Michael Crowe, PharmD, MBA, CSP, FMPA

In past articles, some of the leading smart bottle products and their features were covered. Now, we will turn to considerations for implementing a smart bottle offering in your pharmacy. It may seem like a simple 'use the smart bottle instead of a regular bottle' process, but there a many variables, processes, and protocols to consider before going live with a smart bottle offering.

We will group these considerations under the headings of pre- and post-implementation, and start with pre-implementation in this article. Pre-implementation considerations include decisions to be made before going live, such as who will fund the cost of the smart bottle program and how will staff be trained. There are also decisions around recruitment and distribution of bottles to participating patients.

The first step to take before implementing a smart bottle offering at your pharmacy is to determine how it will be funded. Being new technology, these bottles are relatively expensive. If only bottle cost and the return on investment from increased medication adherence were considered, we would likely conclude that the offering comes at a loss. Furthermore, because these bottles can range from $75 to $200 per patient, per month (which may not include the supporting software costs), the pharmacy’s drug margins alone probably will not support a smart bottle program.

Today, most programs are set up as 3-party arrangements involving the pharmacy, the bottle company, and pharma, for 1 specific drug. This arrangement, for the right drug, becomes a win-win-win situation; pharma gets novel patient medication-taking behavior data, the bottle company gets business, and the pharmacy can demonstrate its progressiveness. All 3 parties also see benefits from bolstered patient adherence.

In considering how your program may be funded, be aware that the arrangement between pharma, pharmacy, and bottle company can vary. In some cases the bottle company may have a relationship with the pharma company, and the bottle company sets up agreements with 1 or more pharmacies to supply the patients. In other cases, pharma may approach the pharmacy about getting involved in a smart bottle program. And last, the pharmacy may try to gain pharma’s support in offering a bottle program for their drug. In all these scenarios, all 3 stakeholders may work together simultaneously, or there may be 2 sets of negotiations taking place.

When we get to patient enrollment, 2 important areas to consider are what patients are offered with the smart bottle program and how, if at all, does your software system facilitate the process. In some arrangements, patient inclusion and exclusion criteria may already be set for you (e.g., you are one of many pharmacies recruiting patients into a bottle company’s program for a specific drug). In other cases, you will get to set the inclusion or exclusion criteria independently or collaboratively with another stakeholder. If you are able to have a hand in setting this criteria, it can be helpful to run historical reports to understand how many patients might qualify. This is important because the number of patients you recruit and manage within the program will impact your staff’s time involved.

Some specific questions to consider around patient inclusion, include:

Will your smart bottle program be for new patients, refilling patients, or both? 

Will patients have to be of a certain age or geographic location? 

Are there certain regimens not compatible, such as multidose regimens? 

Does the patient have to possess a certain diagnosis?

Will you target patients at risk for poor adherence, such as those with a history of late refills?

Once you’ve set your inclusion criteria, it has to be conveyed to your staff communicating with patients. The simplest and lowest-cost means of doing this is to provide a paper checklist; however, that may not be practical for larger programs, and can even result in missed opportunities as staff has to remember to reference that checklist when interacting with potential candidates. This is where using your pharmacy system could be helpful. Depending on the level of control you have of your patient care software, it may be advisable to implement a reminder or even a questionnaire based on patient characteristics that serves as a reminder to your staff to screen patients and offer the program if they qualify. Integration of this questionnaire can also help with data collection, and, if you’re working with a bottle company with an application programming interface (API), you could even pass patient data from your system to theirs, streamlining enrollment and minimizing transcription errors. When it comes to system integration, while it is nice to have, it will come at a cost. Be sure to factor that into your program budget.

Training is important when providing a new smart bottle service. First, you don’t want to mess up what is reaching the patient. Second, you don’t want staff not being familiar with the project, and your pharmacy appearing disorganized to your patients. So training is necessary, but who should be trained? The answer to this will depend on the breadth of your patient population. If you’re expecting hundreds of patients to be involved, more of your staff needs to be trained on the offering. Of course, training requires time and money, so you do not want to pull everyone from their daily duties if it can be avoided. Instead, a starting point would be to ensure all patient-facing staff are aware of the program and know to whom to direct questions. Beyond that, your training decisions are related to the live trainings:

What training content is used; is everyone training on everything, or do you train 1 group on enrollment, 1 group on bottle set up, and 1 group on interventions? 

Where does training take place? Does your pharmacy have more than 1 distribution site? Will all sites distribute the smart bottle? 

How will training be provided? Do you have an internal training department or will you be leveraging the bottle company’s trainers? 

And last, and probably the most important aspect of training is providing an explanation to staff as to why a smart bottle program is being offered at your pharmacy. If possible, staff should also be involved in the project planning phase. Providing this engagement and context will greatly contribute to their buy-in and the success of the program.

Hopefully, these 3 areas of consideration will help you and your staff as you determine how to implement a smart bottle offering at your pharmacy. 

Articles

What to consider when considering a smart bottle program.

Smart Bottles: Implementation Considerations

There are many smart bottle companies competing today. In a 

, the most common features of smart bottles were covered. In this article, a glimpse into 4 specific products (GlowCap, AdhereTech, CleverCap, and SMRxT) is given. These 4 aren’t the only ones available, but they do represent the varied means by which smart bottles record medication adherence and are some of the most well-known products in the space.

Glowcap is probably better defined as a smart cap than a smart bottle. The cap provides visual and auditory reminders when it is time for the patient to take his or her dose. The action of removing the cap at the dosing time is equated to a taken dose. GlowCap has a companion mobile app, as well as an adherence portal. The patient can decide with whom to share their adherence record, whether it be prescribers, pharmacies, or caregivers. Within the cap, there is a button that can be pushed to trigger a refill request to the pharmacy, if so configured.

Compared to GlowCap, the Adheretech bottle moves the technology from the cap to the actual container. Cellular functionality is incorporated into each of its bottles, meaning patients don’t have to pair the bottle with a wifi hub, or app on a mobile device. However, there is a portal where healthcare providers can view their patients’ adherence levels. Like GlowCap, Adheretech equates a dose to removal of the cap at dose time; however, it also incorporates something called capacitance, which is similar to how your smartphone’s screen registers touch. In the same way that your phone can detect two fingers on the screen, the AdhereTech bottle can sense an approximate number of doses remaining based on the capacitance at the floor of the bottle’s interior. This smart bottle stands out in that it can hold a six-month battery life, several months longer than many of the other smart bottles. The AdhereTech bottle also requires no patient setup. It is ready to go when the patient receives it.

With CleverCap, the technology is all in the cap, as it was with GlowCap. However, rather than cap removal equating to a dose, the CleverCap device has a door on the device, and internal mechanics that can be calibrated to track precisely how many dosage units were removed and when. This is helpful as we know that patients don’t solely open their bottles to take a dose; they might remove the cap to determine if they need a refill or to confirm the color or imprint on the dosage unit. Like AdhereTech, the cap does have cellular capabilities built in, so patients are not required to do anything, unless they want to pair it with the companion app for personal management. A feature of the CleverCap, not seen in other bottles, is the option to lock the dosing door between dosing windows, which can be helpful to prevent patients from inadvertently taking extra doses.

Like AdhereTech and CleverCap, SMRxT incorporates cellular connectivity into its bottles so patients are not required to connect the bottle with wifi or pair the bottle with a hub or device. It can also communicate with the patient, caregivers, or healthcare providers. What is unique about the SMRxT system is the 'way'—no pun intended&mdash;in which it measures a dose taken. Each bottle sent to a patient is precalibrated with the weight of each unit (tablet or capsule) and the patient’s dosing schedule. Each time the patient sets the bottle down on a level surface, the bottle weighs the contents. If it detects a weight reduction, it will record that as a dose. Depending on the time and amount, it may be categorized as an on time dose, a partial dose, an extra dose, or a late dose. Missed doses are also recorded. These dosing trends can be monitored over time and, if helpful to the patient, the dosing window can be adjusted remotely by the pharmacy. Besides its method of measuring adherence, a differentiator for SMRxT is its robust companion software, Nomi, which combines the best of data collection and actionable data.  

The smart bottle space is certainly one with many potential benefits and choices. Having a better understanding of the features of smart bottles and available products, you may be in a better position to implement a smart bottle offering in your pharmacy. 

Who are some of the key players in the smart bottle space?

Sampling of Available Smart Bottles

When it comes to promoting and tracking patient adherence, smart bottles are far more advanced than traditional prescription vials. These devices are precise and can monitor adherence over the duration of therapy. Before smart bottles, our best means of measuring adherence were rooted in patient reports, pills counts, and refill history. We know these methods are inherently flawed as they rely on patient recall and honesty. And who has the time to do pill counts? Smart bottles take us 2 steps forward in terms of monitoring adherence (and intervening on nonadherence).

The earliest smart bottles recorded a dose each time the cap was removed. Newer bottles use features such as scales, dose unit removal, and even something called capacitance. Listed below are some of the features that should be evaluated when considering smart bottle usage in your pharmacy.

The first is one that most bottle companies today like to tout. That’s understandable. If a patient isn’t willing to take steps on their own to maintain adherence, why would they take steps to set up a device that is intended to do the same thing? Earlier devices would require the patient to download an app, connect the device to a wifi network, or connect the device to a plug-in hub. Fortunately, as technology has advanced, most companies have integrated cellular connectivity directly into their bottles, meaning the patient does not have to do anything.

Another capability that can impact the 'requires-nothing' goal of the smart bottle is the battery life of these devices. Most bottle companies recognize that their bottle better last at least a month, and some have been able to go much longer than that. The issue with battery life is that as it declines, the burden on the patient goes up. Each time the battery life is depleted, the patient has to either recharge it or swap bottles. And if swapping, they may even be required to return their 'dead' bottle for refurbishment. So the longer the battery life, the better.

The types of alerts utilized by these bottles run the gamut—patients typically see some combination of light and auditory notifications on the bottle when it’s time for their dose and if they’ve missed a dose. Patients and caregivers, in most cases, can usually have text messages, emails, and automated phone calls configured for missed dose alerts as well. Pharmacies most often rely on alerts within the manufacturer’s portal, which may or may not include a corresponding email notifying the pharmacy staff that they have missed dose alerts within the portal.

There are many direct-to-consumer devices and mobile applications available to promote medication adherence. Recognizing patients may want to track their own adherence, smart bottle manufacturers often offer a patient app. Within these apps, patients can visualize their successful doses and missed doses, and in some cases, see their own personal medication adherence score.

In addition to not requiring the patient to do anything, it is also considered important for smart bottles to be fairly inconspicuous. Some adherence devices are rather bulky and hard to transport, thus eliminating some of their adherence-promoting benefits. Fortunately, most manufacturers’ products allow your standard amber vial to be used or they provide their own bottles that look similar to a standard vial.  

Last, since these devices are storing and transmitting protected health information, its important that they be FDA-approved and HIPAA-compliant if your pharmacy is going to get involved.

For more information on smart bottles, read 

 about the business side of pharmacies offering these products to patients.

Common Features of Smart Bottles

Medication non-adherence costs the health care system $300 billion about per year.  

Very few patients carry through with the full process of filling a prescription, picking it up, taking every dose, and repeating the process with refills until the prescriber says they can stop. Sometimes, that non-adherence is intentional, such as when the patient decides that the medication is not necessary or that the cons (eg, the adverse effects, cost, and inconvenience, etc.) outweigh the pros. And sometimes, it is unintentional, mostly showing up as forgetfulness, leading to missed doses. In either case, we know that this is a problem. What has been missing is a solution.

In all likelihood, there never will be a magic bullet that solves the problem of non-adherence for all patients. However, there are a lot of companies out there trying to address non-adherence through the use of smart bottles, which are advanced prescription vials designed to promote adherence through the use of caregiver, health care provider, and patient alerts and reminders. The smart bottle companies also stand to improve medication persistence. Where adherence is defined as the percentage of doses taken as prescribed, persistence is the duration of time from initiation to discontinuation of therapy or to the time a patient exceeds a permissible gap.

But why do we care about improving adherence and persistence? Well, provided that the patient is prescribed the right drug, adherence is in the best interest of all stakeholders. The adage that “the most expensive drug is the one not taken" is true. Adherence is related to positive health outcomes, which obviously benefits the patient. But prescribers also want positive outcomes in order to rate well within their networks, among other reasons. And payors or insurance companies want positive outcomes, because, theoretically, medical costs should then decline. Although manufacturers and pharmacies also want positive health outcomes, it is much easier to measure how improved adherence correlates with improved revenue for payors and prescribers.

Let's look at both the costs and the data related to smart bottles.

Because smart bottles typically are best used in the specialty market, let's look at the drug tofacitinib (Xeljanz) an oral therapy for autoimmune disorders, such as rheumatoid arthritis and ulcerative colitis. Let's look at the relationship between adherence and profit for a pharmacy. Hypothetically, let’s say a pharmacy has 10 patients on tofacitinib. Here are some made-up figures for a 30 days’ supply: At an average wholesale price (AWP) of $4000, reimbursement of AWP, minus 10%, and a pharmacy cost of $3400, the pharmacy is looking at a gross profit of $200 per dispense. Because adherence measures look at things in terms of days medication is possessed or covered (see this article on 

), let's convert that to profit per day. Now, for every extra day that a patient has this medication, that translates to an extra $6.66 of gross profit for the pharmacy. Over a year’s time, a 10% improvement in adherence equates to an extra 36.5 days with medication or about an extra $250 of profit for the pharmacy per patient. Multiply this by 10 patients, and we are looking at a handsome incremental profit for helping those patients improve their adherence by 10%.

This example illustrates a starting point for evaluating return on investment (ROI) for devices geared toward improving adherence, such as smart bottles. It is helpful in answering the questions: How much can I expect intervention X to improve adherence; what does intervention X cost; and will the profit generated from improved adherence cover that cost? In the example, if the intervention were a smart bottle offering for patients taking tofacitinib and it was expected to improve adherence 10%, it could have an ROI and may be worth considering if the cost of that offering was less than $250 per patient per year.

That said, smart bottles are not cheap. Think “miniature cell phone” in terms of some of the capabilities of these bottles. By the time the cost of the bottles including the hardware and software is taken into account, the profit generated by increased adherence may not be enough to justify a smart bottle offering. This is where the value of the data must be considered.

Many bottles record the dose-by-dose, or, more importantly, the missed-dose-by-missed-dose, behavior of patients that can be extracted and reported on in aggregate. And, most bottle programs are drug-specific and involve the manufacturer of that drug. The manufacturer can use the data collected by smart bottles to better understand its drugs.

Let’s consider a new oral oncolytic that was just approved. Clinical trials were completed, and the manufacturer understands the rates of adverse effects reported. But remember that those clinical trials were conducted in a vacuum. The sample size was small and subject to strict inclusion criteria compared with the eligible population that could benefit from the drug post-approval. In real life, data collected by a smart bottle and solicited during interventions prompted by the bottle could pinpoint exactly when specific adverse effects are leading to non-adherence, with or without early discontinuation. The data might even show that a rare adverse effect observed in clinical trials is occurring much more frequently post-marketing. Those adverse effects could better be addressed proactively by the dispensing pharmacies and the manufacturers, in hopes of helping patients overcome them and remain on therapy.

If the data provided by a smart bottle program could allow a manufacturer to do this, then the ROI improves as a pharmacy can add this to the fair market value of the offering when a manufacturer is sponsoring the entire program. Alternatively, the pharmacy could sell the data a la carte to interested manufacturers.   

Here is why to consider the dollars and data behind such pharmacy offerings.

Are Smart Bottles the Solution to Medication Non-Adherence?

During my employment intermission, one valuable piece of advice I received was, 'Your new boss will be the most important factor in your job search. Make position and money secondary factors.' Indeed, your new boss will likely be one of the people you work with most in your new position. They should be one of your primary sources of feedback and mentoring. They should look out for you, because your success is also their success.

It is likely that the first time you meet your new boss will be during an interview. That’s what we’ll talk about in this last piece of the 

You will hopefully have more than 1 interview while you are in the market for a job, but it is not an absolute necessity. You may be fortunate enough to interview for a job you’re confident will be a fit—and get it! But whether it’s 1 interview or 12, you need to prepare. And yes, all that advice about dressing professionally, making eye contact, bringing copies of your curriculum vitae is good advice, but it covers the easy part. 

Chances are it has been a while since you last interviewed. Maybe your only recent experience in interviewing has been on the hiring side. You have used your own set or a human resources-approved set of standardized questions. They seem pretty easy to answer, though perhaps you’ve had some candidates come through where your reaction is just 'Wow! Where did they come up with that answer?,' or 'They kept recycling the same story over and over again!.' You don’t want your prospective new boss to walk away with an impression like these after your interview. To prevent these impressions, the best thing you can do is prepare answers to the most common questions, and prepare questions to ask after the interviewers finish their questions.

Each company will probably have its own unique set of interview questions. And the ones listed below will not all be asked verbatim. In fact, it is possible that none of them will be asked. However, unless you have a 'cheat sheet' of the questions they will ask, my suggestion is to review the questions below (or a similar set), and prepare thoughtful answers to them in advance of the interview. Then, take time to practice giving those answers. Don’t practice too much; just get to the point of being familiar with your answers. The first set of questions are general questions for which to prepare.

 This is often the first question you’ll be asked. Take some time to think about how you might sum yourself up. Balance the professional with the personal; give the interviewers some insight into you. Don’t spend more that a minute answering this question and avoid regurgitating items covered on your curriculum vitae (CV).

Why are you leaving or why have you left your job?

 This is an obvious question for an interviewer to ask. The reason you give isn’t simply an answer to the question; it gives insight into your character and motives. Answer honestly, but professionally, positively, and objectively. Don’t disparage your former employer!

Really think about this question. What sets you apart from other applicants? Of course you probably don’t know the other applicants, but if this question is asked, you don’t have to answer why you’re better. Instead, describe what skills and abilities you have that make you a great fit. Along the same lines, you may be asked to explain why you want the job. It is not enough to state why you’re a good fit; an interviewer wants to know that he/she is hiring someone qualified 

 motivated. Be sure you can elaborate on aspects of the job that excite you. 

 This question answers the obvious, but will also give insight into how well the job for which you’re interviewing fits your goals, and an idea of how long you might remain with the company. Think of how you would answer in order to convey how well the job fits your goals, and that you will be with the company for longer than it takes to get your first paycheck.  

 Don’t forget about that document you submitted with your application. Anything on it is fair game for questions, and you should be the expert to share more details. Review your CV and make sure there isn’t anything on there you’re unprepared to describe in some detail.  

In addition to the questions above, it will also be helpful to prepare for questions that require you to draw upon your professional experiences. It is highly likely that you will be asked to provide specific examples from your past roles; the questions below should help you have examples ready to give in the interview and avoid excessive “ummms” and “ahhhhhs.” Try to have a different example for each question, and try to pull from various roles and projects over the past 1-2 years.

What is your greatest strength? How have you leveraged this in a past role?

What is your greatest weakness? How you have worked to improve upon it?

How do you handle stress and pressure? Give an example.

Describe a difficult work situation or project, and how you overcame it. 

How do you handle success? How do you handle failure? Give an example of each. 

Do you work well with other people? Tell me about a project that illustrates this.

Preparing Questions for Your Potential Employer

It is very important to prepare questions to ask of your potential employer during the interview. If you reach the end of the interview and have asked no questions, it may be perceived that you have no interest in determining your fit in the role. Balance the number of questions you ask with the time allotted for the interview; you do not want to ask too many questions and not respect the interviewer’s time.

Focus on questions that would help you decide if you would want to work for the company, regardless of benefits and compensation. You should have some idea of the compensation based on the role and, if needed, can attempt to negotiate it if you advance in the interview process and receive an offer. 

For the questions you ask, it can be helpful to group similar questions together. This way, if 1 of the interviewers goes beyond your initial question and answers others, you can mark them off and not look disorganized seeking answers that were already given. My suggestion is to group your questions into four areas: company, position, performance, and benefits.

Can you describe the company’s culture to me?

What is the company’s greatest strength right now? Weakness?

What is the company’s biggest opportunity? Threat?

What do you like best about working for the company?

Can you describe a typical day for a person in this role?

I see 'X' in the job description. Can you provide more detail around that?

What does the timeline for training look like for this role?

Who will I work most closely with in this role? Can you provide me with the reporting structure for this role?

How is performance measured and is it associated with a bonus or other incentives?

What tools would a person in this role be given to audit/empower their own performance?

What are your expecta-tions of the person you hire 'X' months after being hired?

What attributes do you see as the most import-ant predictors of being successful in this role?

Can you describe the opportunities for advancement?

While it can be important to understand the benefits offered, it may be the best use of time to simply ask for a summary of benefits offered to take home and review after the interview. 

Vacation time policy (paid/unpaid time off) including holidays 

Flexible spending account, health savings account

Long-term and short-term disability insurance

After your interview is complete, take time to reflect on it. How well did you do in answering questions? How happy were you with the answers your received from the interviewer(s)? Remember, the interview is as much about you making sure you’d be a good fit in the role as it is about the employer finding the best candidate.

. Document notes. Add more columns comparing the variables of each position. Update your rankings if the interviews have caused them to change. If all goes well, following your interviews, you’ll start to receive some offers and then it will be time to make a decision—the intermission is over.  

Hopefully, my first-hand experiences and advice shared in this article and series can be a help to you, should your find yourself as an unemployed pharmacist. Reach out to me with questions. Remember, you’re part of a great profession with a diverse range of career options and, again, pharmacy is a small world. Use those aspects to your advantage. Best of luck! 

Interview well, get an offer, and end the employment intermission.

Unemployed Pharmacist: Interviews

Search Indeed, The Ladders, Monster Jobs, and other career posting sites. That seems like a logical place to start when you find yourself looking for a new job. Be sure to couple the results of those searches with the leads you gain from your professional contacts, as described in my 

Document them all in a 'search spreadsheet,' and this will give you a great overview of your job prospects. This spreadsheet will be your go-to for the next several weeks to months, so be detailed and thorough in your documentation; consider including, for each opportunity:

 Indicate the name of the company. There may be more than one opportunity for the same employer. 

 It is probably best that this be the hiring manager; however, early on in your contact with the employer, it may be a recruiter within the company or a recruiter working for a third party. In addition to a name, collect a phone number, and email whenever possible. You can also include other employees of the company who are involved in the hiring process. 

 List the name of the position, and include the hyperlink to its posting or job description. As you move along in the process, it will be important for you to be very familiar with the title and general description of the role to convey your interest in it. 

 Is this academia, managed care, community, hospital, specialty, or some other area of practice? If you are open to multiple practice types, it may be helpful to have some additional labels on your prospects for sorting and filtering. 

Where will you be working? You could list the position’s city, distance from home, commute time, or all of the above for each role. And if this is an important consideration for you, as it is for many people, you should have some way of comparing opportunities in terms of your time on the road.  

 Keep track of when and what you did last for each prospect. Did you email the recruiter? Did you complete the online application? Keeping track of these will help you see where you stand, and may be motivating to see what you’ve accomplished in your job search journey. 

Perhaps the most important thing to document (and take action on) are the next steps. Most hiring managers will have a goal of filling their open requisitions with the best candidate as soon as possible. Best candidates aren’t typically defined as lackadaisical. Be diligent, and follow up when you say you will in order to show your interest in the position, and as a reflection of your work ethic if you were to be selected for the role. 

 Have an area to take notes for each position, especially the aspects that set it apart from other opportunities (for better or worse). 

As you’re building your prospects spreadsheet, be thinking about personal contacts who may have a connection with each company. Search through your contacts to see if you have any who are employed for the company of interest. Or, reach out to some of your particularly extroverted and connected contacts to see if they know someone within the organization. These are the people that can give you advice moving forward in the application process, and perhaps help you get a foot in the door. Provided you have had a strong working relationship with them, they would also be great candidates for providing you with a letter of recommendation.   

Also, I would recommend having some method of assigning a preliminary rank to each opportunity. Granted, you may not have had an interview yet, but you need to have a method of prioritizing the time you put into each opportunity. You may not be able to write that perfect letter of intent for each opportunity—you might not even want to in the early stages of your search. If travel is involved, it may not be possible to fly all over the country interviewing and learning more about every prospect on your list. Thus, prioritizing with some form of ranking will help you focus on the jobs you are most interested in pursuing.  

Last, don’t close any doors as you go through your search. The timing of applications being accepted, interviews being scheduled, and offers being made are not going to align for all your prospects. Unless you’ve made a commitment to give a decision or have been given a deadline to decide, do not tell the hiring manager to count you out, unless you are certain the position is not for you (even as a fallback option). Keep your options open for as long as possible without souring your relationship with the hiring manager. 

Use your spreadsheet as a tool to narrow down your interview ambitions, and as a tool for preparing for interviews. The interview will be of critical importance for both sides in determining if there is a good fit; I’ll cover that topic in my fourth and final piece in the 

Searching for jobs is one thing. Keeping your prospects organized is another.