Anyone questioning whether retail pharmacies want to become big players in the healthcare game should take a look at their recent clinical and technological moves. Since the beginning of 2014:

  • The two largest retail pharmacy companies in the nation, Walgreen Co. and CVS Caremark, joined with three former U.S. senators, five telehealth companies, plus Verizon Communications, health insurance giant WellPoint, medical device-maker Welch Allyn and medical supplier Cardinal Health to form the Alliance for Connected Care. This group, as Health Data Management has reported, will promote telehealth and remote patient monitoring by advocating for federal and state policy changes.
  • CVS, Walgreens, Kroger Co., Rite Aid and Safeway all endorsed the Blue Button initiative as an easy way for pharmacy customers an easy way to download and share their prescription records via a Web portal or mobile app. They were joined by the National Association of Chain Drug Stores, the National Alliance of State Pharmacy Associations and the Pharmacy Health IT Collaborative, which represents nine national professional pharmacy associations. The five retail chains have pledged to collaborate on "standardizing patient prescription information to fuel the growth of private-sector applications and services that can add value to this basic health information," according to a White House statement.
  • Walgreens signed a deal with Bowie, Md.-based healthcare analytics company Inovalon to offer an automated patient assessment system for the more than 400 Walgreens Healthcare Clinic locations across the company.
  • CVS started a pilot of telehealth services at 28 MinuteClinic locations in Southern California so offsite nurse practitioners can assist licensed vocational nurses serving patients in person. The Woonsocket, R.I.-based chain expects to bring the pilot to an unspecified second state later this year.
  • CVS contracted with electronic health records vendor Epic Systems to replace the home-grown EHR currently serving the more than 800 MinuteClinic sites in 28 states and the District of Columbia.
  • Interestingly, CVS Caremark also joined the CommonWell Health Alliance, a coalition of health IT vendors committed to interoperability of health data. Allscripts, athenahealth, Cerner,  Greenway Health and McKesson started CommonWell in 2013, largely as a response to the perception that Epic was reluctant to connect to other vendors' systems.
  • Rite Aid launched the Rite Aid Health Alliance, a series of partnerships among traditional healthcare providers and care management service company Health Dialog to improve the health of people with multiple chronic diseases. Pharmacists as well as Health Dialog coaches in Rite Aid stores will work with patients and their physicians to manage conditions such as congestive heart failure, chronic obstructive pulmonary disease, high cholesterol and diabetes. This program is starting in Buffalo, N.Y., Greensboro-High Point, N.C., and the Los Angeles area.
  • The CEO of Wegmans Food Markets, an upscale supermarket chain in the Northeast that also operates a national online pharmacy, wrote to New York state legislators urging them heed Gov. Andrew Cuomo's request to appropriate $65 million to the Statewide Health Information Exchange, known as SHIN-NY. "As a large, self-insured employer, Wegmans benefits from lower healthcare costs. The use of the SHIN-NY which allows for swift and confidential transferring of electronic health records, has been shown to lower healtcaare costs in our region and throughout the state," said Danny Wegman.
  • Higi, a startup company supported by hip-hop artist Lupe Fiasco, announced plans to put 4,100 kiosks in Rite Aid stores by early 2015, offering, basic self-service health screening. Chicago-based Higi already has contracts with several regional supermarket chains, while competitor SoloHealth has screening kiosks in 2,500 Walmart locations.
  • In perhaps the biggest news of the year so far from drug stores, CVS said it would stop selling tobacco products in all its stores by Oct. 1, even though it would cost the company $2 billion in annual revenue.

"Pharmacies are becoming more involved in chronic disease management to help patients with high blood pressure, high cholesterol and diabetes. All of these conditions are exacerbated by smoking. When we thought about where we expect to be in five years as a healthcare company, it was clear that removing tobacco products from our stores was the right thing to do," CVS Caremark explains in an e-mailed statement attributed to Chief Medical Officer Troyen Brennan, M.D. (Major pharmacy chains were reluctant to give spoken interviews for this story, but some provided written answers to Health Data Management's questions.)

"CVS Caremark's purpose is helping people on their path to better health and every action that we take and decision we make is viewed through the filter of this purpose. It guides everything we do," Brennan adds.

The CVS decision on cigarettes drew immediate praise from the wellness community. "I think it sets a new bar for retail pharmacy in redefining the pharmacy's role in health and in the community," says health economist Jane Sarasohn-Kahn, a strong advocate of applying technology to help people navigate the healthcare system and live healthier lives.

It also has put pressure on competitors. Target gave up selling cigarettes years ago, but smokes remain at the front of tens of thousands of stores that also have pharmacies.

For its part, Walgreens is playing up its role in helping people quit smoking. Deerfield, Ill.-based Walgreens said in January it would work with pharmaceutical giant GlaxoSmithKline on an online smoking cessation program called Sponsorship to Quit. GSK markets Nicorette nicotine gum and NicoDerm CQ transdermal patches in the U.S.

"Over the past year alone, Walgreens has conducted innovative, broad-based, in-store smoking cessation campaigns, including the free, online quit-smoking program ( launched earlier this year that incorporates social engagement as a support lever and allows tobacco users to personalize their program with customized tools.  We will continue to seek additional ways to help people quit for good," Walgreens says in a statement.

Since 2011, the chain has been calling its customer experience "Well at Walgreens." Since then, Walgreens has rebranded some of its private-label medications and health products with the same name and is starting to feature the tagline around its pharmacy counters and walk-in clinics.

The company has pledged to donate $100 million through January 2015 to prevention of heart disease, cancer, diabetes and other common ailments, an initiative called the Walgreens Way to Well Commitment.

Walgreens spokeswoman Markeisha Marshall provided a list of why the company says "well" is "more than a tagline element":

  • Pharmacists offer medication review and medication therapy management services to help customers stay on their drug regimens and improve health outcomes;
  • Walgreens claims to be the largest retail provider of flu shots in the U.S., and offers 17 different immunizations to consumers in 40 states;
  • Basic testing of cholesterol, blood glucose and body composition;
  • Disease management for hypertension, diabetes and other common chronic ailments;
  • The more than 400 Walgreens Healthcare Clinic locations, while half the number that CVS has, is the second largest network of convenience clinics in the country.

Marshall highlights the new "Well Experience" in new and redesigned stores—now numbering about 500 but growing by the month—that is "tailored to meet healthcare needs of the community by  creating greater access to pharmacists and more patient consultations to help improve medication adherence and outcomes." She also says that Walgreens is the only major pharmacy chain to form accountable care organizations with physician practices, hospitals and health systems, though the new Rite Aid Health Alliance program, announced March 10, should change that.
As Walgreens renovates its stores to feature this Well Experience, fresh foods, including fruits and vegetables, are starting to appear closer to the entrance and to the checkout counters. This is an important move, according to Sarasohn-Kahn. "I think Walgreens has been ahead of CVS in developing a strong health and wellness presence," she says.

Many of the other recent moves illustrate how retail pharmacies are linking with other healthcare entities through IT and data exchange. As with hospitals and physicians striving for meaningful use of EHRs, pharmacies are at different stages of progress, illustrated by their embrace of Blue Button and Blue Button Plus standards as well as their own EHR projects.

"Rite Aid, through its MyPharmacy online portal, currently provides its customers with electronic access to their own prescription history, tools to better manage their prescriptions and medication management reminders via phone, email or text message," says an e-mailed statement from spokeswoman Kristin Kellum. "Rite Aid has committed to improving patient engagement and empowerment through expanded access to their own health data and an evolving set of online service capabilities." That is the exact wording shared by the White House on behalf of Rite Aid.

CVS also deferred to the White House statement on Blue Button, which is a protocol developed at the U.S. Department of Veterans Affairs, then offered to the public via the Office of the National Coordinator for Health Information Technology. Blue Button Plus includes an application programming interface so software developers can add structure to the plain text of the VA's version. Customers of CVS retail locations and Caremark's mail-order pharmacy can download medication lists and prescription histories and refill prescriptions through secure Web portals, the company says.

Walgreens has Blue Button on its online pharmacy portal and soon will add Blue Button Plus capabilities that include data sharing with other healthcare providers and caregivers, including through third-party applications. 

Kroger, headquartered in Cincinnati, is still catching up, as only about half its customers currently can see their pharmacy records online. Some of its locally branded stores, including Smiths and Fry's, do not yet have portals. The company still is "developing new functionality that will enable all of its customers to download a copy of their records, and is exploring plans to provide customers with a machine-readable copy of their records that can be shared and uploaded into third-party applications and services," according to the release.

Safeway is new to Blue Button, but promises to give customers online access to and the ability to share their pharmacy records.

Meanwhile, the nation's two largest drugstore chains are pushing interoperability at all levels of their healthcare operations and among other providers.

"Walgreens is committed to meeting HITECH requirements around use of certified EMRs, documentation of transitions in care, as well as further promoting e-prescribing," Marshall writes. She notes that the company belongs to the National Council for Prescription Drug Programs (NCPDP), the eHealth Initiative (eHI) and the DirectTrust for secure healthcare messaging. 

"To communicate with primary care physicians, for example, Walgreens integrates with Direct-compatible delivery networks such as Surescripts," Marshall says. She notes that Walgreens sends electronic physician notification letters—an initiative among pharmacies to notify doctors that their patients have received immunizations—directly to physician EHRs. "Additionally, we are advancing the delivery of immunization reporting to state [registries] and currently deliver electronic messages to more than 40 states," Marshall adds.

The CVS decision to switch MinuteClinic records to an Epic EHR signals that MinuteClinic is a true healthcare provider, according to Sarasohn-Kahn. "When I saw CVS doing Epic, that's not trivial," she says. "They're making a huge bet that they're an integral part of the healthcare delivery system," Sarasohn-Kahn says.

"As a healthcare provider, MinuteClinic is focused on delivering high-quality, accessible care for common illnesses.  We are committed to continuity of care, fully support the patient-centered medical home model and believe that MinuteClinic can play a complementary role with primary care practices," CVS's Brennan says.

Brennan adds that CVS has affiliated with 30 major healthcare organization across the country "that provide collaborating physicians, electronic medical record (EMR) integration and opportunities for joint clinical programs." He says that the switch to Epic will "further enhance collaboration."

Walgreens, which has been using a commercial EHR from Greenway Medical Systems not only at its retail clinics, but also in its traditional pharmacies, since 2012, is adding clinical decision support and enhancing care management by virtue of its link-up with Inovalon.

Inovalon's Electronic Patient Assessment Solution Suite (ePASS) CDS platform helps identify gaps in care, quality, accuracy of risk scores and utilization. According to Inovalon Chairman, President and CEO Keith Dunleavy, a poorly calculated risk score can lower insurance reimbursement by 5-8 percent.

"We will be doing outreach to identify patients who would best benefit from a face-to-face encounter [with a nurse practitioner] at Walgreens," Dunleavy says.

During the encounter, ePASS can alert the NP if a patient is past due for a test or vaccination, for example, following Medicare payment and National Committee for Quality Assurance guidelines, Dunleavy says. The system creates a complete SOAP (subjective, objective, assessment, plan) encounter note for the EHR, then can send the information to the patient's primary care physician.

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