Research Example

[Pharma Co] PAP
Ethnographic Research
Final Presentation
Tuesday, May 8, 2007
Agenda
Project review
Findings and implications
Recommendations
Next steps
Project Review
Goals
Team
Methodology
Sites
Analysis approach
Research goals
What are the profiles, work process,
and technology-related
characteristics of the user
population?
How might an internet-based
system impact users current
processes across the entire lifecycle
of interaction with the program?
Are some segments of the
population more likely to adopt the
online channel than others?
Confidential | Prepared for [Pharma Co] by Moment
What performance and usability

requirements would an online
solution need to meet in order to
encourage self-service on the part
of the prescriber?
Are there value-added services or
features that an online solution
could provide to help encourage
adoption and improve the user
experience of accessing the
program?
p4
Research methodology
Ethnographic research
11 sites (24 participants)
1-3 hour interview & observation,
audio taped when possible
Internal stakeholder
interviews
8 interviews (22 participants)
Participants included:
Short tour guided by the subject
CSRs
Participants included:
Operations
Social workers
Program and Clinic directors
Pharmacists
Pharmacy Technicians
Non-medical administrators
Volunteers
Stakeholders
Distribution
CSR call shadowing
127 calls reviewed (5+ hours)
5+ hours of calls logged for
process, information provided,
and points of confusion
p5
Health care sites
p6
Teaching IndependentIndependent Teaching Independent Public Independent Private

hospital
free clinic health center hospital
free clinichealth center free clinic hospital
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Organization
Public
hospital
Private
hospital
Private
organization
Location #
Utilization
Medium
High
Medium
Low
Low
Very
High
Medium
Medium
Medium
Medium
Very
High
IVR
IVR
Live op
Fax
IVR
IVR
IVR
IVR
IVR
IVR
IVR
Reorder channel
preference
Participants
People #
Social
workers
Non-medicalNon-medical
Social
Manager & Manager &
worker
Admin
Admin
Pharmacy
Software in use
Aggregator
Non-medical
Non-medical Manager,
Pharmacy Pharmacist /
Non-medicalNon-medical
Manager, Pharmacy Pharmacist Technician
/
/ non-medical
Worker & Manager &
Admin, & Technicians / VolunteersNon-medical Workers, &
Volunteers
Admins
VolunteersNon-medical
Admin
Volunteers
Admins
4
3+
1+
p7
Analysis | Transcribe and organize

Audio from all sessions was reviewed and
debrief notes summarized. Other data (artifacts
and images) were aggregated and organized
for review.
p8
Analysis | Code the data
Medication Processing
Communications
All notes and other data were reviewed in work

sessions where research observations and
comments were drawn out and categorized.
Interaction w/ PAP
Interaction w/ HCP
Interaction w/ Patient
PAP information
p9
Analysis | Find patterns and themes

Observations and comments were transcribed and
grouped by category. The resulting entries were then
sorted and reviewed in work sessions to identify
patterns and
themes.
Confidential
| Prepared
for [Pharma Co] by Moment
p10
Findings and
implications
Process
Philosophy of care giving
Personas
Batching and fragmentation
Communications and information
Process
1
Initial patient
meeting to
evaluate needs and
screen for
elegibility to
receive services.
2
Patients supply
personal and financial
data to be submitted
to the appropriate
PAPs by
the PAP coordinator.
3
Reorders and
reenrollments, often
triggered by reports,
are executed on
behalf of the patient
by the health center.
4
After executing a
transaction for the
patient (enrollment,
reordering,
reenrollment) a record
is created for tracking.
5
Medication is
organized, bottles
are labeled, and
patients are
contacted to pick
it up.
p12
Process | Patient consultation and screening

All sites visited had an initial meeting to consult
with the patient, evaluate their needs, and screen
them to determine eligibility to receive services.
If qualified, this consultation is followed by activities
to locate appropriate resources for the patient.
Patient Assistance Programs are one of those
resources.
Some sites have dedicated personnel focused
exclusively on this activity.
Observations and implications

Although physicians may identify the need for PAP
intervention, patients are typically referred to a PAP
administrator for their initial consultation. Because of this
issue, communicating primarily with physicians may not keep
all parties well informed about the program.
Enrolling and participating in PAPs is a complex and daunting
process. The expert consulting a PAP administrator provides
is a valuable and integral component of the service of the
health care sites we visited. Sites who are high-utilizers of PAP
have developed this expertise.
Some sites gather all necessary financial documentation at the
time of the initial screening, others wait until it is needed for
PAP application. Being clear about the necessary financial
documentation necessary (as [Pharma Co] is) simplifies the
task of pre-screening.
1
p13
Process | Enrollment
At the sites we visited, enrollments are typically
handled by the PAP coordinator on behalf of the
patient.

There is a 10-30 day gap prior to medication availability
through PAP. Sites have a variety of ways to fill this gap,
including using samples and their own supply of medication.
If accepted for care by a site, patients are required

to provide personal data to be recorded on
enrollment forms by the PAP coordinator. Patients
also supply financial data that is submitted with a
completed PAP enrollment form.
The requirements around financial documentation lengthen

the enrollment process and are a pain point for sites and their
patients. Frustrations include:
This enrollment form is bundled with a prescription

signed by a physician prior to submission.
stringent requirements not flexible enough to adapt to

changes in income (i.e. last years tax return may not
reflect their current income)
explaining financial documentation requirements to

patients adequately and procuring all appropriate financial
documentation
PAP coordinators design methods to clarify forms and focus

patient and physician attention (specifically where signatures
are required).
Enrollments are often assigned to different (sometimes more
experienced) personnel than reorders.
2
p14
Process | Reordering and reenrollment

Reorders are triggered by patient calls or
reports based on a calendar of orders. They
are executed on behalf of the patient by the
site.
Reenrollments (which require updated
financial information) are typically triggered
by reports based on a calendar of
enrollments or status updates from each
specific PAP.
Sites have strong channel preferences, but may be swayed by

an opportunity for increased efficiency. These preferences
should be reflected in a web channel.
Reorders by CSRs are preferred because they provide
immediate feedback and problem resolution but may
require a wait for service.
IVR reordering is preferred for its immediate access and
feedback but problem resolution requires CSR intervention.
Fax reordering provides the ability to batch reorders at the
expense of immediate feedback and problem resolution.
Communication of order and patient enrollment status is a
critical element of reordering.
Web-based reordering is not commonly used by sites we
visited. Anecdotal evidence suggests that initial bad
experiences and lack of trust are key factors.
Many sites generate reports (from third-party PAP management
software or databases) in order to drive workflow. Streamlining
the process of acquiring data for these reports would save the
user time.
Reordering can be conducted by less experienced individuals
than enrollments. Reorders dont require the same degree of
specialized knowledge as enrollment.
3
p15
Process | Recordkeeping and tracking

After executing each transaction on behalf of
the patient (enrollment, reordering,
reenrollment) a PAP coordinator generates a
record of that transaction.
These records are tracked in elaborate
calendar based filing systems, databases, or
by third-party software.
Reports generated by these records help to
trigger reordering, reenrollment, order
tracking, and problem resolution activities.
Sites with high PAP utilization require robust PAP management

and administration systems and dedicated personnel.
Sites are willing to pay third parties for software or services
that reduce the administrative burden of PAP management.
Sites who currently use third-party software system for PAP
management have deeply integrated the software into their
processes, making switching difficult. Activities covered
include:
Generating, filling-out, and tracking enrollment applications
Generating, filling-out, and tracking prescriptions
Timing PAP reorders
Recording medication tracking information (such as
expected arrival date, date arrived, date picked-up, etc.)
Generating reports to drive workflow
Centralizing patient PAP history and information.
While some sites are well funded and have robust IT
infrastructure in place (including multiple software systems
that share data), others are remotely located and have little IT
support or expertise thus reducing their interest in complex
technology solutions.
4
p16
Process | Medication processing and distribution

Upon arrival, medication is organized by
patient and date, bottles are labeled for
patients (in most cases) and prepared for
distribution, and patients are contacted and
told that their medication has arrived.
This process is radically different between
sites with an in-house or contracted
pharmacy, and those without.

Three models of medication distribution emerged.
Distribute to patients on-site (through pharmacy or an
HCP) This model was the most often encountered.
Send medication to a contracted distribution site (a
pharmacy).
Send medication to multiple points of distribution (such as
individual physicians offices). This model has additional
address book needs.
Non-pharmacy distribution process is ad-hoc.
Sites create their own hand written instructions and labels.
They sometimes provide medication literature from thirdparty sites, such as NeedyMeds.com.
Some require patients to consult with a caregiver before
leaving with their medication.
Medication pick-up, physician appointment, and PAP
consultation may all happen in different locations.
5
p17
Findings and
implications
Process
Personas
Philosophy of caregiving
Many sites view the service they provide as a
patients last resort and will do whatever they can
to help the patient. Within this perspective, we
observed a high-level split in the approach that
sites took to managing their patient relationships:
The Enable Philosophy

Some sites assume the entire burden of
managing their patients interactions with
PAPs. A specific example is tracking
medication reorder dates.
The Empower Philosophy
Other sites prefer to help patients help
themselves. This means assigning more
responsibility to the patient for managing their
own PAP interactions, including monitoring
reorder dates.

Caregivers who subscribe to the Enable approach:
These tend to be PAP administrators, pharmacists, or
part-time volunteers, who have a more tactical, focused
perspective on PAP.
They often focus their caregiving around PAP-related
issues.
They assume the responsibility of monitoring their
patients reorder dates and triggering reorders.
Caregivers who subscribe to the Empower approach:
These tend to be Social Workers who have a more holistic
view of their patients well-being.
They extend their caregiving to areas outside of PAP, such
as suggesting other social services.
They place responsibility on their patients to alert them
when it is time to place a reorder.
One social worker had patients sign a contract outlining
the PAP process and the patients responsibilities.
p19
Findings and
implications
Process
Personas
Personas
Personas are fictionalized descriptions of
users that have been distilled from the
participants we observed and
interviewed in the field. They are
hypothetical archetypes which
represent individual program users, and
embody critical characteristics of key
user segments.
The goal in creating this set of personas
is to understand the attitudes and work
patterns of program users, and how their
needs may differ. Moving forward, these
personas can keep the design team
focused on the specific needs of actual
user types in specific contexts.
p21
Maria
Health Access
Consultant
Jacqueline
PAP Coordinator
Needs
Empower
Current status on the enrollment and reorders of her

patients
Current knowledge of PAP details and changes
Clear messages and communication materials with which

to educate her patients
Needs
Empower
Jane and Tom
Enable
Enable
Ways to place multiple reorders at once

Quick feedback of the status of enrollment and
reorders, especially if something is wrong
Easy access to answers if she has a question
Needs
Empower
Enable
Supporters
The opportunity to help others

Defined tasks that fit within the time they are giving
Straightforward directions
Help when they need it
Needs
Frank
Manager
Empower
Enable
Reliable arrival of reordered medication

Ability to track orders and reorder dates
Needs
Melinda
Manager
Simple and organized requirements and procedures
Empower
Enable
Ways to stay current on the PAP rules

Keep patient records current and up-to-date
Ways to reduce administrative work and spend more
p22
money on patients
Persona | Health Access Consultant

Maria
Enrollment Expert, 39
Hanner Health Center
Portsmouth, VA
Background
Maria is a Social Worker at the Hanner Free Health Center where she keeps daily patient
appointments. She has worked at Hanner for nearly 8 years and was influential in training the other
Social Workers there and developing the system they use to work with PAPs. When not consulting
with patients, she organizes community outreach programs that focus on educating the local
Hispanic community on the importance of health care. She loves her job, but sometimes she finds it
emotionally taxing.
Technology usage and preferences
She uses Microsoft Word and Outlook daily. She keeps her networked schedule up-to-date and uses
a database to access patient information. She is comfortable with programs that she knows, but
doesnt always understand their quirks.
Duties
Meets with patients to determine their eligibility for Hanners services
Identifies what kinds of help patients need, and what resources exist to serve their needs
Enrolls patients in programs that offer free or discount services
Meets regularly with patients to check on their progress, keep them on track, and take care of
any administrative work needed
Values
Accountability and being proactive
Ive always said that if it

was my family member in
that situation, Id do
whatever I needed to do to
get them help.
She feels successful when she has helped someone take care of themselves. Her success
depends on the reliability of the programs that provide resources to her patients.
Accurate knowledge of the PAP status of her patients and orders
Clarity and flexibility in the requirements for services.
Simplicity
p23
Persona | PAP Coordinator

Jacqueline
PAP Coordinator, 26
Johnson Clinic
Delray Beach, FL
Background
Jacqueline is a 26-year-old non-medical worker studying to become a Pharmacy Technician. She has
been the PAP coordinator at Johnson Clinic for two years. Her days are spent working between the
pharmacy and a small cubical next to the receptionist desk. She spends a lot of time on the phone with
(or writing letters to) patients to track down details. She likes to go to the in-house pharmacy because
she likes to talk to the Pharmacy Technicians there. She divides time between her computer and PAP
phone calls, she almost never sees patients. Her desk is immaculate. Shes hyper-organized and proud
of it.
She uses Microsoft Word, Outlook, a DOS-based pharmacy program, and a PAP software called
Prescription Hope. She likes the software that shes been trained on, but isnt sure she wants to learn
anything new.
Duties
Enters patients into a database that will automatically fill out applications so she may enroll them in
patient assistance programs
I never thought that I

would know all of the
requirements and
companies - but I guess
its inevitable.
Communicates with patients to gather financial information and notify patients that medications
have arrived
Double checks the requirements for each program application
Arranges for physicians to sign applications that are complete
Maintains the patient database so that she will know when to reorder medication and re-enroll
patients
Reorders medication
Organizes and labels medication for patients to pick it up
Values
Jacqueline values multitasking - anything that saves her time.
She appreciates being able to talk to someone on the PAP side if she has a problem or question.
Knowing the status of the patient enrollments and orders so she can plan her work
p24
Persona | Supporters
Jane and Tom
Volunteers, age: (None of

your business)
Charity Hospital H.C.
Danbury, North Carolina
Background
Tom is a retired naval officer who volunteers at the nearby Charity Hospital Health Center for few hours
one day a week. He is one of three volunteers who help the health center run smoothly. He often drives
from the health center to doctors offices to drop off and pick up applications and prescriptions. Jane is
a retired teacher who volunteers on the same day as Tom. She organizes the packages for Tom to
deliver and places medication reorders by phone.
Jane uses email almost daily. She sometimes checks her account on the health center computers.
Tom doesnt use email. He only uses the computers when she needs to look up something from the
patient database (A physicians DEA number for example).
Duties
Its nice to know that you

are helping someone who
needs it.
- Tom
We joke that we are sort
of walking computers.
- Jane
Call patients to get the correct information for PAP applications
Drive applications that need signatures to physicians offices, and pick them up
Call to place reorders for medications for that month
Stamp, address, and stuff envelopes to mail applications
Pick up medication that arrives several times a day and bring it to the pharmacy
Organize paperwork
Values
Helping people
Feeling of accomplishment
Straightforward directions for complex problems
Simple, courteous service
p25
Persona | Manager
Frank
Pharmacist, 54
Memorial Hospital
Albuquerque, New Mexico
Background
Frank is an experienced retail pharmacist who now runs a PAP pharmacy for Memorial Hospital. He has
recently taken over this pharmacy and relies on his staff of two (a pharmacy technician and a nonmedical administrator) to stay current on each patient. He oversees the process and makes sure that
regulations and procedures are being followed, but only deals directly with filling prescriptions and
consulting with patients when they arrive to pick up their medication.
Frank has a computer terminal running a DOS program which he uses to generate pharmacy labels
and medication information sheets on a dot matrix printer. Others in his office have more modern
computers connected to the internet, but he doesnt use them.
Duties
Its hard for our patients to

do things for themselves, so
we have to take care of
them.
Managing his staff, interns, and volunteers
Training people on proper procedure and record keeping
Accurately filling prescriptions and filing them appropriately
Consulting with patients on their medications
Accounting for finances of the pharmacy
Getting the word out to the local doctors about the PAP pharmacy
Determining the most efficient work processes
Values
Adherence to required procedures and processes
Clean, simple organization
Efficient processes
Cost savings
Taking care of people who cant take care of themselves
p26
Persona | Manager
Melinda
Administrator, 46
Providence Helping Hands,
Providence, Rhode Island
Background
A few years ago, Melinda, a former business accountant, changed her career path to focus on
giving back. For the past 5 years she has run operations for Providence Helping Hands, a churchaffiliated free clinic. One important (and time consuming) aspect of her job is PAP administration. For
years, she did this on her own, but for the past year, she has had part-time help in conducting the
day-to-day chores of keeping medication flowing to the patients who need it.
Melinda and her assistant both have internet-connected computers which they use to maintain PAP
records in an online system. This PAP management software maintains an internal database where
they store the PAP history and records of all their patients.
Duties
Coming to a clinic like ours

is often a last resort for a
person Helping someone
find the motivation to get
back on her feet, those are
my best days.
Training and managing her assistant
Determining the most efficient approach to PAP management
Maintaining accurate and auditable records of medications
Staying current on the rules of all PAPs
Interacting with patients to explain requirements and responsibilities
Ensuring that patients get accurate and helpful instructions on how to take medications
Evangelizing the clinic and recruiting volunteers
Values
Helping people help themselves
Working with others who share her values and beliefs
Minimization of administration costs, to maximize care for patients
Giving back to her community
p27
Findings and
implications
Process
Personas

The PAP management process is frequently split
up among the participants in ad hoc ways. Sites
exhibit a variety of different sub-processes,
organized around people, time, technology and
task.
Sites reported habits such as doing all reorders on
Monday, calling in reorders in batches by
manufacturer, driving the circuit to deliver
prescriptions to physicians and collect those they
have signed.

The most common process split is to assign enrollment and
reordering to different parties. Web-based reordering should
take this into account.
As sites scale up, patient consulting and medication
processing may be taken on by different parties as well. Webbased reordering should take this into account.
At the largest of the sites we visited, each of these tasks may
be further sub-divided into tasks that can be accomplished by
volunteer labor in small batches. Tasks like these were
typically assigned to one individual and accomplished once a
week.
Gathering all enrollment materials
Procuring physician signatures
Addressing and mailing enrollments
Calling in reorders
Labeling & storing medication bottles
Calling patients for pick-up
p29
Findings and
implications
Process
Personas

Communications sent to both patients and health
centers are critical touch points in the Connection
to Care user experience. In general, these
communications are very helpful to patients and
health centers in managing their relationship with
the program .
However, we did observe specific instances in the
field in which these communications created pain
points and contributed to process inefficiencies.
These included communications or information:
From the program to patient
From health center to patient
From the program to health center
From third parties to health center
p31

From the program to patient
Many sites mentioned that letters sent from the
program to patients (such as the enrollment
acceptance letter) are potential points of confusion
for some of their patients.
In addition, we observed a lack of marketing or
guideline material available for patients at most
sites.

Patients often think that the initial enrollment letter means that
their medication is ready to be picked up. This confusion can
sometimes trigger a call to a CSR.
Some patients are confused by the presence of a reenrollment
form sent with their written reorder notifications. This confusion
can sometimes trigger a call to a CSR.
Many patients are non-English-speaking and dont understand
the communications sent to them from the program. This can
become a pain point for PAP coordinators, who must spend
extra time explaining communications to their patients.
Other PAPs seemed more active in providing program
marketing materials for patients.
p32

From health center to patient
Patients typically receive communications from
both [Pharma Co] and their health center
concerning the program. Often, the health center
acts as the primary communication source for
patients.

The purpose of communications sent from health centers to
patients is typically to let the patient know that some action is
required of them. These include:
Medication ready for pickup
Signature required on PAP form
Financial documentation needed
p33

From the program to health center
Some sites expressed a desire to have greater
control over the communications sent to them from
the program. This includes the types of
notifications theyd prefer to receive, as well as the
channels through which theyd prefer to receive
them.

Some sites want to receive copies of all communications sent
to their patients. This would help them more efficiently manage
their patient relationships.
Some sites were unaware of recent program changes (such
as the expedited or hardship processes), and expressed a
desire to receive communications from the program regarding
such program changes.
Some sites want to receive communications from the program
via email.
p34

From third parties to health center
For many health centers, third-party PAP
management software or PAP information hubs
(such as RxAssist or NeedyMeds.com) serve as
their primary PAP information resource. Typically,
health centers will not visit pharmaceutical
company web sites to seek answers to their PAP
questions.

Many sites we visited rely on PAP management software or
PAP information hubs to stay up-to-date on:
PAP rules and availability
Recent PAP procedure or service updates
PAP forms
Information from these third parties is not always complete or
accurate.
p35
Recommendations
Usability improvements
Internet-based program access
Other considerations
Usability improvements | Enrollment letter

One issue with written communications
reported to us was patient confusion due to
misunderstanding of the enrollment letter. This
misunderstanding can cause unnecessary
calls to SDS for program questions.
Suggested improvements
Clarify patient next steps
Improving direction on necessary actions the
patient must take (or not take) could reduce patient
confusion.
Improve information design of communications
Improved information design could highlight
important elements of the communication and
improve scannability.
Ability to select Spanish or English preference
Providing the ability for the patient or the health
center to select a language preference for
communications could improve patient
understanding.
UE Improve
Investment
Time the communications carefully

Changing the timing to coincide with medication
arrival may reduce misunderstanding.
Cost Savings
Reduced
patient
calls to
call
center
Inclusion of pertinent patient data

Including reorder number for prescription and
patient enrollment expiration date on all
communications would simplify recordkeeping for
the sites.
p37
Usability improvements | Presence of unexpected forms

The presence of unexpected forms in patient
communication can be another source of
confusion. In many cases, patients being
treated through a health center or clinic may
not be knowledgeable enough about their
participation in the program to understand what
to do with forms provided.
UE Improve
Investment
Option to receive no forms
Since many sites utilize auto-generated forms,
offering the ability to opt-out of form inclusion in
mailings may reduce confusion.
Option to cc on all patient communications
Our research suggested that when the patient is
confused, the first call they may make is to their
clinic or health center. Offering the ability to receive
all communication the patient receives may enable
them to answer questions before they get to SDS.
Cost Savings
Reduced
patient
calls to
call
center
p38
Usability improvements | Availability of program

materials
The presence of program materials at
prescribing sites improves general
understanding of the program by the patient
and the PAP coordinator. Increasing this
understanding may reduce patient calls to the
call center. The tactic of mailing materials to
the ship-to addresses on file with SDS may
only achieve part of this goal.
UE Improve
Investment
Identify PAP sites as communication targets
Since the person who places reorder calls is
sometimes in a different location from the
prescribing physician, capturing a ship-to address
for the caller may identify the appropriate PAP
administration location.
Ship materials to caller address
Shifting shipments of materials from the medication
ship-to addresses on file to the caller ship-to
address may improve ability to get materials into
the hands of the patients.
Cost Savings
Reduced
patient
calls to
call
center
p39
Usability improvements | IVR improvements

Since IVR is the least expensive means for a
user to place reorder calls, it is critical for the
user to have a good experience through this
channel.
Examine IVR timeout
Sites reported an unexpected IVR timeout after 8
minutes (or 5 orders). Investigate the removal of
this timeout. If this is impossible, provide clear
feedback that the timeout is approaching.
Balance loudness of recorded voices
Data being reviewed for the user (like medication
name) was reportedly difficult to hear for some.
Strive to balance the loudness of all IVR recordings.
Test IVR against workflow and requirements to
look for bugs
Several issues were reported that may promote
errors on the part of the caller. Test to identify all
deficiencies and make improvements.
UE Improve
Investment
Cost Savings
Increased
adoption
of
IVR
channel
Provide IVR login PIN and personalization

Offering the ability to support a personalized
logged-in experience may streamline order
placement and enable callers to access their
patient data more conveniently.
Increase caller understanding of IVR
Offering a printed cheat sheet or demonstrations
by CSRs may improve adoption.
p40
Usability improvements | Form design & requirements

Some sites pointed out that features of other
manufacturers forms that they felt were
beneficial. Making improvements to the form
design and requirements may improve their
processing efficiency greatly (but may not have
as great an impact on cost savings).
Inclusion of prescription
Inclusion of a prescription directly on the form
would obviate the need for a separate prescription
to be attached and mailed. This would reduce the
administrative burden on the sites.
Ability to fax enrollments
Changing the requirement for an original
prescription (and original signatures) would enable
sites to fax in enrollment forms. This could reduce
initial enrollment time.
Ability to batch reorders on one fax form
Offering a batch reorder form for fax (and mail)
could reduce the amount of paper necessary for the
site to process, thus reducing their administrative
burden.
UE Improve
Investment
Cost Savings
p41
Usability improvements | Packing and packaging

materials
Information shipped with the medication is
critical for the PAP coordinators. They often
use these materials as a work sheet when
processing medications. Improving those
materials may increase their accuracy (but
may not present cost savings for [Pharma Co]).
Inclusion of pertinent patient data
Including reorder # for prescription and patient
enrollment expiration date on packing slip would
simplify recordkeeping for the sites.
Inclusion of preprinted patient labels for bottles
Including preprinted labels with patient name and
space for additional information could improve
health center medication processing and
communication to patient.
Inclusion of Prescription Information
Including prescription information for medications
shipped would ensure correct usage of
medications.
UE Improve
Investment
Cost Savings
p42
Usability improvements | New communications

Some sites pointed out communications from
other manufacturers that they felt were
beneficial. In other cases, we observed their
own creation of these materials to use as
working documents. Developing new forms of
communication may increase site efficiency
and on call center calls.
Reorder and Reenrollment reports
Reorder reports containing all pertinent patient
information for upcoming reorders and
reenrollments would streamline order placement
and record entry for the sites.
Order status & Issue reports
Reports of problems with orders or enrollments may
reduce the need for call center calls on unresolved
issues.
Notifications
Providing a site the ability to receive notifications
(or send them to patients) based on common
triggers in workflow (enrollment successful, order
received, order shipped, order delivered, etc.) may
increase site efficiency and reduce call center calls.
UE Improve
Investment
Cost Savings
Reduced
site calls
to call
center
Notification channels
Providing a site the ability to determine their
preferred channel of communication (mail, e-mail,
voice-mail, or fax) may reduce the need for
mailings.
p43
Recommendations
Internet-based access | Web channel features

One critical goal of this project was to
determine if a web-based reorder channel
would provide necessary value for adoption by
high-utilizing sites. Such a channel could
provide enough value, but reorders alone are
not enough.
Features required for adoption

Secure login with unique user ID
User profiles tied to patient data (shared with SDS)
Ability to batch reorders (via web-form and/or
upload)
Immediate order status feedback (submitted, issue
id, reason for issue)
Clear and simple access to safety net for issue
resolution (online help, live chat, call back request)
UE Improve
Investment
Offloading
Cost Savings IVR and
Live
Operator
transactio
ns
Reduced
cost of
processin
g
transactio
ns
p45
Internet-based access | Web channel supporting

features
These features would further increase the
likelihood of adoption by high-utilizers by
supporting existing user needs, workflow, and
activities and addressing reported pain points.
Features to increase adoption

likelihood
Ability to track order shipping (across all reorder
channels)
Ability to add medications for patients already
enrolled in program
Support for language, communication, shipping
preferences (for site and / or patient)
Ability to opt-in to reminders for reorders,
enrollments, medication arrival, order problems (for
site and / or patient)
Ability to generate reports on reorders,
reenrollments, status, and issues
UE Improve
Investment
Offloading
Cost Savings IVR and
Live
Operator
transactio
ns
Reduced
cost of
processin
g
transactio
ns
Ability to obtain latest forms / program information

online in English & Spanish
Ability to obtain Prescribing Information sheets for
all available products in English & Spanish
Ability to import / export patient records and other
reports in common file formats (CSV, XLS, etc.)
p46
Internet-based access | Web channel enrollment

features
Beyond reordering and other supporting
features, with some changes in program
requirements a web channel could support
enrollment, expedited enrollment, or
reenrollment as well. Adoption of web-based
enrollments would have significant cost
savings implications.
Additional areas of opportunity

Ability to track enrollment status
At the most basic level, providing simple status of
pending enrollments would reduce call center calls.
Expedited enrollment processing
For expedited enrollments, the current workflow would
support entry of all necessary information via a web
channel.
Standard enrollment processing
If requirements could be modified to support digital
submission of most (if not all) necessary materials for
enrollment cost of enrollment processing could also be
reduced.
If program requirements could be changed to allow
pre-approval shipment of medication, our research
suggests that adoption would be much more likely.
UE Improve
Investment
Cost Savings Reduced

cost of
processin
g
transactio
ns
p47
Internet-based access | Web channel supporting activities

If development of a web-channel is pursued,
there are some supporting activities that
should be executed alongside any design and
development project.
Supporting activities
Rigorous usability and performance testing prior to
launch
Because of anecdotal references to reactions to
unreliable web-based order channels from other
manufacturers, providing a good experience to the first
user is vital. For this reason, rigorous user involvement
in design, usability testing, and performance testing
prior to launch are critical.
Rollout communication strategy
Because some sites seemed less knowledgeable about
the breadth of program features available (expedited,
hardship, etc.) than others, a communication initiative
highlighting the addition of a web-based channel is vital.
Such a program should target the PAP coordinators in
addition to the ship-to addresses on file.
UE Improve
Investment

cost of
processin
g
transactio
ns
p48
Internet-based access | Application programming

interface
Our observations uncovered a variety of thirdparty software solutions aimed at the
administrative problem of managing PAP.
Because of the presence and entrenchment of
these programs [Pharma Co] may be able to
provide an Application programming
interface (API) to enable end-to-end PAP
management.
UE Improve
Investment
Additional areas of opportunity

Read only access to the program
At the most basic level, an API could provide read only
access to program data. This would increase efficiency
of sites by reducing double entry while reducing costs to
the call center.
Transactional access to the program
Through an API, third-party tools could also enable
transactional functions (reordering and medication
additions., etc.) and data editing directly. The API should
support all features and requirements noted under webbased channel recommendations.

cost of
processin
g
transactio
ns
p49
Internet-based access | API supporting activities

If development of an API is pursued, there are
some supporting activities that should be
executed alongside any design and
development project.
Supporting activities
Rigorous performance testing of each third-party
site prior to launch
Because exposing an API will restrict [Pharma Co's]
control over the user experience, testing will be the
primary tool to ensure that third-party applications have
adequate performance for users.
Establish formalized contractual relationships with
third-party developers
It will be necessary to establish relationships with any
third parties who enable API based access to the
program to:
Ensure that the API is used only in approved ways,
and
Ensure appropriate marketing value of the program
through that channel.
UE Improve
Investment

cost of
processin
g
transactio
ns
p50
Recommendations
Other considerations | Changes to program requirements

Frequently sites mentioned frustrations with
perceived inflexibility around financial
documentation and requirements for original
prescriptions and signatures. They reported
that other manufacturers were more flexible
and didnt have similar requirements.
UE Improve
Investment
Suggested actions
Increase flexibility around financial documentation
Do not require original prescription or signatures
Accept faxed prescriptions
Incorporate prescription into enrollment form
Cost Savings
p52
Other considerations | Changes to initial medication

supply
Some of the means reported of closing the
initial 30 day enrollment gap are problematic.
In particular the use of samples as initial
supply for patients applying for enrollment in
the program is an issue. This causes
misleading usage of samples and incurs
unnecessary cost for [Pharma Co].
UE Improve
Investment
Suggested actions
Investigate the costs of providing a PAP medication
starter supply to alleviate the need for physicians
to use medication samples for this purpose.
Investigate means of incorporating PAP usage of
samples into the ROI accounting for sampling.

consumption
of samples
p53
Other considerations | Additions to program

From our research it appears that there is an
opportunity to establish a new type of program
(situated between a bulk-replenishment
program and the current program) for
Preferred Partners. Several sites reported the
desire for such a program. One site reported
an existing relationship like this with Express
Scripts RxOutreach program. RxOutreach
provides low-cost medications and bills
AmeriCares monthly (rather than pay as you
go).
Suggested actions
Preferred Partner Program
Establish guideline requirements
Existing program relationship w/ adequate
history for benchmarking
In-house pharmacy
Auditable practices
Establish target utilization ranges
Audit sites screening & medication processing
practices
Enable bulk replenishment via voucher
Monitor utilization ranges against target
Conduct periodic audits
UE Improve
Investment
Cost Savings Reduce

individual
order
processing
costs for
enrolled
sites
p54
Next steps
Paper-based communications
IVR
Web-based reorder channel
API
Any internet-based program access
Required documentation
Preferred partner programs
Next steps | Paper-based communications

Review the necessity and timing of each
mailing and investigate the effort involved
with:
Redesigning mail going to patients and
PAPs
Translation of all communications for
presentation in both Spanish and English
Inclusion of all available, pertinent patient
data where allowable
Determine feasibility of preferences

Selecting Spanish or English
Opting into or out of forms in patient mailings
Requesting duplicate statements be sent to
PAP coordinators
Send more literature to Health Centers;
especially high-volume centerswhich are not
necessarily ship-to addresses.
p56
Next steps | IVR

Examine IVR timeout
Comprehensively review the IVR for errors.
If its a requirement, look into the addition of

user feedback.
It currently reports there are no more

medications for a patient when there are.
i.e. This session will time-out in 90 seconds.

All in-progress orders will not be completed.
The IVR allows for multiple reorders under a

single DEA number; this leads to inaccurate
data.
Balance loudness of recorded voices

Determine where inconsistencies in volume
exist, such as product names.
Rerecord dynamic areas of the IVR with
similar sounding (if not the same) voice
actors.
Examine the feasibility of adding personalized

accounts to the IVR.
Understand if this could, at the very least,
allow repeat users to bypass legal
information.
p57
Next steps | Web-based reorder channel

Reexamine the underlying business case.
The assumption of $300K for development
cost may be optimistic.
Given the complexity of required features,
a $450 - $550K investment in requirements
definition, software design and
development is more realistic.
The level of recommended usability testing
and the scale of the rollout communication
will add an addition $50 to $100K; a cost
not currently reflected in the business case.
The assumption of 100% adoption is also

optimistic.
Given entrenched processes, a first year
adoption rate of 20 to 30% is more realistic.
Adoption of a web-based system should only
be expected amongst those sites reordering
around 10 or more prescriptions per month.
Adoption will continue to increase in
subsequent years, but will likely never reach
100%.
If 75% of all reorders eventually went
through a web-based system that should
be considered optimum.
p58
Next steps | Application Programming Interface

Understand the landscape of third-party
products.
Begin an audit initiative to understand more
comprehensively the number and types of
third-party services/systems being used.
Determine which questions would need to be
answered in order to determine technical
feasibility.
p59
Next steps | Any internet-based program access

Reach out to third-party providers.
Once the landscape is understood, reach out
to providers to make sure they have the
correct forms and are aware of the latest
program details.
As the program changes, you should maintain
ongoing communications with at least the
largest third-party software providers.
Administer a quantitative survey with the

objective of influencing requirements gathering.
At minimum, the survey should be designed to
uncover the following information:
What percentage of sites have an on-site
pharmacy?
What percentage of sites use third-party
software the track and manage aspects of
their PAP data?
And, which products are being used?
Which sites aggregate orders multiple offsite
prescribers (ship-to addresses)?
How many orders do those aggregators
handle?
p60
Next steps | Required documentation

Review the necessity of tax returns and paper
prescriptions.
If a pay-stub or W-2 will suffice, understand
those are much easier for PAP coordinators
to obtain.
If signed prescriptions are not required,
explore the use of faxed or scanned
prescriptions.
p61
Next steps | Preferred partner program

The implications of a Preferred Partner Program
are far reaching.
If you are considering bulk replenishment,
understand that it will likely supplant the need
for web-based reordering at the largest sites,
further diluting ROI.
p62
Appendices
Appendix A | Other deliverables
Appendix B | Analysis session themes

Categorized analysis session data (XLS)
CSR call shadow log (XLS)
Field visit audio files (MP4)
p64
Appendices

Participants and process
Patient consultation
Enrollment
Reordering
Recordkeeping and administration
Medication processing
Philosophy of caregiving
Communication and information
p66
Analysis session themes | Participants and process

Functional roles / personas
There were generally four types of functional roles in PAP
administration:
Services Broker
PAP Coordinator
Supporter
Manager
Skills differ for each step in the process
Initial patient consultation was sometimes a separate role from
other portions of the PAP process. Those who specialize in
this task had expertise in dealing with patients, assessing their
situation, and advising them on how to apply.
PAP management process is often split or fragmented

Sites developed a variety of different processes, organizing
them around people, days of the week, technology and tasks.
One common process split is to separate enrollment,
reordering, and medication processing into independent jobs
and possibly different people.
At large sites, reordering may be split up between volunteers
by manufacturer.
PAP management tasks are optimized into batch processes
Sites reported habits such as doing all reorders on Monday,
batching reorders by manufacturer, preparing enrollments to
send / fax in batches, and prepping medications for distribution
in batches.
Enrollment was most often executed by more experienced

PAP coordinators (those with expert knowledge of
requirements, participating programs, and medication
available).
Reorders were sometimes executed by less experienced PAP
coordinators and sometimes by volunteers (under guidance
from the more experienced coordinators). This task requires
less specialized knowledge.
Medication processing was sometimes executed by separate
members of the team. This task was most often broken up into
subtasks because of FDA requirements and legal issues.
p67
Analysis session themes | Patient consultation

Expert PAP consultation
Enrolling in PAPs and maintaining standing is a
complex and daunting process akin to doing
income taxes. The expert consulting a PAP
administrator provides is a valuable and integral
component of the service of the health care sites
we visited.
Patient screening
Many sites screened patients for their own
programs with stringent requirements that matched
or exceeded those required by PAPs.
Some gathered all necessary financial information
up front, others waited until it was needed for PAP
application.
Direct vs. indirect interaction with patient
Some PAP coordinators have frequent and direct
interaction with patients. Others are handling the
enrollment and reorder processes but have no
direct interaction with patients.
Special considerations for Spanish-speakers

Many sites have solutions in place to communicate with
Spanish-speakers. Some requested the ability to have PAP
communications sent to patients in Spanish.
Most sites fill out applications for the patient and direct patient
involvement in PAP in English, so Spanish language
applications are not widely used.
Physicians involvement in patient consultation
Physicians sometimes refer a patient to a PAP coordinator.
Physicians sometimes consult PAP specialists to prescribe
medication covered by a PAP.
Alternative methods of getting medication
Wal-Mart offers a very low (~$5) co-pay on generic
medication, but for some patients the $5 is still too much of a
barrier.
Some clinics pay for the prescription medications patients
require or reimburse the pharmacy for the medications after
patient pick-up. These generally require a small copay as well.
Several sites mentioned samples as a way to provide
medications to patients who might need a starter dose, or
immediate care.
One site mentioned a separate indigent program administered
through the Emergency Room of the hospital they were
affiliated with. In this case, free medication is provided to
patients admitted to the ER.
p68
Analysis session themes | Enrollment

Initial enrollment gap work-arounds
Many sites have work-arounds in place to cover the initial 30day enrollment gap, including:
Giving patients vouchers to fill prescription immediately
at a pharmacy
Giving patients samples the site has on stock
Establishing an inventory system in which PAP orders
are placed but medication is distributed immediately
from the site's inventory
Dealing with required financial documentation
Many sites felt that the need for financial documentation
extended the enrollment process unnecessarily and was a
pain point for them and their patients.
Most sites expressed a frustration about explaining which
financial documentation was required and procuring all
appropriate financial documentation from the patient.
Some sites thought that the documentation requirements were
too stringent and not flexible enough to adapt to changes in
income (i.e. last years tax return may not reflect current
income).
Work-arounds to simplify patient involvement

Sites designed methods to focus patient attention
and simplify points of the process involving the
patient signature.
Sites used highlighters and hand written notes
to emphasize where patients should sign and
explain the meaning of parts of the form.
Sites may have patients sign multiple forms on
their first visit.
Sites had patients sign advocate consent forms
that gave the site permission to sign on the
patients behalf.
Physicians involvement in enrollment
Obtaining the physicians signature on forms and
prescriptions adds time and effort to the PAP
process.
Many physicians volunteer their services (which
reduces the amount of time that they will commit to
administrative work).
Some PAP coordinators have developed methods
to streamline the physicians time commitment.
p69
Analysis session themes | Reorder

Channel preferences
Status and feedback are crucial
Sites have a strong channel preference and with that have

strong suggestions to improve them.
Sites rely on PAP communications (even the packing slip) to

give them updates about the status of orders and patients.
Sites that favor the fax to reorder do so to take advantage of

the batch reordering capabilities (at the expense of immediate
feedback on order acceptance).
When a user encounters a problem with an order using the

IVR, they may not make a note and attempt to resolve that
problem at another time.
CSRs are thought of as a valuable safety net in case any

problems arise when placing an order on the IVR.
Other companies provide status updates on packing slips

which many sites viewed as being valuable.
Sites felt confident in placing an order through the IVR or a

CSR. They were thought of as reliable methods (possibly
because they received a confirmation).
Web-based reordering not commonly used (even when
offered)
Problems cited include:
Lack of trust in web-based system
Lack of immediate feedback on order acceptance
Report-driven workflow
Many sites generate reports from third-party PAP management
software in order to drive workflow. These reports include:
Enrollment reports of patients waiting for their first round
of medication
Reorder reports of patient medications (organized by
upcoming reorder date)
Reenrollment reports of patient enrollments that must be
refreshed
Order reports of medications ordered but not received
(In one case) target reports of patients receiving
medication that is not currently but could be procured
through a PAP
p70
Analysis session themes | Recordkeeping &

administration
Sites value reducing the burden of administering PAP
Some sites paid to use third-party software systems to help
reduce the burden of PAP management.
Others paid third-party companies to take on the entire
administrative process themselves.
Third-party PAP management software
Sites who currently use a third-party software system for PAP
management have deeply integrated the software into their
processes and it is very unlikely that they will replace the
software with another system.
Typical uses of third-party software include:
Generating, filling-out, and tracking enrollment
applications
Managing PAP medication orders
Recording medication processing information
Generating reports to drive workflow
Centralizing patient PAP history and information
Organizing system based on date

Many sites use monthly organizing systems
(physical and digital) to trigger PAP enrollments and
reorders.
Software vs. paper-based PAP management
systems
Some sites use a paper-based PAP management
system, while others track PAP information using
software.
Most sites store patient medical information and
PAP information separately.
Larger sites require more robust PAP management
systems. If they choose not to use software,
standardized workflow and volunteer workers can
fill this need.
Technology support
While some sites are well-funded and have robust
IT infrastructure in place (including multiple
software systems sharing data), others are
remotely located and have little IT support or
expertise.
p71
Analysis session themes | Medication processing

Medication processing stages
There are multiple steps between the arrival of medication at
the PAP site, and the distribution to patients. These include:
Intake processing (make a record in a database of date
of receipt and # or reorders remaining)
Patient labeling (handwritten or pharmacy label)
Prescription filling (pharmacy only)
Checking that prescription is accurate and

complete
Bundling of medication information (instructions

or other literature)
Organizing by patient and date

Contacting patient to notify that medications have
arrived
Distributing and consulting to patient on medication
Pharmacy vs. non-pharmacy medication distribution
Pharmacies are legally required to be accountable for their
process.
Medication pick-up
Many sites require patients to consult with a caregiver before
leaving with their medication. These sites will often provide
medication literature from third-party sites, such as
NeedyMeds.com.
The laws requiring a secure location to store medication affect
the ways in which medication is distributed to patients.
Medication pick-up often happens in a location that is different
from their physician appointment and PAP consultation.
Medication Distribution
Three models of medication distribution emerged:
Distribute to patients on-site
Send medication to a single point of distribution (such as a
hospital pharmacy)
Send medication to multiple points of distribution (such as
individual Physicians offices)
Physicians involvement in medication processing
Pharmacy process is structured and rigorous.
Some physicians distribute medication directly to patients, but

many prefer to defer the distribution of medication to a
pharmacy.
Many non-pharmacy sites create their own ad-hoc processes

such as providing hand written literature and labeling.
Sometimes other parties besides physicians will distribute the

medications on their behalf.
p72
Analysis session themes | Philosophy of caregiving

Approaches to patient relationship
Many sites see the service they provide as a patients last
resort and will do whatever they can to help the patient. Within
that purpose, there are two philosophical approaches to the
patient relationship:
"Empower" - These sites make the patient responsible
for notifying them than a reorder is needed. Tend to be
Social Workers who have a more holistic view of the
patient's well-being.
"Enable" - These sites take on the responsibility of
tracking reorder dates for patients. Tend to be PAP
administrators, pharmacists, or part-time volunteers,
who have a more tactical, focused perspective on PAP.
p73
Analysis session themes | Communication &

information
Communications to sites
Some sites expressed interest in receiving notifications
through email.
Some sites expressed a desire to have additional patient and
order information on packing slips.
Other PAPs seemed more active in providing marketing
materials for patients.
Confusion over communications sent to patient
Many patients are confused by the initial enrollment
acceptance letter, and think it means their medication is ready
to be picked up.
Some patients are confused by the presence of a form in the
letter with their written reorder notifications.
Patients receive letters from multiple sources (from [Pharma
Co] and from their HCP).
Many sites expressed interest in being copied on information
that is sent to their patients so that they may be aware of
potential issues.
Some sites expressed a desire for pharmacy labeling of
medication bottles instead of bulk medication bottles.
Awareness of [Pharma Co] PAP overall

Most sites were unaware of the full spectrum of [Pharma Co's]
PAP offers, and unaware of the [Pharma Co] Patient
Assistance Program organization.
Many sites were unaware of recent changes to the Connection
to Care program.
No one we spoke with goes regularly to the [Pharma Co]
Patient Assistance Program web site for information.
Sites created their own fables to explain aspects of the the
program's process.
Sites believed that requirements such as financial
documentation and physical applications were in place to
slow down the process.
Sites had differing beliefs on how the IVR worked, and
ways to get around its quirks.
Third-party information resources
Sites look to and trust third-party resource for objective
information.
Pap rules and availability
Recent updates
Process rules
p74

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[Pharma Co] PAP

Confidential | Prepared for [Pharma Co] by Moment

What performance and usability

Short tour guided by the subject

Confidential | Prepared for [Pharma Co] by Moment

Health care sites

Confidential | Prepared for [Pharma Co] by Moment

Teaching IndependentIndependent Teaching Independent Public Independent Private

Confidential | Prepared for [Pharma Co] by Moment

Analysis | Transcribe and organize

Confidential | Prepared for [Pharma Co] by Moment

Analysis | Code the data

All notes and other data were reviewed in work

Confidential | Prepared for [Pharma Co] by Moment

Analysis | Find patterns and themes

Confidential | Prepared for [Pharma Co] by Moment

Process | Patient consultation and screening

Observations and implications

Observations and implications

If accepted for care by a site, patients are required

The requirements around financial documentation lengthen

This enrollment form is bundled with a prescription

stringent requirements not flexible enough to adapt to

explaining financial documentation requirements to

PAP coordinators design methods to clarify forms and focus

Process | Reordering and reenrollment

Observations and implications

Sites have strong channel preferences, but may be swayed by

Process | Recordkeeping and tracking

Observations and implications

Sites with high PAP utilization require robust PAP management

Process | Medication processing and distribution

Observations and implications

The Enable Philosophy

Confidential | Prepared for [Pharma Co] by Moment

Observations and implications

Confidential | Prepared for [Pharma Co] by Moment

Current status on the enrollment and reorders of her

Clear messages and communication materials with which

Jane and Tom

Ways to place multiple reorders at once

The opportunity to help others

Reliable arrival of reordered medication

Simple and organized requirements and procedures

Confidential | Prepared for [Pharma Co] by Moment

Ways to stay current on the PAP rules

Persona | Health Access Consultant

Meets with patients to determine their eligibility for Hanners services

Enrolls patients in programs that offer free or discount services

Accountability and being proactive

Ive always said that if it

Accurate knowledge of the PAP status of her patients and orders

Clarity and flexibility in the requirements for services.

Confidential | Prepared for [Pharma Co] by Moment

Persona | PAP Coordinator

I never thought that I

Double checks the requirements for each program application

Arranges for physicians to sign applications that are complete

Organizes and labels medication for patients to pick it up

Jacqueline values multitasking - anything that saves her time.

Confidential | Prepared for [Pharma Co] by Moment

Volunteers, age: (None of