the three core systems that form the “digital command center” of a modern specialty pharmacy: the Specialty PMS (the brain), the CRM (the heart), and the Workflow Platform (the central nervous system). Understanding how to evaluate, select, and integrate these systems is the single most important strategic decision you will make. It is the foundation upon which your entire operation—and your ability to provide high-touch care at scale—is built.

28.1.2 Deep Dive: The “Brain” – The Specialty Pharmacy Management System (PMS)

The Specialty PMS is the evolution of the system you already know. It is your core system of record, the central database for your patients, prescribers, and prescriptions. It is the “brain” that handles the core logic of dispensing. However, a specialty PMS is built with a completely different set of assumptions. It is designed to handle low-volume, high-complexity, high-cost medications, whereas your retail PMS was built for high-volume, low-complexity, low-cost medications.

This distinction changes everything. The feature set you must look for is fundamentally different. Let’s break down the key modules you must evaluate, comparing them to the retail features you’re used to.

Key Feature Deep Dive: What Makes a PMS a “Specialty” PMS?

1. The “Patient Profile 2.0” (The Intake Module)

In retail, a patient profile has a name, address, DOB, allergies, and insurance. In specialty, this is just the first 5%. A specialty profile is a robust clinical chart. It must have dedicated, structured fields for:

• Diagnosis & Co-Morbidities: Structured ICD-10 code fields. You must be able to link a prescription to a specific diagnosis.
• Payer & Benefits: Not just one insurance card. You need fields for Primary, Secondary, Tertiary, and both pharmacy benefit (NCPDP) and medical benefit (J-code) information.
• Clinical Data: Fields for patient weight, height, BSA, CrCl (auto-calculated), and key lab values (e.g., LFTs, ANC, viral load).
• Program Status: Fields to track enrollment in REMS programs, manufacturer hub services, and financial assistance.
• Custom Fields: The ability for you to create new fields without calling the vendor. What if a new drug for Crohn’s requires a “Harvey-Bradshaw Index” score? You need to be able to add that field yourself.

2. The “Billing & Reimbursement 2.0” (The Financial Module)

This is, without exaggeration, the most complex and important part of a specialty PMS. Billing errors in retail cost dollars; billing errors in specialty cost thousands of dollars per claim. Your system MUST be able to:

• Handle Dual Billing: Can the system seamlessly submit a claim to the pharmacy benefit (via an NCPDP D.0 switch) and also submit a claim to the medical benefit (via an ANSI X12 837P/I file, i.e., a CMS-1500 form)? This is non-negotiable.
• Manage J-Codes & HCPCS: Can the system store and bill with HCPCS codes (e.g., J9035 for Avastin) and automatically calculate “AWP minus” or “ASP plus” reimbursement contracts?
• Copay Card Management: Does it have a robust module for managing manufacturer copay cards? Can it “split bill” (bill the primary payer, then automatically bill the copay card as the secondary) and track the remaining balance on the card?
• Revenue Cycle Management: Can you track A/R (Accounts Receivable)? When a $20,000 claim is rejected, you can’t just “let it go.” You need a work queue to manage that rejection, fix it, and resubmit it until it’s paid.

3. The “Inventory 2.0” (The Logistics Module)

Your retail inventory is “just in time.” Your specialty inventory is “just in case” and costs a fortune. Your PMS must be able to:

• Track High-Cost, Lot-Specific Inventory: You must be able to track every vial by its specific lot number and expiration date. This is critical for recalls and reporting.
• Manage Cold Chain: Can the system flag a drug as “Refrigerated” or “Frozen” at every step of verification and shipping?
• Handle Limited Distribution Drugs (LDD): Can the system “hard stop” a dispense if the patient’s payer or state is not on the approved list for that specific LDD?
• Manage Consignment: Can the system track inventory that you are “consigning” from a manufacturer (i.e., you don’t pay for it until you dispense it)?

4. The “Clinical Management 2.0” (The Therapy Module)

The PMS must support your clinical programs. This blurs the line with a CRM, but the PMS should be the source of truth for the medication regimen.

• Disease-Specific Care Plans: Can you build care plans and document against them? (e.g., “Oncology – Oral” plan with adherence checks, side effect monitoring for hand-foot syndrome, etc.).
• REMS Management: Can the system “hard stop” a pharmacist from verifying a REMS drug (e.g., isotretinoin, clozapine) if the required authorization (e.g., a “Do Not Dispense” date) is not documented?
• Adherence & Gap-in-Care Reporting: Can the system calculate a Medication Possession Ratio (MPR) or Proportion of Days Covered (PDC) and flag patients who are falling below 90%?

Masterclass Table: Evaluating a Specialty PMS Vendor

Use this checklist when you are sitting in a demo with a vendor. Your community pharmacy experience has prepared you to ask tough questions. Here is your script.

Feature Category	Key Question to Ask the Vendor	“Gotcha” / Red Flag to Watch For
1. Patient Profile & Intake	“Show me how you handle a referral packet. How do you attach the 30-page PDF? How do you abstract the ICD-10 code into a structured field? How would I create a new, custom field for a lab value myself?”	If they say “You can just attach the PDF” and don’t have structured fields for diagnosis, labs, etc., the system is just a fancy document holder. You won’t be able to run reports on this data. This is a critical failure.
2. E-Prescribing & Connectivity	“Show me how your system handles an NCPDP SCRIPT e-prescription. How does it auto-populate the patient? Now, show me how it receives a prescription via your EMR integration API. How does it handle a REMS requirement?”	If their e-Rx module looks clunky or they don’t have live integrations with major EMRs (like Epic or Cerner), your intake process will be 100% manual data entry.
3. Dispensing & Inventory	“Show me your inventory module. How do you receive a high-cost, cold chain product? How do you scan the lot number? Now, show me how the pharmacist is blocked from dispensing that drug if the lot is expired or on recall.”	If lot number tracking and cold chain management are not enforced by the system (i.e., they are just optional note fields), it is not a true specialty PMS.
4. Medical Billing (Part B)	“Please walk me through billing for a J-code (e.g., J1745 for Infliximab). How does the system generate the CMS-1500 form? How do you track that A/R separately from your pharmacy benefit claims?”	This is the #1 test. If the salesperson looks confused or says “our partners handle that,” the system cannot do medical billing. This is a deal-breaker for many specialty models (especially for infusion).
5. Copay Card & Financials	“Show me how you add a manufacturer copay card. Now show me a claim that is split-billed: $10,000 to the primary payer, and the $100 copay is automatically billed to the secondary copay card. How do you track the card’s $15,000 annual max?”	If this process is manual (i.e., “you bill the primary, then manually create a new claim for the copay card”), your billing department will need 3x the staff. It must be automated.
6. Reporting & Data	“Show me your reporting module. I need to run a report for a manufacturer that shows all new patients on {Drug X} in the last 30 days, their adherence (PDC), and the average turnaround time from referral to first ship. How long does that take?”	If they say “we can build that custom report for you” (for a fee), it means their standard reporting is weak. You need a powerful, self-service reporting and analytics tool.
7. Integration (The Exit Strategy)	“Do you have a fully documented, bi-directional, RESTful JSON API? Can my developer get a sandbox key today? What is your data ownership policy, and what is the data export format if we choose to leave?”	If they get defensive, don’t have an open API, or charge you to get your own data back, run away. This is vendor lock-in, and it’s a 10-year mistake.

28.1.3 Deep Dive: The “Heart” – The Customer Relationship Management (CRM) Platform

The second pillar of your command center is the CRM. If the PMS is the “system of record” for the prescription, the CRM is the “system of engagement” for the patient. It is the “heart” of your high-touch model. Its entire purpose is to manage and document every single interaction you have with a patient, prescriber, or payer.

“But wait,” you’re thinking, “my retail PMS has a ‘notes’ field. Why can’t I just use that?”

This is the critical translation of your retail skill. A PMS note is a passive, disorganized, and un-reportable text blob. A CRM is an active, structured, and reportable system. Imagine the difference between writing a sticky note (PMS note) and logging a case in a professional ticketing system (CRM).

In specialty, you are not an individual pharmacist talking to a patient. You are a team of intake specialists, benefits investigators, pharmacists, and adherence nurses all talking to the same patient over a period of weeks. You must have a single source of truth for all communications, or chaos will erupt. The patient will get called three times by three different people asking the same question. This is the opposite of high-touch care.

The CRM solves this. It gives every team member a “360-degree view” of the patient, showing every single touchpoint, in chronological order.

Masterclass Table: Core CRM Features for Specialty Pharmacy

t-

Core CRM Feature	Why It’s Critical for Specialty	How It Translates Your Retail Skill
Omni-Channel Communication Logging	Your team must be able to log every phone call, email, text message, and patient portal message in one central feed. When a patient calls, any tech can pull up their record and see, “Oh, I see you spoke with nurse Jen yesterday about this.”	This translates your “sticky note on the patient’s profile” into a permanent, searchable, and professional communication log that the entire team can see.
Clinical Program Management	You can build “programs” for patients (e.g., “New to Therapy – Humira”) that automatically schedule tasks for your clinical team (e.g., “Day 1: Welcome Call,” “Day 7: Side Effect Check,” “Day 28: Adherence Assessment”).	This translates your one-off MTM counseling sessions into a structured, scalable, and reportable clinical service that you can prove you are doing.
Automated Communication Workflows	The CRM can integrate with the PMS to send automated, personalized messages. For example, it sees a fill date in the PMS and automatically texts the patient: “Hi {Patient}, your {Drug} is scheduled to ship on {Date}. Please reply ‘Y’ to confirm.”	This translates your manual “refill reminder calls” into an automated, efficient, and trackable system, freeing up your team to handle only the exceptions.
Case Management / Tasking	When a patient calls with a clinical question, the technician can create a “Case” or “Task” in the CRM and assign it to the “Clinical Pharmacist” queue. The pharmacist can then work this queue, resolve the issue, and log the outcome.	This translates the “Hey, can you call this patient back?” shout across the pharmacy into a formal, auditable, and managed task list. Nothing gets lost or forgotten.
Patient Satisfaction & Surveys	After a patient’s first fill, the CRM can automatically email them a one-question satisfaction survey (e.g., “How likely are you to recommend us?”). This data (NPS) is critical for payer contracts.	This translates your informal “how are we doing?” at the counter into hard data you can use to prove your value and improve your service.
Integration with PMS & Telephony	When a patient calls in, the phone system (CTI) integrates with the CRM to automatically pop up the patient’s record on the screen. The CRM integrates with the PMS to show all their recent fill dates right next to the call log.	This translates your “Can you spell your last name for me… what’s your date of birth?” into a seamless, professional experience where you greet the patient by name.

28.1.4 Deep Dive: The “Nervous System” – The Workflow/BPM Platform

This final component is the “air traffic controller” from our analogy. It is the “central nervous system” that connects the “brain” (PMS) and the “heart” (CRM) and orchestrates the entire process from start to finish. This is often the most overlooked but most powerful piece of the puzzle.

A Workflow Platform, also called a Business Process Management (BPM) suite, doesn’t store much data. Instead, it is a powerful rules engine. It is the “conductor” that tells every other system and every human what to do, when to do it, and who to give it to next.

In many “all-in-one” specialty PMS systems, this workflow engine is built-in. In “best-of-breed” models, this is a separate piece of software (like Appian, Pega, or a custom-built solution) that sits in the middle and orchestrates everything. Its entire purpose is to manage the “Case” or “Referral” from intake to fulfillment, ensuring no step is missed.

This system is what allows you to answer the two most important questions in specialty pharmacy:
1. “Where is this patient’s referral right now?” (e.g., “It’s in the PA queue, assigned to Jane.”)
2. “How long did it take us to get that drug to the patient?” (e.g., “Our average turnaround time from Referral to Ship was 4.8 days.”)

You cannot answer these questions without a workflow platform. You would have to manually dig through PMS notes, email chains, and sticky notes.

Visual Diagram: The Anatomy of a Specialty Referral Workflow (Powered by a BPM)

This is a simplified view of how the BPM platform routes a single “Case” (a new patient referral) through the pharmacy. Each box represents a “Queue” that a human team works out of.

28.1.5 The “Digital Command Center”: Tying It All Together

Now, let’s put our “Air Traffic Control” tower together. No single system does everything. They must work in concert, each playing its specialized role. Your primary job as a leader is to understand this division of labor and ensure the systems you choose can communicate.

The previous diagram shows the process. Here is how the systems interact to make that process happen.

Masterclass Table: The Tri-System Model (PMS vs. CRM vs. Workflow)

Case Status (e.g., ‘PA Pending’)

Turnaround Time (TAT) Data

Team/User Queues

Audit Trail of Steps

Patient Demographics

Prescription & Fill History

Inventory (Lots, Exps)

Billing Records (Claims)

Call/Email/Text Logs

Clinical Assessments (e.g., QOL)

Adherence Program Status

Patient Satisfaction Surveys

System	The Analogy	Primary Purpose (“System of…”)	Core Data It “Owns”	Key Functions
Workflow / BPM Platform	The Central Nervous System (The Air Traffic Controller)	System of Orchestration (Manages the *process*)	Routes the “Case” from queue to queue Enforces business rules (e.g., “Cannot move to Scheduling until PA_Status == ‘Approved'”) Tracks time-in-step for reporting Assigns tasks to users/teams
Specialty PMS	The Brain (The Radar / Instrument Panel)	System of Record (Manages the *dispense*)	Stores the legal prescription Performs DUR & pharmacist verification Manages inventory & shipping Submits claims & tracks A/R Stores prescriber & payer data
CRM Platform	The Heart (The Radio / Comms Log)	System of Engagement (Manages the *relationship*)	Logs all patient/MD interactions Runs automated outreach (texts/emails) Manages clinical programs Logs patient-reported outcomes (PROs) Houses patient education materials

28.1.6 Your Implementation Strategy: “Buy vs. Build” and Due Diligence

You understand *what* you need. Now, how do you get it? You have three fundamental choices, each with profound consequences for your budget, timeline, and flexibility.

The Three Paths to a Tech Stack

1. The “Build” Path (Proprietary):
   This is the path taken by the largest national players (Accredo, CVS Specialty). They hire hundreds of software engineers and build their *own* custom, proprietary systems from the ground up.
   Pros: Perfectly tailored to your exact workflows. You own the code and your roadmap.
   Cons: Astronomically expensive (tens of millions of dollars), incredibly slow (a 3-5 year build-out), and requires a massive, permanent internal IT and development team to maintain and update.
   Verdict: Not a viable option for a new or regional specialty pharmacy.
2. The “Buy – All-in-One” Path (Monolith):
   You purchase a single, pre-built “Specialty Pharmacy” platform from a vendor (e.g., Therigy, CRx, Asembia-1). This system provides the PMS, a built-in workflow engine, and a built-in CRM module.
   Pros: Fastest to market (can be live in 6-9 months). One vendor, one contract. Integration is (mostly) handled for you.
   Cons: You are 100% locked into that vendor. You are stuck with their (often mediocre) CRM. Their workflow is often “hard-coded” and difficult to change. You are at the mercy of their development priorities.
   Verdict: The most common path for new pharmacies, but carries significant long-term strategic risk.
3. The “Buy – Best-of-Breed” Path (Ecosystem):
   You buy three separate systems: a powerful Specialty PMS, a world-class CRM (like Salesforce Health Cloud), and a flexible Workflow/BPM platform. You then pay an integration partner to build the APIs to connect them.
   Pros: You get the best tool for every job. You can change your workflow on the fly. You can swap out your CRM in 5 years if a better one exists. You are not locked in.
   Cons: More expensive upfront. More complex to manage. You are responsible for the “glue” (the integrations) that holds them together.
   Verdict: The most powerful and flexible model, but requires more capital and IT expertise.

28.1.7 Conclusion: Your Foundation for Scale

In your retail practice, the PMS was the tool you used to do your job. In specialty, your technology stack—the PMS, the CRM, and the Workflow engine—is the scaffolding that allows your entire team to do its job.

Choosing these systems is not an “IT decision.” It is the most important clinical and operational decision you will make. A bad system will force your expert pharmacists and technicians to spend 80% of their time fighting the software, performing manual data entry, and fixing errors. It will cap your growth and burn out your team.

A great, integrated system does the opposite. It automates the automatable. It makes the complex simple. It provides the right information to the right person at the right time. It frees your clinical team from data entry and allows them to spend 100% of their time on the only thing that matters: managing the patient. It allows you to provide high-touch, personalized care to 500 patients with the same precision and safety as you did with 50. It is the key to scale.

Now that you understand the “Digital Command Center,” the next critical question arises: how do you connect this tower to the rest of the world? How do you get data from the prescriber’s EMR, and how do you send data to the payer’s portal? That is the focus of our next section: Integration.