A Qualitative Approach to Exploring Workflow and Cost Factors of Dispensing Services in Community Pharmacies in Taiwan

Introduction

Community pharmacies serve as convenient primary care venues through offering extended opening hours, walk-in services, easy medication access, and customized professional care.¹ While pharmacists are allowed to offer a broad spectrum of pharmaceutical services in the community, including primary to tertiary health prevention activities (eg, recommending healthy lifestyles, promoting cancer screening, and providing medication refills),^2–5 it is important to note that dispensing services make up the mainstay service compensated regularly by the Taiwan public health insurance plan.^6,7 Medication dispensing is one of the traditional roles and the most common tasks undertaken by community pharmacists.⁸ Over the years, dispensing services have not only ensured medication availability for patients but also constituted a vital revenue source to support typical independent pharmacies and their pharmacists.⁹ In Taiwan, it is customary for one “prescription” to be issued per person rather than per medication, meaning that usually more than one medication is prescribed per ambulatory visit. Annually, approximately 360 million prescriptions (with an average of 3.9 medications per prescription)¹⁰ are issued in Taiwan, of which 35% are dispensed in community pharmacies.^11,12 The process of prescription dispensing encompasses various stages, from prescription drop-off to receiving medications with individualized counseling. Ensuring reasonable reimbursement that remunerates operational costs and inflation is imperative to support the vitality of the pharmacy profession.¹³ Therefore, evaluating the framework of pharmacy dispensing services and its associated cost factors is essential to bolster pharmacy management and ensure the provision of high-quality pharmaceutical care services while sustaining Taiwan’s universal healthcare scheme.¹³

Despite the imminent importance of accurately estimating the cost structure of pharmacy dispensing services in community pharmacies, the National Health Insurance Administration (NHIA), the government entity responsible for universal healthcare in Taiwan, has not explicitly conducted such measurement. The inherent complexity of pharmacy dispensing process allows for various depictions and,¹⁴ in many countries, the work process remains inadequately defined.¹⁵ Dispensing service costs among pharmacies vary; pharmacy size, type, and location are all essential elements that count.^16–19 Previous research has indicated higher dispensing costs in specialty pharmacies, independent pharmacies, and pharmacist-run clinics as compared to their counterparts.²⁰ A positive correlation was found between dispensing costs and prescription pricing, while a negative correlation was noted between dispensing costs and prescription volume.²⁰ Additionally, pharmacies providing enhanced professional services beyond prescription preparation exhibited higher overall dispensing costs than the average.²⁰ Kaplan and Porter highlighted that relevant costs in the dispensing process encompass clinical and administrative personnel, medications, supplies, devices, space, and equipment used throughout a patient’s complete care cycle for a prescription.²¹ They also suggested that an accurate estimation of dispensing service costs, grounded in real-world investigations, could provide valuable insights for optimizing staffing, equipment, facilities, and administrative resources, thereby enhancing the efficiency of patient care within the healthcare system.²¹ Gaining insight into the workflow and procedures involved in prescription dispensing in pharmacies in Taiwan helps a stride forward to comprehensively documenting prescription dispensing process and identifying necessary resources within such pharmacy settings for serving the public with quality care continually.²²

Gaining a comprehensive understanding of dispensing services within community pharmacies from limited literature has been quite a challenge within the realm of pharmacy practice. Firstly, the intricate nature of dispensing services is seldom fully encompassed. The execution of dispensing requires a wide array of resources, such as personnel, equipment, space, and supplies. These resources come into play throughout processes initiated by a patient’s initial prescription visit, extend through professional and administrative procedures, and culminate in the patient receiving dispensed medications along with helpful individualized consultation.²³ Secondly, the path of patient care differs across healthcare systems and cultural contexts, rendering the applicability of findings from other nations suboptimal to Taiwan’s unique healthcare landscape, characterized by a universal, mandatory, and public single-payer system.^14,23,24 Thirdly, relying solely on claims data to estimate dispensing service costs may lead to an underestimation due to the oversight of essential composite resources (eg, rental, utilities, storage spaces, and medication acquisition preparation) required in real-world pharmacy practice.¹⁴ This scarcity of published reports conducted within community pharmacies might lead to the apparent negligence in claims studies. An operational definition of “dispensing service” in the context of community pharmacy practice awaits to reach consensus.

The study aimed to explore and document the framework and procedures of dispensing services in Taiwan through in-depth perspectives from community pharmacist practitioners. The initial imperative approach to thoroughly investigate the resources essential for sustaining quality dispensing services in a pharmacy involves gathering firsthand accounts from engaged practitioners. The study outcomes would offer insights into the workflow and resources vital to dispensing services for a better allocation of healthcare resources in the future.

Materials and Methods

Study Design

This cross-sectional study was conducted by a pragmatic, descriptive, and qualitative approach to investigate pharmacists’ perspectives of pharmaceutical care pertaining to dispensing services,^25,26 focusing on exploration of how prescriptions/refills are dispensed in community pharmacies. We interviewed community pharmacists through a face-to-face approach to explore the full process of prescription dispensing in community pharmacies from March to July 2022. Medication dispensing services involve a myriad of factors which would be too difficult to be captured and dissected by common quantitative approaches. Instead, the qualitative approach provide flexibility to delve into the intricacies of field research, thereby advancing systems thinking within the healthcare context.^14,27 Therefore, it is appropriate to apply a pragmatic qualitative approach to describe what and how prescriptions are dispensed in community settings. Authors in this study had training and backgrounds in pharmacy or healthcare research, and therefore understood the importance of dispensing services for patient care.

Before the interviews, one of the researchers provided prospective participants with oral and written details about the study purpose and methods, voluntary involvement, and the right to withdraw from the study at their discretion. If agreed to be included, the participant signed informed consent. All data materials were pseudonymized and stored on encrypted drives with limited access, back-up, and 24-hour logging. The study was approved by the Research Ethics Committee of National Taiwan University Hospital.

Data Source and Collection

A purposive sampling approach was used to enroll 10 pharmacists who partnered with National Taiwan University for experiential courses in community pharmacy practice. Participants were selected based on their professional identity and the primary pharmaceutical services they offered (eg, medication refills, disease management counseling, and recommendations for over-the-counter products), and they were recruited from communities situated in various districts with diverse characteristics (eg, residential or commercial areas). To be eligible, participants had to be at least 18 years of age, currently working as community pharmacists, and able to communicate in Mandarin. A one-on-one, face-to-face, semi-structured interview with each participant was carried out to elicit individual first-hand experiences of the process of medication dispensing and relevant resources required in performing the task. For qualitative interviews, there is no fixed rule to determine the sample size.²⁸ However, based on previous research, a sample size of 9 to 17 participants is considered adequate to achieve data saturation when studying well-defined populations.²⁹ To ensure a systematic approach, a protocol was developed to guide the interview process. The interview questions (Box 1) were carefully formulated based on a thorough review of existing literature and inputs from three experts experienced in pharmacy practice and healthcare research.^16,22,23 The participants were allowed to freely share experiences in their dispensing workflows and identify patterns of major dispensing processes. This rigorous process ensured that the questions were closely aligned with research objectives and effectively explored the participants’ experiences in their daily practice of dispensing services. All the interviews were conducted in quiet office spaces within their practice sites to create a comfortable environment for open and honest communication. Additionally, the interviewer took field notes during each interview to capture important details and observations. The interviews were audio-recorded and transcribed verbatim by certified professionals, coupled with interview memos and field notes taken by interviewers during interviews.

Box 1 Questions for the Semi-Structured Interview

Data Analysis

The interview transcripts were subjected to direct content analysis, which is a suitable approach when existing theories or empirical literature can provide guidance and help identify crucial concepts of interest.³⁰ Following the principles advocated by Elo and Kyngäs, researchers analyzed data through the lens of established knowledge, avoiding a simplistic perspective.³¹ The benefit of direct content analysis lies in its capacity to corroborate and build upon existing theories.³⁰ Consequently, researchers can juxtapose new discoveries with earlier literature, thereby extending and supplementing established theories to enhance the understanding of the subjects under investigation.

A six-phase content analysis was performed in data assessment.³² Patterns (ie, themes) of insights into the research questions across interviewees that either aligned with or deviated among various community pharmacies were considered. The research team initially familiarized themselves with the data, then proceeded to generate initial codes through both descriptive and in vivo coding techniques.³³ Through cross-referencing these codes, the researchers embarked on identifying potential themes by grouping related codes. Each transcript was independently coded by two researchers, who subsequently reached a consensus on each code and its interpretation to ensure alignment with the textual context. Subsequently, the team assessed the congruence between the identified themes and the coded excerpts, as well as the entire dataset. Finally, the research team defined and labelled the themes to identify the key steps and cost factors integral to prescription dispensing process. A qualitative data management software, MAXQDA 2020, was employed to organize codes and maintain the codebook. The coding and preliminary analysis occurred concurrently with the data collection phase, facilitating the exploration of emerging themes in subsequent interviews and enabling the assessment of data saturation.

Results

Ten community pharmacists agreed to participate in the study and successfully concluded the interview process. Among them, 7 were males and 3 were females, ranging in age from 29 to 62 years. The average length of pharmacy practice was 11.4 (SD: 6.3) years. We present below participants’ responses about the six consecutive steps that comprise a dispensing service in community pharmacies (Figure 1).

Figure 1 The process workflow, task content, and cost factors for dispensing services in community pharmacies.

Illustration of the Dispensing Service Process in the Community Pharmacy

Step 1: Receiving and Clarifying Legality and Completeness of Prescriptions

The majority of participants mentioned that upon receipt of a prescription, a standard completeness and legality check was conducted. This involved clarifying the signature of the prescribing physician and the prescription date to ensure its validity. Subsequently, pharmacists determined whether the prescription was for a new medication or a refill, as they have different timeframe allowance for filling. Additionally, checking if the prescription was eligible for the NHIA reimbursement often led to an extra step in the prescription processing.

When a patient presents a prescription, we initially check whether it is a new prescription or a refill. Also, we determine whether it is covered by health insurance or if it should be entirely out-of-pocket.

Typically, regular prescriptions need to be filled within three days. We will check whether this prescription is currently eligible for filling or if it can only be refilled after a specific date.

Step 2: Profiling and Verifying Patient Prescriptions

Participating pharmacists stated that they used an electronic card reader to access and assess the patient’s health status in the National Health Insurance (NHI) MediCloud System for evaluating prescription appropriateness (eg, checking for medication duplication and potential drug-drug interactions.) Subsequently, pharmacists profiled any demographic update of the patient and prescription details into the medication reimbursement system and calculated any applicable copayment.

I use patients’ National Health Insurance cards to access the NHI MediCloud System, check their medication history, and make sure their prescriptions can be filled without any duplication or harmful interactions. Basically, I compare their history with today’s prescription to avoid duplicates. If it all checks out, that’s good.

Basically, it’s like taking the details of prescription information into my computer one by one. This includes things like the prescription type and date, medical institute code, prescriber, and the date of medication pick-up. Once those are filled in, you move on to type in prescription details, including medication name, medication code, as well as dosage frequency and administration route. It’s a step-by-step process.

Step 3: Preparing Prescription Labels and Containers

All participants said they printed all required information on medication paper bags as receptacles for dispensed medications, following after finishing the prescription profiling step. One bag per medication was a norm, yet in a few cases a single bag for all medications was produced for non-refills, such as dental prescriptions. They also made labels for attaching to containers, showing medication names and expiration dates, particularly when medications were provided in bulk.

For prescriptions from dental or rehabilitation office, we often pack multiple 3-day-supply medications in a single bag. Each medication still has its own separate usage instruction attached to individual outer package.

For refills, since the medication quantity is larger, we prepare one bag per medication. Each bag is printed with clear details like indications, administration, potential adverse effects, and storage instructions. We only print all the information on one bag if the customer requests fewer bags.

Step 4: Dispensing Right Medications with Right Quantity

Pharmacy law in Taiwan stipulates that pharmacists are responsible for executing all steps in dispensing, including reading and gathering the medications specified in the prescription. Participants revealed that they cross-checked printed information on each medication bag with the prescription to ensure accuracy of details, such as medication name, usage instructions, and quantity. Some noted that after the cross-check, they used both the prescription and bag information for collecting medications. The bags were also printed with on-site storage shelf and inventory, aiding in effective dispensing. For scheduled medications, stored in a locked cabinet stipulated by law, pharmacists made extra efforts to unlock, acquire accurate amount, record exact quantity dispensed, and again lock securely. Unlike blister-packaged medications, bulk medications required manual counting, which could be more time-consuming.

I go through each medication in the bags and compare them with the prescription. After this check, I refer to both the prescription and the information printed on medication bags. The paper bags are printed with information such as storage locations and inventory data, so I know where the prescribed medications are shelved and the quantity available.

For dental needs, medications are often in bulk containers, so we need to use a spatula to count exact quantity. As a result, the actual dispensing time for a single medication can be lengthened as compared to direct-to-consumer packaging.

When dealing with scheduled medications, we need to keep records and manage inventory and quantities. So, when we retrieve medication, we may need to document it right away. For instance, if we need to dispense 28 tablets, a timely bookkeeping is exercised. Relevant log indicates that 28 tablets were retrieved for dispensing. … In simple terms, the log for scheduled medications must always be accurate and consistent with records. It’s a meticulous work.

Step 5: Inspecting Dispensing Accuracy

Ensuring the accuracy of dispensed medications is vital for medication safety. Many participants highlighted that double-checking the correctness of dispensed medications was a critical step. Pharmacists cross-referenced patient and medication details with the information on the prescription. The other partnered pharmacist, not involved in initial selecting or counting steps, conducted a double-check process to ensure that the contents of medication bags corresponded precisely to the prescription. This double-check encompassed checking the medication names, strengths, directions, and quantities against those specified in the prescription.

It’s possible that medications may have been profiled in the electronic system incorrectly. Therefore, the crucial step is to double-check the medications in the bags against the prescription. This involves a thorough review to ensure that right medications and correct quantities are being dispensed.

First, I verify the quantity of the medication, checking if the item and its quantity are correct. Then, I cross-reference it with the prescription. I do this by comparing the medication and the prescription side by side to avoid any mistakes on my end. It’s a way to ensure accuracy.

Step 6: Handing Over Medications and Providing Counseling

Most participants shared that offering professional counseling empowered patients to manage their treatment effectively and enhanced the patient-pharmacist relationship. Pharmacists routinely provided patients with essential medication details upon dispensing, including medication indication, frequency, administration, and quantity. When handing over medications, pharmacists also assessed patient’s medication use habits and lifestyle for providing a tailored consultation as much as possible. For special medications (eg, injectables, inhalers, or eye drops), pharmacists encouraged patients to share their experiences and strengthened their skills of medication administration. When providing scheduled medications, patients signed their names on prescriptions while receiving their medications. This final step facilitated meaningful communication between pharmacists and patients, aiming to improve disease management skills through lifestyle adjustment, dietary modification, and appropriate medication use.

For dental care, we emphasize completion of the whole course of antibiotics prescribed, but pain relievers are usually as needed. We explain in detail antibiotic resistance if deemed necessary. A misnomer in Chinese between anti-inflammatory medications and antibiotics could deviate patients from correct use of medications.

For certain specific inhalers, we sometimes encounter elderly individuals who struggle with assembling the device. In such cases, we help them assemble the inhaler properly, administer two puffs to ensure the medication is ready to use, and then hand it to the seniors. It’s not a big deal for us, as some of them are older and might find it challenging.

Upon dispensing Schedule III controlled substances, there are extra steps for us to process. We double-check the patient’s identification and ask him/her to sign the prescription as part of the process.

Cost Factors Embedded in Dispensing Process

All pharmacists involved expressed their viewpoints on possible expenses arising from resources used during the process of dispensing services within community pharmacies. The costs linked to dispensing services were classified into three categories: indirect, direct, and miscellaneous costs (Figure 1). Among the consecutive steps of dispensing process, the majority of participating pharmacists underlined the pivotal role of pharmacist manpower in achieving effective and competent dispensing service, which in turn constitutes a significant determinant in overall budget. A new prescription may require pharmacists to pay a bit more attention (time) on verification within the prescription. However, efforts for prescription verification against existing medication profiles of an individual patient would be similar between new and refill prescriptions. Furthermore, rental, utilities, consumables, equipment, and maintenance emerged as other crucial cost factors entailed in conducting quality dispensing services. Consequently, pharmacists suggested that dispensing service reimbursement should also consider these long-overlooked expenses, yet covered by pharmacies to ensure sustainment of dispensing services in the long run.

We use pill counting trays for the convenience of dispensing larger quantities, and these trays are essential for counting pills out of bulk package. Medication spoons are consumables. Certain medications need to be stored at 4 °C. Hence, a medicine fridge has to be kept on all the time. And don’t forget, we have to pay for things like water, electricity, and storage space.

During the dispensing process, pharmacists are key players. They’re needed in every step, which adds to the cost. For instance, a printer is only required for printing medication bags. But from start to finish, every pharmacist contributes to the overall cost.

I think in order to have sustainable growth, we need to have reasonable renumeration that can offset our dispensing service endeavors. This is essential to sustain the operation of the entire system and encourage future pharmacists to be willing to engage in serving the public.

Discussion

This study articulated the dispensing process and associated costs required in community pharmacy dispensing practice in Taiwan. Uniquely qualitative research was performed to delve into task content and cost factors involved in dispensing services. Unlike the current claims-data payment model in Taiwan, this research identified real-world resource usage for prescription dispensing. The findings can inform stakeholders of a novel and close-to-reality reimbursement model for NHIA’s community pharmacy dispensing services. It is a well-known management axiom that what is not measured cannot be managed or improved.²¹ A comprehensive understanding of the costs tied to dispensing workflow allows policymakers and opinion leaders to drive the advancement of quality services, rational resource allocation, and the revitalization of healthcare network.

The dispensing process outlined in the study shares similarities with the community dispensing stages introduced by Rose et al and Naybour et al.^34,35 However, variations emerge in certain steps of dispensing services due to distinct healthcare policies and cultural context.¹⁴ Even within the same stages, the specific tasks can differ among professionals under different healthcare schemes. For instance, in Canada, pharmacists must obtain authorization before refilling a prescription (one medication per prescription) and are granted to approve a single renewal.³⁴ In contrast, the NHI MediCloud System in Taiwan permits prescription refills after pharmacist verification without additional authorization. Notably, pharmacists in Taiwan are not empowered to authorize any refill, leading to the omission of the authorization stage in our model. While the six-step community dispensing services exhibit similarities between Taiwan and the United Kingdom, a noteworthy contrast lies in the final accuracy check. In the United Kingdom, a qualified technician can perform this check,³⁵ whereas in Taiwan, legal limitations on the pharmacy technician’s role necessitate a double-check by a second pharmacist.³⁶ The dispensing services can only be offered when pharmacists are on-site. These subtle divergences in healthcare systems among countries can yield variations in pharmacy workflow, resource allocation, and cost structures.

The study findings suggest opportunities for potential adjustment of reimbursement policies for pharmaceutical services. Detailed insights into various cost items involved in the dispensing process within community settings were revealed from the qualitative research. Analogous to the cost analysis conducted by Cardoso et al on dispensing services in community pharmacies,³⁷ this study highlighted manpower-related expenses (eg, pharmacist salaries and professional training) would be the primary contributor to the cost components of providing dispensing services. Furthermore, factors such as infrastructure costs (eg, rental and utilities), expenses related to equipment and supplies, patient handouts, and computer systems all contribute to dispensing service costs.¹⁶ Cost elements identified in this study can serve as a prelude for future research aimed at either qualitatively or quantitatively estimating costs associated with each single step involved in dispensing services. This, in turn, can provide rich information for stakeholders and policymakers in effective modification of the reimbursement scheme for dispensing services on a rolling basis.

To sum up, the dispensing process is inherently intricate and can be represented using diverse system mapping techniques. Varied healthcare systems add complexity when attempting to compare dispensing services internationally. Drawing from the outlined process framework and extensive cost breakdown for dispensing services in the study, future alignment of assets and expenses among studies would be feasible. The seemingly impossible integration of past, present, and future valuable data would enable the implementation of suitable pharmaceutical services in practice, thereby enhancing patient health outcomes.

Strengths and Limitations

The study exhibited several strengths, including the researchers’ ability to establish participants’ trust through transparent information about study procedures and emphasizing their significant roles in shaping future community pharmacy practices. This rapport facilitated candid sharing of relevant experiences and greatly contributed to the study’s overall quality. The researchers’ healthcare backgrounds as well as user observations enabled the formulation of insightful questions for exploring participants’ dispensing service experiences in community settings. Additionally, a robust analysis was ensured through independent coding by two researchers, followed by consensus-building, enhancing the credibility of identified themes. We demonstrated researcher reflexivity at various stages (ie, pre-research, data collection, and data analysis) and the diverse expertise of the research team collectively worked to mitigate potential biases and maintain objectivity throughout the study.³⁸

While the study design demonstrated some strengths, it is crucial to interpret the findings with acknowledging their limitations. Participants were drawn from community pharmacies that employed varying computer systems for prescription data management, potentially introducing discrepancies in data processes. Recruitment bias might be present due to recruitment via professional contacts. Consequently, the findings should be approached as exploratory in nature. To enhance robustness of the findings, future investigations could encompass a more diverse array of community pharmacies to verify the applicability of the processes outlined in this study. Given that the majority of the enrolled pharmacies were independent, further research could also include more chain pharmacies to discern potential discrepancies in dispensing services attributable to differing pharmacy types in Taiwan. The data gathered regarding pharmacy workflow in this study predominantly possessed a qualitative nature, making cross-study comparisons challenging. Subsequent research endeavors could potentially adopt time and motion techniques to acquire quantitative data on workflow and practice operations, enabling the quantification of costs associated with dispensing services.^39,40 Furthermore, the distinct healthcare system in Taiwan, characterized by its universal, mandatory, and publicly-funded single-payer structure, may curtail the extent to which these findings can be generalized to similar practice contexts.

Conclusions

The seamless integration of future pharmacy interventions into practice could be hindered if without an understanding of real-world pharmacy workflow. The study intricately outlines the complete process of dispensing services within community pharmacies. The study outcomes enhance our comprehension of present dispensing practices in Taiwan and provide valuable insights for crafting strategies to improve quality pharmaceutical services. This framework could potentially serve as a basis for evaluating costs associated with dispensing services in community settings.