Pharmacy formularies in integrated health systems.

Formulary management implications are described for an Oklahoma integrated health system comprising 14 acute care facilities, numerous owned medical practices, and a fledgling HMO. A systemwide pharmacy director has yet to be appointed; however, the position of pharmacy operations management for the Oklahoma City area has been created. A physician group has been formed that is expected to address system-wide pharmacy and therapeutics (P&T) committees and formulary strategies. Currently P&T committee activities take place at the individual hospital level. The hospitals do not have restrictive formularies. An overall formulary system would likely be patterned after the largest hospital's system, including a formal approval process in which a P&T subcommittee reviews drug use outside established guidelines and the P&T committee asks the appropriate medical department to address the problem. For ambulatory care, the HMO has contracted with a pharmacy benefit manager (PBM), and there is no coordination of formulary efforts between the PBM and health system entities. Although this and other problems remain to be resolved, some standardization of drug use has begun. Also, all entities in the system use the same purchasing group and plan to use the same information system. Drug use among hospitalized patients in this integrated health system is influenced by the usage guidelines established at the largest hospital, and drug use among ambulatory managed care patients is influenced by an external PBM.