Impacts of a Mail-Order Service for Refilling Prescriptions on Patient Satisfaction and Operational Load at a Comprehensive Cancer Center in Jordan

Abstract

Background

Mail-order services for refilling prescriptions for medications have been established in many countries and have increased patient satisfaction. We developed a mail-order service for the outpatient pharmacy of a comprehensive cancer center in Jordan.

Objective

To describe the implementation of a mail-order service and to report the impact of the service on patient satisfaction and the pharmacy workload.

Methods

A multidisciplinary team was formed to plan a mail-order service for refilling prescriptions for medications, and a survey was designed to evaluate patient satisfaction with the service. Patients were instructed to call the refill call center and order their medications at least 48 hours before their refill is due. The pharmacy workflow for refilling prescriptions was evaluated, and the time required with and without the mail-order service was documented, with a calculation of the time saved.

Results

At 1 year after the mail-order service had been established, 14 200 prescriptions had been refilled through the service, with the majority (97.5%) dispensed within 48 hours of the order time. As per the survey conducted with 219 patients, on the overall satisfaction, 69.4% reported being highly satisfied with the service and 27.9% reported being satisfied. The problems reported with the service were delay in arrival (n = 23, 10.5%), medication-related errors (n = 9, 4.1%), cash-related error (n = 1, 0.45%), improper storage condition (n = 1, 0.45%), and delivery to the wrong address (n = 4, 1.8%). The service was also associated with reduced overall time for processing in the outpatient pharmacy service; for patients receiving their medications from the pharmacy, resulting in reduced patients’ overall waiting time (from 11.4 to 8.2 minutes). The service resulted in saving of 0.4 full-time employee at 1 year of implementation.

Conclusions

A mail-order service for refilling prescriptions within a hospital setting had positive outcomes on both patient satisfaction and the pharmacy workflow. The major issues were related to transportation and logistics.

Background

Refilling prescriptions by mail-order has been introduced in many countries as a convenient way for delivering refillable prescriptions to patients’ doorsteps, avoiding patients’ travel to the pharmacy and contributing to their health outcomes. ¹ -4 In the United States, up to one-third of medications for chronic illnesses are dispensed to patients through mail-order,^5,6 which has been associated with patient satisfaction, improved medication compliance, and better clinical outcomes. ¹ -4 The main benefit was easier access to medications for patients with time constraints or limited access to transport.^3,4 Furthermore, plan sponsors saved medication dispensing costs. ⁷ The socioeconomic status of patients may affect their ability to use the service, ⁴ and the location of the nearest pharmacy and other factors may affect patients’ preference for mail-order rather than face-to-face redemption of prescriptions. ⁸

The outpatient pharmacy at King Hussein Cancer Center (KHCC) serves an average of 900 patients per day. The pharmacy processes new and refilled prescriptions of cancer and non-cancer-related medications. Because of the large number of patients served and the complex nature of many orders, the pharmacy has a heavy workload and patients often have to wait for long periods of time. Aiming to reduce patients’ waiting time, improve their satisfaction, reduce the pharmacy’s workload, and optimize resource utilization, the pharmacy introduced a mail-order service for refilling prescriptions.

We describe the experience of developing the service and report on the impact of the service on patient waiting time and satisfaction as well as its impact on the pharmacy workload.

Methods

This project was conducted at KHCC, a 370-bed comprehensive cancer center serving inpatients and outpatients. The center has 3 main pharmacy services: the inpatient, outpatient, and chemotherapy pharmacies, in addition to areas for sterile preparations. It employs around 80 pharmacists and pharmacy technicians, who rotate among the pharmacy services. Daily, there are around 16 pharmacists and 5 pharmacy technicians working at the outpatient pharmacy, covering various shifts and tasks throughout the day, starting at 8:00 am until 6.00 pm Sundays through Thursdays, and 9:00 am until 4:30 pm on Saturdays.

The project was initiated by forming a multidisciplinary team consisting of pharmacists, pharmacy technicians, a finance representative, and an information technology (IT) expert. The team met regularly to discuss the proposed steps and to assess the process, once implemented.

The process of preparing and dispensing refilled prescriptions was reviewed, and the average time required for each step was documented by observing the full process for 2 hours in the morning and 2 hours in the afternoon for 1 week. Following that, the team identified the steps required for providing the same service by mail-order and once the service was fully implemented, the average time required for each step was determined. The impact of the mail-order service on the pharmacy workload was determined from the difference in the time required for processing refilled prescriptions to be picked up from the pharmacy from that when they were sent through the mail-order service.

Of the 900 prescriptions filled per day, refilled prescriptions compose an average of 300. For these prescriptions, about half (n = 150) are picked up by the patients on the day of their physician appointments or chemotherapy sessions. Therefore, patients who may use the mail-order service were considered as the remaining 50%. The target was to have two-thirds of the latter’s prescriptions sent through mail-delivery, forming an average of 100 prescriptions per day.

The team evaluated the courier services available, that could be used to deliver medications, which had to have controlled temperature delivery vehicles, with recorded temperature logs, controlled temperature stores for storage before distribution, a license from the Jordanian Food and Drug Administration to transport medications, and full coverage of all governorates, towns, and rural areas in the 89 000 km² of Jordan. ⁹ Apart from oncology units and centers in some Jordanian medical institutions, KHCC is the only comprehensive cancer treatment center in Jordan, ¹⁰ serving patients from all parts of the Kingdom. Licenses and approvals for the courier agent and for KHCC to provide this type of service had to be obtained. The service also required internal operating procedures for mail-order prescriptions that complied with all policies and procedures to assure the quality and safety of the medications and the maintenance of patient confidentiality. To optimize integration and customization of the IT systems, cooperation was required between the courier service, and the hospital’s IT, pharmacy, and finance departments.

To evaluate the impact of the mail-order service on the waiting time for patients who came to the pharmacy to pick-up their medications, we recorded the patients’ waiting time before and after introducing the mail-order service. This data were obtained from the reports of an automated patient queuing system, which provided the total time for processing a prescription, starting at patient queuing and ending with patient counseling and dispensing of the medications.

Once the mail-order service had been introduced, the number of patients requesting their refilled medications through this service was tracked daily, and a delivery status report was obtained from the courier service showing the time of delivery after pick-up from the pharmacy and the undelivered prescriptions that were returned to the pharmacy, with the justifications listed for all returns.

To evaluate patients’ satisfaction with the service, a survey was developed with the assistance of the hospital’s survey and research development unit. The survey elicited patient demographics, educational level, means of transport to the hospital, average travel time, number of refilled medications, and the number of times the mail-order service was used. On a 5-point Likert scale, with 1 being very unsatisfied and 5 being very satisfied, the patients were asked to rate their overall level of satisfaction with the mail-order service. In addition, patients were asked to indicate whether they would use the service again, whether they would recommend the use of the home-delivery service to others, and whether they considered the service fees to be reasonably priced. Patients were asked about their level of satisfaction with the time to receive the medications and the quality of the products received. Finally, the survey asked patients to identify problems they have faced. At 4 months after introducing the mail-order service, we identified all patients who had used the service over a period of 2 weeks and contacted them over the phone to conduct the survey, after agreement to participate.

Statistical Analysis

A descriptive analysis was performed. Continuous data were reported as means with standard deviations and/or medians with ranges, while nominal data were reported as counts and percentages. Chi-squared test was used to compare nominal data and t test to compare continuous data. Both univariate and multivariate analyses were performed to evaluate the relations between patients’ level of satisfaction as well as the likelihood to use the service, as dependent factors and the independent factors of age, gender, educational level, number of years of treatment at KHCC, means of transport, and time required to reach the hospital. The value of P < .05 was considered statistically significant.

Results

The Service

In April 2018, the outpatient pharmacy launched the mail-order service for refilling prescriptions. The new service was announced through flyers distributed to patients and in courier booths located within the Center. In addition, text messages were sent to all patients active in the hospital’s database and pharmacists informed patients about the service at the pharmacy dispensing windows.

The prescription refilling process was modified to create a separate list for mail-order patients, with a different workflow. A standard operating procedure (SOP) was developed for processing mail-order prescriptions. The SOP included verification of addresses, communication about the mail-order service fees, the process for handing medications to the courier, and a shipment tracking system. The mail-order fees were determined as a fixed rate of $5, regardless of the number of medications, weight of shipment, or delivery location. The IT departments at both KHCC and the courier service collaborated to create a patient address databank linked to each patient’s medical record number, but with patients’ medical information completely blinded. Patients’ addresses and contact numbers were entered manually into the courier system by pharmacy staff and updated as necessary, mainly to ensure that the address was the most recent or that chosen by patients, as some chose to have their medications delivered to their work address. The workspace, tasks, and workflow within the pharmacy were re-structured to separate mail-order refilled prescriptions from those picked up at the pharmacy.

Patients request prescription refills through a call center, which provides the option of the mail-order service. The option is offered at every refill, as patients may sometimes pick up their medications at the time of an appointment. For patients who choose the mail-order service, the address and contact number are documented and verified on the shipment tracking system. The patient file is then accessed, and the prescriptions are refilled according to standard procedures. For patient privacy, the medicines are packaged in plain boxes with no KHCC identification, and the labels bear only the patient’s name, address, and storage instructions for medicines that require refrigeration. Once the medications are packaged and labeled, they are picked up daily by the courier for delivery within 48 hours in the main cities and within 72 hours in rural areas. The courier personnel are instructed to maintain strict patient confidentiality when handling the packages. Delivery is attempted 3 times. If all 3 attempts fail, for whatever reason, the shipment is returned to the pharmacy with documented justification.

Table 1 lists the steps and time required for processing and dispensing refilled prescriptions picked up from the pharmacy and those sent by the mail-order service.

Table 1.

Steps and Time Required for Processing Mail-Order and Pharmacy Pick-up Refilled Prescriptions.

Step	Average time, minPharmacy pick-up	Average time, minMail-order service
Obtaining patient contact information	Not applicable	1
Entering data on courier data system	Not applicable	0.37
Billing	1.44	1.03
Filling	1.78	1.22
Checking	1.24	1.02
Packaging	0.47	0.7
Dispensing a	3.86	Not applicable
Handing over to courier service	Not applicable	0.28
Total	8.79 min/refill order	5.62 min/refill order

^aDispensing step includes obtaining the ready patient’s medications, referring patients/caregiver to finance to cover any related obligations, dispensing the medications to patient/caregiver, and closing the pending request on the queuing system.

Outcomes of First Year

During the first year of the service, 14 200 refills were requested through the mail-order service. During the first 2 months, the average was 25 prescriptions per day, and the number increased subsequently to reach an average of 65 refilled prescriptions per day. Figure 1 shows the number of patients who requested delivery of refilled prescriptions each month over 1 year. During the first 6 months (pilot phase), 91.5% of prescriptions were delivered within the first 24 hours of courier pick-up, 6% were delivered within the next 24 hours, and the remainder were delivered within 72 hours. During the pilot phase, <1% of the shipments were returned to the pharmacy because of an incorrect address, no one to receive the medication, or, in a few cases, for financial reasons. At 1 year, the delivery time and the returned shipments were similar to those reported in the first 6 months.

Figure 1.

Number of patients requesting mail-order service for refilled prescriptions during the first year of the service (April 2018 to March 2019).

The average time for processing mail-order refills was 5.62 minutes, which was 3.17 minutes less than the time required for processing prescriptions picked up at the pharmacy (Table 1). Given the current average of 65 home-delivery refills per day, the time saved by the service at 1 year was equivalent to 0.4 of 1 full-time employee equivalent. Furthermore, the average waiting time for patients receiving their medications from the pharmacy decreased from 11.4 to 8.2 minutes (an average decrease of 3.2 minutes per prescription) due mainly to elimination of the dispensing step for mail-ordered medications, which freed more time for other patients.

Of the 300 patients contacted for the survey, 219 agreed to participate. Table 2 outlines the characteristics of the patients who completed the survey and the survey results. For the overall satisfaction, 69.4% reported being highly satisfied with the service and 27.9% reported being satisfied. The majority of the patients stated that they would use the service again and that they would recommend it to others (97% and 96%, respectively) and 91% considered the service fees to be reasonable. In regard to the delivery time and the quality of the medication order received, 96.8% and 100% reported being very satisfied or satisfied.

Table 2.

Patients’ Characteristics and Survey Results.

Parameter	Frequency	Percentage
Gender
Female	155	70.8
Male	64	29.2
Age of patient, y
<18	12	5.5
18-40	31	14.2
41-60	82	37.5
>60	93	42.4
Educational level
High school or less	87	39.7
Diploma/Bachelors	129	58.9
Masters/PhD	3	1.4
Employment status
Unemployed	154	70.2
Employed	65	29.8
Transportation time to reach KHCC, min
<10	2	1
10-30	48	21.9
31-60	101	46
>60	67	30.6
Method of transportation
Public transportation	74	33.8
Taxi	73	33.3
Private car	70	32
Usual refill receiver
Patient	152	More than 1 response is accepted per patient
Family member	76
History of chronic diseases
None	83	More than 1 response is accepted per patient
Hypertension	66
Diabetes mellitus	42
Thyroid	25
Osteoporosis	57
Other	30
Length of treatment at KHCC, y
<1	5	2.3
1-2	45	20.5
3-5	106	48.4
>5	57	26
No. of refilled medications per month
1-2	50	22.8
3-4	74	33.8
≥5	95	43.4
No. of times you used the mail-order service
Once	34	15.5
2-3 times	136	62.1
≥4 times	48	22
Usual reason for using the mail-order service
Routine monthly refill	143	65.3
No other appointments at the Center	71	32.4
Service fees were reasonable
Agree	200	91.3
Disagree	19	8.7
I want to continue using this service
Agree	213	97.3
Disagree	6	2.7
I recommend others to use this service
Agree	211	96.3
Disagree	8	3.7
Overall satisfaction level
Highly satisfied	152	69.4
Satisfied	61	27.9
Unsatisfied	6	2.7
Highly unsatisfied	0	0

Note. KHCC = King Hussein Cancer Center.

The problems reported with the service were delay in arrival (n = 23, 10.5%), medication-related errors (n = 9, 4.1%), cash-related error (n = 1, 0.45%), improper storage condition (n = 1, 0.45%), and delivery to the wrong address (n = 4, 1.8%) (Figure 2). In the univariate and multivariate analyses, the age group, demographics, educational level, or location of residence of the patients who used the service were not associated with their level of satisfaction or their likelihood to use the service.

Figure 2.

Reported problem.

Discussion

Establishment of a mail-order service for refilled prescriptions at our cancer center was associated with positive outcomes for both patient satisfaction and pharmacy workflow. The service was provided to a large number of patients and resulted in a good level of patient satisfaction and a reduction in 0.4 of full-time employee requirement. The financial outcomes of the implementation have not been studied at this point and maybe considered in future impact assessments. To our knowledge, no such service is currently being used in the kingdom.

Patient satisfaction with the service was mainly due to the convenience of receiving their medications without the need to drive to the hospital and wait at the pharmacy. The effect of the service on the pharmacy workflow was to reduce the waiting time for patients who picked up their prescriptions at the pharmacy window. The satisfaction of these patients was not measured but will be assessed later.

According to our survey, the age group, demographics, educational level, or location of residence of the patients who used the service were not associated with their likelihood to use the service. In contrast, reports in the literature reported that mail-order pharmacy was more likely to be used by younger, employed users or those with a higher level of education and by those with established chronic conditions. ⁸ Other studies showed relations to older age, repeated medication use, that is, more than 30 days or for chronic diseases, and increasing distance to the nearest pharmacy.^11,12 The difference from our study may be due to the heterogeneity of our patient population, as the KHCC serves cancer patients from all parts of Jordan, both adult and pediatric, of all cultural and educational backgrounds.

Pinto et al ¹³ evaluated the validity and reliability of a modified survey to assess patient satisfaction with the services provided by mail-order and in community pharmacies. We adapted many of their survey components for our survey. Pinto et al ¹³ assessed patient satisfaction according to efficient functioning of the pharmacy (including delivery time) and the role of the pharmacist in managing therapy. Our survey focused on whether the new service met patients’ needs in terms of cost, the flexibility of the courier personnel, delivery to the correct address, the quality of medications, and the punctuality of delivery. Other studies on patient satisfaction with services provided by independent and chain pharmacies reported their experience with only 1 method, either mail-order or directly from the pharmacy. ¹⁴ At KHCC, patients were given the option of picking up their medications from the pharmacy or through the mail-order service, with the ability to alternate between the 2 refill service options at their convenience according to their needs. KHCC provides the service strictly through a call center, whereas some mail-order services provide more than 1 option, such as online request, phone request, mobile application, or mail request.^15,16 Although this choice may be more convenient, it is currently not available at KHCC.

Patients’ concerns and complaints were addressed, analyzed, and followed up to further improve patient satisfaction and service efficiency. Concerns were communicated to the pharmacists at the pharmacy window or at a contact number provided for queries and complaints. The contact number was provided to overcome a complaint reported by our patients as well as in the literature about patients’ wish to speak to a pharmacist about their medications.^1,6 The reported complaint about substitution of medications for those originally prescribed by the physician ⁶ was not a problem at our center, as all medications are dispensed as prescribed at our in-house pharmacy. The main concerns expressed in our study were preservation of the confidentiality of information, storage of medications during transport, and timely delivery of the medications. Patients were reassured mainly by explanations of the procedures in the service. The same complaints were reported in other services and surveys.^1,6 Concern about mail-order services was reported previously to be mostly among patients aged ≥65 living in rural areas. ⁶ We found no correlation with patients’ residence or age; however, more complaints were made from nonrural areas, including delivery delays, financial issues, and problems in the number of received medications. These minor complaints were due mainly to procedural factors, and further assessment of the quality of the service may be warranted during continuous service improvement.

Several studies included analysis of the impact of mail-order services on patients’ adherence and clinical outcomes. ² -4 We did not address this aspect, which might be difficult to assess, given the wide diversity of underlying diseases and demographics, although it will be considered for future analysis.

Challenges

Many challenges were encountered during implementation of the service, including obtaining the required licenses for the service, especially for the storage conditions of medications, and finding a courier service with all the requirements of licensure, storage, and area coverage that could ensure punctual delivery, which required close monitoring and follow-up on shipment status. This was difficult mainly because of the lack of a dynamic report, which facilitates quick access and detection of delays, so that they can be predicted before a patient complains. Another challenge was creation of a patient address databank internally linked to the patients’ medical files, with complete blinding of clinical details. Manual entry of patient contact information and updating the information when needed added a further task for the pharmacy team.

In addition, several internal challenges were encountered, including finding suitable packaging for medications; creating space for processing, packing, and stacking shipments before signing them off; redesign of the work flow; and area and space redistribution. Patients asked for interaction over the phone instead of the automated call center in order to communicate address changes, specific requests regarding their medications and other queries, and also for making complaints about shipment delivery time, quality, and content. Addressing patient concerns and assuring their understanding of the advantages of the service were the main challenges, which required another adjustment of the internal workflow, which was to create a contact number for patient queries about the service. Regular reports are now made of frequently encountered problems for analysis and process improvement.

Conclusion

A mail-order service for refilling prescriptions had positive outcomes on both patient satisfaction and the pharmacy workflow, despite the technical and logistic limitations, the wide geographical distribution of patients, modifications to the workflow, and patient concerns.