Build vs Buy: A Pharmacy Expert System Dilemma
Brief Summary
Pharmacy Expert Systems play a critical role in Pharmacy Benefit Management (PBM) solutions sold across the region. While some companies develop these systems in-house, others opt to purchase them from vendors. This paper will delve into a key question faced by Third Party Administrators (TPAs) and insurers: Should we build our own Pharmacy Expert System or buy one from a vendor and integrate it with our existing systems?
Introduction
The Pharmacy Expert System includes various rules which pharmacy claims are adjudicated to. Those rules are applicable to thousands of active pharmaceutical ingredients (APIs) which are available under international brand names, locally manufactured drugs and generics. The active pharmaceutical ingredients are the core of the PBM engine, and the pharmacy expert system is therefore built around them.
The comprehensiveness of these rules directly impacts the level of automation within the Pharmacy Benefit Management (PBM) engine, with more comprehensive rules facilitating faster and more efficient claim adjudication, thereby optimizing resource utilization.
As shown below these rules, may vary in complexity and coverage depending on the maturity of the PBM engine.
Table 1: Components of Pharmacy Expert System
Rule Name& Description
Drug to disease indication
A medical condition that a medicine is used for. This can include the treatment, prevention and diagnosis of a disease (1)
Drug to disease contra-indication
Contraindication is a medical term used for a specific situation or factor that makes a procedure or course of treatment inadvisable because it may be harmful to a person (2)
Drug Age Compatibility
Certain medications are not compatible for babies/children or elderly (3)& (4)
Drug Gender Compatibility
Certain medications are exclusively used for males or females (5) & (6)
Drug Duplication of Therapy
Medications with different active ingredient(s) that act on same organ/system in different ways
Drug Duplication of Medication
Medications with same active ingredient (s)
Drug Drug Interaction
Occur when two or more drugs react with each other (9)
Drug Renal insufficiency and Dialysis consideration
Drug doses should be altered based on the predicted reduction in the clearance of the drug (10)
Drug Pregnancy compatibility
Medications that are not safe during pregnancy & some to avoid (7)
Drug Breastfeeding compatibility
Certain Medications can pass through breast milk and affect babies (8)
Drug Dose consideration
Medications have a dose range to be administered
Drug Cross Allergy
Cross-sensitization is the process by which taking out one drug enhances the response to other drugs acting at the same neurobiological site (11)
Multi active Ingredient drug handling
One medication having more than one active ingredient
Explanation of the Problem
Despite the importance of all the above rules, three of them require the longest time to build and complete: drug-to-disease indication, drug-to-disease contraindication, and handling multiple active ingredients. Hypothetically, if we consider 100 active pharmaceutical ingredients to be completed for these three rules, based on my experience and analysis, it would take approximately three months to complete them at a rate of 1.5 active ingredients per day.
Table 2: Drug vs. ICD Time Estimate
Scope of Work(done/to be done)
One pharmacist
100 active pharmaceutical ingredient
3 months with 80% productivity, rate of 1.5 active ingredients/day
Beyond the Drug vs. ICD rule (Table 2), establishing contraindication rules will take an extra 60% of the time and resources, regardless of whether the work is done simultaneously or sequentially. Furthermore, the complexity of handling multiple ingredients is a different issue that needs separate analysis to estimate the time required.
To tackle this, there are generally two approaches:
Building from Scratch: Developing the database independently.
Purchasing a Pre-built Database: Acquiring an existing database.
The first Option
Building the database from scratch will be a lengthy process. This delay could put the TPA or insurer at a competitive disadvantage.
The costs of this approach include:
● Pharmacist salaries and time
● Ongoing maintenance for coding and medication updates
● IT costs
● Lost opportunities to offer PBM services
The cost of employing pharmacists needs to be estimated over multiple years, considering the number of pharmacists required. Maintaining the database will be an ongoing expense, necessitating long-term growth of the pharmacy department.
The second option
The alternative is to purchase a pharmacy expert system database from a vendor. These vendors specialize in pharmacy databases and offer a range of solutions, from comprehensive drug databases to formulary management and electronic health records. To obtain more information, TPAs/insurers typically need to sign a Non-Disclosure Agreement (NDA).
Vendor-provided systems cover a comprehensive set of pharmacy expert system rules. TPAs/insurers can either integrate the database directly into their legacy systems for faster processing or integrate the data while relying on the vendor's decision-making routines.
Vendor databases often organize medicines using the Anatomical Therapeutic Chemical Classification (ATC) code for active ingredients, as well as the National Drug Code (NDC). Some vendors also use local coding conventions like the Dubai Drug Code (DDC). This linking system enables the connection of brand-name and generic drugs to their active ingredients and to each other.
Vendor-provided systems require regular checks for updates to coding, new drugs, drug information, and other relevant data. The cost of such databases typically includes fixed and variable fees. The fixed fee is an annual charge, often locked in for a three-year period. The variable fee is an annual charge based on the monthly volume of processed claims.
Cost Benefit Considerations
It's crucial to assess the local adaptations of the vendor's system and weigh the economic implications of both options to make an informed decision.
For the in-house development option, the costs include hiring pharmacists to build the database and ongoing maintenance for updates to new medications, drug information, and coding.
With the vendor option, the database needs to be installed, integrated into the TPA/insurer's system, and ensure smooth communication within the system. The vendor's support, including installation assistance and regular updates to the database, is essential. These updates should encompass all drug-related and coding changes. Typically, the IT department's involvement is minimal, and two qualified pharmacists can manage the system.
Conclusion
The economic factors don't make the straightforward decision between building or purchasing a database. However, a vendor-provided database offers a complete, ready-to-implement solution, significantly faster than developing one in-house. This is particularly crucial considering the following factors:
Database Source Quality: Clients are increasingly concerned about the quality of the database used in pharmacy expert systems.
Potential Savings: A robust pharmacy expert system can generate significant cost savings.
Formulary Management: Offering cost-effective future solutions through formulary management is an attractive option.
References
1- “Indication | European Medicines Agency (EMA).” European Medicines Agency (EMA), 2024, www.ema.europa.eu/en/glossary-terms/indication.
2- France, Nicole . “What Does Contraindication Mean?” Drugs.com, 2021,www.drugs.com/medical-answers/contraindication-mean-3561035/.
3- Arnold, Michael J. “Key Potentially Inappropriate Drugs in Pediatrics: The KIDs List.” American Family Physician, vol. 103, no. 10, 15 May 2021, pp. 633–636, www.aafp.org/pubs/afp/issues/2021/0515/p633.html.
4- Cleveland Clinic. “Medications on the Beers Criteria List.” Cleveland Clinic, 3 May 2023, my.clevelandclinic.org/health/articles/24946-beers-criteria.
5- “List of Gynecological Conditions Medications.” Drugs.com, www.drugs.com/condition/gynecologic-surgery.html.
6- Abbe, Carmen R, et al. “Male Contraception.” The Yale Journal of Biology and Medicine, vol. 93, no. 4, 30 Sept. 2020, p. 603, pmc.ncbi.nlm.nih.gov/articles/PMC7513428/.
7- “Medicines to Avoid When Pregnant.” WebMD, www.webmd.com/baby/medicines-avoid-pregnant.
8- “Breast-Feeding and Medications: What’s Safe?” Mayo Clinic, 2018, www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/breastfeeding-and-medications/art-20043975.
9- Research, Center for Drug Evaluation and. “Drug Interactions: What You Should Know.” FDA, 17 Mar. 2020, www.fda.gov/drugs/resources-drugs/drug-interactions-what-you-should-know.
10- Kyriakopoulos, Chris, and Vikas Gupta. “Renal Failure Drug Dose Adjustments.” PubMed, StatPearls Publishing, 2021, www.ncbi.nlm.nih.gov/books/NBK560512/.
11- Nona, Christina N., et al. “Behavioural Sensitization to Alcohol: Bridging the Gap between Preclinical Research and Human Models.” Pharmacology Biochemistry and Behavior, vol. 173, Oct. 2018, pp. 15–26, https://doi.org/10.1016/j.pbb.2018.08.003. Accessed 10 Apr. 2020.
