# Presentation: 077142

## #213 Pharmacy Cost Initiatives For A Few Dollars Less 

- John Lowe, R.Ph., M.B.A.
- Associate Chief Consultant, PBM
- Monica Schaefer, Pharm.D.
- Director, Pharmacoeconomics, Kansas City VA Medical Center

## Objectives

- Review the history of the national pharmacy cost avoidance program
- Discuss the variance in outpatient drug costs per patient
- Review the different pharmacy cost data sources and how formula are created and scored
- Discuss the national pharmacy cost avoidance plan for FY 08
- Discuss strategies that can be implemented locally to reduce costs

## Factors Leading to National Pharmacy Cost Avoidance Plan

- High variance in drug costs per unique patient in FMP and Proclarity
- Variance does not appear to be related to patient mix
- Potential $1 billion cost avoidance based on lowest cost per unique
- Variance highlighted by network director to DUSH and Chief Consultant, PBM

## Proclarity vs. KLF

- PBM SHG ProClarity® Database
- Outpatient pharmacy costs only
- Denominator is OP Pharmacy users only
- Numerator is based on VistA dispensing data
- Drug costs based on local drug file

## Proclarity vs KLF

- KLF
- Numerator is based on pharmacy purchases for inpatient and outpatient
- Denominator is unique medical center patients
- KLF report 101(Drug costs per unique) includes pharmacy salaries, equipment leases, training, etc.
- KLF report 101a (drug cost only per unique) includes CMOP operating expenses for labor, mailing, supplies

## FMP Cost/Patient FY 07 (Oct-May)

| VISN |  |  Expenditures  | Uniques | Rate | LFYTD Rate | % Change  |
| --- | --- | --- | --- | --- | --- | --- |
| V18 | 101a Drug costs/Unique |  $100,720,256.36  | 215,046.00 | 468.37 | 490.13 | -4.44 |
| V04 | 101a Drug costs/Unique |  $144,716,707.50  | 272,476.00 | 531.12 | 555.53 | -4.39 |
| V03 | 101a Drug costs/Unique |  $  90,763,996.47  | 166,885.00 | 543.87 | 573.87 | -5.23 |
| V22 | 101a Drug costs/Unique |  $127,018,113.04  | 229,804.00 | 552.72 | 543.54 | 1.69 |
| V05 | 101a Drug costs/Unique |  $  65,373,169.60  | 117,955.00 | 554.22 | 587.78 | -5.71 |
| V12 | 101a Drug costs/Unique |  $121,144,709.94  | 214,478.00 | 564.84 | 592.41 | -4.65 |
| V21 | 101a Drug costs/Unique |  $116,372,062.10  | 205,984.00 | 564.96 | 543.57 | 3.93 |
| V20 | 101a Drug costs/Unique |  $107,494,648.87  | 190,169.00 | 565.26 | 577.96 | -2.20 |
| V10 | 101a Drug costs/Unique |  $  99,198,887.42  | 174,698.00 | 567.83 | 564.38 | 0.61 |
| V07 | 101a Drug costs/Unique |  $160,243,240.33  | 279,072.00 | 574.2 | 608.36 | -5.62 |
| V08 | 101a Drug costs/Unique |  $273,627,385.25  | 474,547.00 | 576.61 | 604.86 | -4.67 |
| V11 | 101a Drug costs/Unique |  $118,722,317.87  | 205,173.00 | 578.64 | 601.28 | -3.76 |
| V19 | 101a Drug costs/Unique |  $  80,560,972.74  | 137,602.00 | 585.46 | 583.34 | 0.36 |
| V02 | 101a Drug costs/Unique |  $  69,942,317.06  | 119,176.00 | 586.88 | 608.84 | -3.61 |
| V06 | 101a Drug costs/Unique |  $145,059,566.29  | 246,272.00 | 589.02 | 592.16 | -0.53 |
| V23 | 101a Drug costs/Unique |  $145,678,045.70  | 244,399.00 | 596.07 | 608.81 | -2.09 |
| V16 | 101a Drug costs/Unique |  $239,877,583.15  | 401,675.00 | 597.19 | 644.34 | -7.32 |
| V09 | 101a Drug costs/Unique |  $139,725,472.79  | 233,601.00 | 598.14 | 603.12 | -0.83 |
| V01 | 101a Drug costs/Unique |  $129,053,736.87  | 213,382.00 | 604.8 | 623.69 | -3.03 |
| V15 | 101a Drug costs/Unique |  $126,175,492.13  | 208,382.00 | 605.5 | 640.68 | -5.49 |
| V17 | 101a Drug costs/Unique |  $137,994,708.01  | 226,547.00 | 609.12 | 674.86 | -9.74 |

## Proclarity FY 07 (Oct-April)

| VISN |  | Cost/Unique Patient |
| --- | --- | --- |
| 17 | Drug Cost Only | $511.53  |
| 21 | Drug Cost Only | $499.08  |
| 1 | Drug Cost Only | $498.99  |
| 10 | Drug Cost Only | $496.64  |
| 3 | Drug Cost Only | $495.98  |
| 2 | Drug Cost Only | $491.05  |
| 5 | Drug Cost Only | $489.49  |
| 8 | Drug Cost Only | $486.15  |
| 15 | Drug Cost Only | $482.33  |
| All Location | Drug Cost Only | $479.95  |
| 22 | Drug Cost Only | $479.59  |
| 6 | Drug Cost Only | $473.05  |
| 16 | Drug Cost Only | $472.84  |
| 7 | Drug Cost Only | $465.30  |
| 20 | Drug Cost Only | $463.83  |
| 23 | Drug Cost Only | $458.48  |
| 19 | Drug Cost Only | $457.38  |
| 11 | Drug Cost Only | $457.08  |
| 9 | Drug Cost Only | $451.36  |
| 12 | Drug Cost Only | $435.25  |
| 4 | Drug Cost Only | $431.10  |
| 18 | Drug Cost Only | $429.50  |

## Potential Cost Avoidance FY 07 (Proclarity)

| VISN | Unique Patients | Cost/Unique Patient | Total Cost |  Lowest Cost  | Projected Cost |  Cost Avoidance  |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | 189,424 | $498.99  | $94,520,601.77  |  $      429.50  |  $  81,357,608.00  | $13,162,993.77  |
| 2 | 103,192 | $491.05  | $50,672,547.85  |  $      429.50  |  $  44,320,964.00  | $6,351,583.85  |
| 3 | 139,419 | $495.98  | $69,149,251.90  |  $      429.50  |  $  59,880,460.50  | $9,268,791.40  |
| 4 | 242,780 | $431.10  | $104,661,730.45  |  $      429.50  |  $104,274,010.00  | $387,720.45  |
| 5 | 89,655 | $489.49  | $43,884,847.02  |  $      429.50  |  $  38,506,822.50  | $5,378,024.52  |
| 6 | 221,889 | $473.05  | $104,965,145.73  |  $      429.50  |  $  95,301,325.50  | $9,663,820.23  |
| 7 | 245,376 | $465.30  | $114,172,294.01  |  $      429.50  |  $105,388,992.00  | $8,783,302.01  |
| 8 | 417,441 | $486.15  | $202,937,045.92  |  $      429.50  |  $179,290,909.50  | $23,646,136.42  |
| 9 | 208,563 | $451.36  | $94,136,000.69  |  $      429.50  |  $  89,577,808.50  | $4,558,192.19  |
| 10 | 154,484 | $496.64  | $76,723,649.46  |  $      429.50  |  $  66,350,878.00  | $10,372,771.46  |
| 11 | 189,276 | $457.08  | $86,514,437.46  |  $      429.50  |  $  81,294,042.00  | $5,220,395.46  |
| 12 | 191,907 | $435.25  | $83,526,572.11  |  $      429.50  |  $  82,424,056.50  | $1,102,515.61  |
| 15 | 189,341 | $482.33  | $91,325,474.13  |  $      429.50  |  $  81,321,959.50  | $10,003,514.63  |
| 16 | 364,937 | $472.84  | $172,556,543.92  |  $      429.50  |  $156,740,441.50  | $15,816,102.42  |
| 17 | 196,564 | $511.53  | $100,548,443.62  |  $      429.50  |  $  84,424,238.00  | $16,124,205.62  |
| 18 | 178,995 | $429.50  | $76,878,799.98  |  $      429.50  |  $  76,878,352.50  | $0.00  |
| 19 | 119,885 | $457.38  | $54,833,223.47  |  $      429.50  |  $  51,490,607.50  | $3,342,615.97  |
| 20 | 168,713 | $463.83  | $78,254,697.60  |  $      429.50  |  $  72,462,233.50  | $5,792,464.10  |
| 21 | 162,982 | $499.08  | $81,341,573.22  |  $      429.50  |  $  70,000,769.00  | $11,340,804.22  |
| 22 | 187,072 | $479.59  | $89,718,654.03  |  $      429.50  |  $  80,347,424.00  | $9,371,230.03  |
| 23 | 224,929 | $458.48  | $103,124,888.65  |  $      429.50  |  $  96,607,005.50  | $6,517,883.15  |
| Nation |  |  |  |  |  | $176,205,067.51  |
| Annualized |  |  |  |  |  |  $302,000,000.00  |

## National Cost Avoidance Plan

- Each network assigned a cost avoidance target
-  Target based on a list of initiatives
- Initiative targets based on average of 5 networks with highest performance
- Network goals based on achieving 75% of gap between current performance and target

## National Cost Avoidance Plan

- Each network required to develop a plan to achieve targeted cost avoidance goal
- With prior approval, networks may develop alternate cost avoidance measures to replace any or all of the national initiatives
- Network plan must be approved by PBM and DUSH
- Quarterly progress reports
- Goal to reduce variance in drug cost per unique

## National Cost Avoidance Plan

- Plan will be dynamic based on changing market and/or clinical evidence
- Networks may adjust plan throughout the year
- Included in National Finance Council Operation Efficiency Program and/or Network Director’s Performance Plans

## Selection of National Initiatives

- Review of high cost and high volume areas with significant variability in prescribing patterns
- Lack of evidence to support prescribing differences
- New contracts or Blanket Purchase Agreements (BPA) that create incentives
- Areas of concern where community standard may not be evidenced based

## Examples of Targeted Drugs

- ACE/ARB
- ARBs prescribing ranges from 3.1% of all patients in VISN x to 8.6% in VISN y
- Cost of ARBs 3 times ACEs
- PBM has developed drug use criteria for ARBs
- CCBHP
- Shortage of felodipine
- Price increase of felodipine
- Price decrease with generic amlodipine
- $0.28 for amlodipine vs. $0.45 for felodipine
- Potential cost avoidance of $27 M

## Examples of Targeted Drugs

- Treatment of Diabetes
- Total drug cost/unique for diabetic patients ranges from $49.6/qtr to $83.63
- Glitazone use ranges from 1.84% of patients in VISN x to 6.75% in VISN y
- Recent safety alerts
- VISN with lowest cost has best outcomes on the diabetic performance measures

## Examples of Targeted Drugs

- Long Acting Opioids
- Morphine SR tablets lowest cost option
- Oxycontin generics pulled from market due to patent infringement
- Fentanyl patch available generically but costs still exceed morphine
- Methadone not included in measure due to safety concerns

## Examples of Targeted Drugs

- Isosorbide dinitrate SR 40mg
- Mononitrate formulation less expensive
- No apparent clinical issues
- Goal to convert 90% to monohydrate
- Potential $1.1 M

## Formula

- Most measures changing from 30 day fills to cost per 30 day fill
- Cost per 30 day based on total costs for drugs in market basket and number of 30 day fill equivalents
- Market basket to include all relevant drugs in targeted area
- Drugs costs used in calculations come from local drug file
- Results calculated quarterly by PBM

## Definitions

- Target – based on average of top 5 VISNs for majority of initiatives
- Goal – network specific goal based on 75% of the difference between network baseline and the target (top 5 networks average)

## Performance Measure

- Dollar amount based on the national initiatives
- Finance Committee satisfactory goal (green) is 50% of dollar amount based on the national initiatives
- National initiatives are not mandatory

## FY 07 Results

- All networks reached satisfactory level of performance (green)
- Project cost avoidance based on 2nd qtr FY 07 exceeds $150 M annually
- Drug cost per patient decreased compared to FY 06 in both Proclarity and FMP
- Actual pharmacy expenditures $100 M less in FY 07 compared to FY 06 (8 months data)

## VARIANCE IN COSTS

## FY 08 Plan

- Targeted cost avoidance of $100 M
- Fewer number of initiatives than FY 07
- VISNs can elect to use none, some or all of the national initiatives
- Based on top 5 networks rather than top 3
- Baseline will be 2nd Qtr FY 07

## Strategies for Success

## Objectives

- Summarize successful cost avoidance strategies and results
- Therapeutic interchange checklist
- Reminder dialogs for therapeutic interchange
- Reminder dialogs for prior approval
- Automated prescription processing

## Therapeutic Interchange

- A “staple” of cost avoidance programs
- Dynamic VA formulary system
- Mandatory National contracts
- Market share driven cost reductions
- Evidence based guidelines
- Economic and clinical performance monitors
- Evolving clinical, economic and humanistic data  = changing value

**Notes:**
Therapeutic Interchange. Therapeutic interchange is defined,
for the purpose of this document, as the interchange
of various therapeutically equivalent drug products by pharmacists
under arrangements between pharmacist(s) and authorized
prescriber(s) who have previously established and
jointly agreed on conditions for interchanges.
Therapeutic interchange occurs pursuant to development
of agreements between pharmacists and prescribers and implies
that there is appropriate and timely communication between
them. Therapeutic interchange agreements can vary from simple
understandings to complex protocols. For example, a therapeutic
interchange agreement permitting interchange between
cephradine and cephalexin may be a simple arrangement; the
dose and dosage form of the two drugs are equivalent, and the
drugs typically can be interchanged in the treatment of any
disease for which the drugs are indicated. A therapeutic interchange
arrangement that permits the interchangeability of different
colony-stimulating factors in treating a specific diagnosis
pursuant to specific protocols might be more complex. In either
case, the P&T committee acts on behalf of the medical staff to
develop and approve these arrangements.
The approval of a therapeutic interchange arrangement
is typically a separate decision by a P&T committee,
unrelated to adding or deleting drugs from the formulary.
In some settings, all drugs that may be therapeutically interchanged
are acceptable to the formulary, and the pharmacy
is authorized to purchase and dispense the most
cost-effective products. In other settings, certain drug products
are deemed interchangeable, but the P&T committee
designates a preferred product and approves it for formulary
addition. Then the other equivalent drugs or products
are deleted from the formulary.
To remain effective over time, therapeutic interchange
decisions should be routinely reviewed and revised as
appropriate. Therapeutic interchange may not be appropriate
for all patients. Professional judgment must be exercised
by the pharmacist and the prescriber. Consultation with the
prescriber and the patient may be necessary. Prescribers
have the prerogative to override a therapeutic interchange.
In some cases, a patient preference may negate an otherwise
acceptable therapeutic interchange.
Pharmacists should strive for consistency of product
use to avoid unnecessary switching of products dispensed
to patients. When a change is made, the pharmacist should
ensure that appropriate monitoring and followup are undertaken
to identify and prevent any unexpected or untoward
patient response. The pharmacist should provide appropriate
notification and educational materials to prescribers, patients,
and other health-care providers as needed regarding
therapeutic interchange decisions.

## Coordinate Process with Affected Customers

- Automatic substitution by pharmacy vs. manual process
- Establish criteria for eligible patients
- Identify relevant drug interactions/contraindications
- Delineate prescription parameters
- Computer edits and templates
- Establish lead clinic
- Drug utilization evaluation (DUE)
- Estimate time commitment and feasibility of proposed process(es)

## Administrative Approval

- Create patient notification letter
- Create provider notifications
- Obtain P&T approval
- Provide plan and materials to other VISN sites
- Obtain other committee approvals (for computerized modifications, patient education committee, medical executive committee, etc.)

## Education and Notification

- Develop patient letter
- Inpatient and outpatient pharmacy in-services prior to conversion (updates as needed)
- Provider notifications
- Weblink if available
- Service meetings (i.e. Primary Care, Subspecialty, Surgery)
- Alert telephone triage stations
- Shared information repository (letters, process outline, referral phone numbers, etc.)

**Notes:**
Note that some may elect to use automated phone messaging services such as Audio Care

## Inventory

- Order new drug for both outpatient and inpatient stock
- Pull and return old agent from stock
- Load/unload automation with new drug
- Unit dose a stock of new drug for distribution
- Coordinate transition/supply with CMOP

## Cost Analysis

- Create database for baseline cost analysis
- Select time points to track cost avoidance
- Don’t forget to monitor migration!

## Perform Interchange

- Create database of all eligible patients
- Identify and convert inpatients to new agent
- Convert eligible patients to new agent
- Patient letter mail merge
- Update local drug file, if applicable (formulary status, drug message field, CMOP marking, etc.)
- Update CPRS menus and order sets
- Discontinue “old” drug
- Chart documentation, if applicable

## Reminder Dialogs In-Clinic Therapeutic Interchange

## Target Drugs

- Therapeutic interchanges due to newly negotiated contracts, newly designated preferred agent in a class, etc.
- Specialized training or process necessary prior to transition to alternate product (inhalers, blood glucose test strips, etc.)

## Reminder Function

- Reminder shows “due” for anyone with active prescription for the “old” drug
- Reminder provides
- Brief description of interchange, evidence-based guidelines, dosing recommendations, etc.
- User-friendly ordering process for “new” drug
- Discontinuation of the “old” drug will make reminder go away

## Slide 36

## Slide 37

## Long-acting Beta-AgonistsKansas City VA – Day 30 Rxs

## Long-acting Beta-AgonistsKansas City VA – Total Cost

**$103,000**

**$75,000**

## Inhaled SteroidsKansas City VA – Day 30 Rxs

## Inhaled SteroidsKansas City VA – Total Cost

**$91,342**

**$51,742**

## Reminder Dialogs Prior Approval

## Prior Approval/Non-formulary drug requests

- All non-formulary drugs require approved consult
- Formulary “prior approval” drugs had little control
- NF consult
- Restriction messages
- Have used “reactive” methods to ensure appropriate usage

## Target Drugs

- Formulary with criteria for use or specific restrictions
- High volume
- High cost
- Significant safety concerns

## ARB example

- Formulary, restricted to VA HTN guidelines
- 50% of patients did not meet VA criteria
- Medication conversion
- Labor intensive individual patient review
- Inconvenience for patient
- Required NF consult and review

**Notes:**
Estimate loss of $150,000 annually due to inappropriate utilization of ARBs alone in year previous to the conversion

## Reminder-based Prior Approval/Non-formulary Drug Request

- New process that functions via reminder dialogs
- Access reminder while in a progress note
- ARBs were first drug to use reminder dialogs for prior approval

## When in a note, select  “Reminders”, then select “Prior Approval/Non-formulary Drug” to enter request

**When in a note, select  “Reminders”, then select “Prior Approval/Non-formulary Drug” to enter request**

## All other prior approval or non-formulary drug requests, click on your sites’ consult.  This will take you to the consult process that is already in place at your site

**All other prior approval or non-formulary drug requests, click on your sites’ consult.  This will take you to the consult process that is already in place at your site**

**If requesting ARB (losartan, valsartan) click here and will take you through reminder request**

## After clicking on ARB, begin processing request

**After clicking on ARB, begin processing request**

**Choose indication for ARB and will start a cascade of questions to determine if patient meets VA criteria for use**

## Click responses to each question and the reminder will “automatically” determine whether patient meets criteria for use of an ARB

**Click responses to each question and the reminder will “automatically” determine whether patient meets criteria for use of an ARB**

**If patient meets criteria, allows you to enter the medication order (and allergy/ADR if applicable) immediately after clicking “Finish”.  Note:  you can continue to process other reminders for the patient by clicking “Next” and order drug at the end when finished.**

## After clicking “Finish” automatically pulls up allergy/ADR package for entry if you checked that the allergy was not documented – enter allergy/ADR, then takes you to the order entry

**After clicking “Finish” automatically pulls up allergy/ADR package for entry if you checked that the allergy was not documented – enter allergy/ADR, then takes you to the order entry**

## Automatically takes you into a quick order for entry of the medication order (defaults for dose, route, schedule, days supply, quantity, refills, built in for efficient ordering) 

**Automatically takes you into a quick order for entry of the medication order (defaults for dose, route, schedule, days supply, quantity, refills, built in for efficient ordering) **

**Default comments say “MUE criteria met” so that pharmacy knows drug has been approved and OK to process = no delay**

## If patient does not meet criteria for use of ARB, you are notified with suggested alternatives and also given the option of proceeding to an abbreviated consult if you feel there is further information that should be considered 

**If patient does not meet criteria for use of ARB, you are notified with suggested alternatives and also given the option of proceeding to an abbreviated consult if you feel there is further information that should be considered **

## This is the abbreviated consult that simply requires a free text statement – provider enters the additional relevant information that is not already entered in the note from the ARB reminder

**This is the abbreviated consult that simply requires a free text statement – provider enters the additional relevant information that is not already entered in the note from the ARB reminder**

## NOTE: sign progress note with reminder information included whether patient meets criteria or not – sign note so that information is retained for review in case an abbreviated consult is entered documentation

**NOTE: sign progress note with reminder information included whether patient meets criteria or not – sign note so that information is retained for review in case an abbreviated consult is entered documentation**

## ARBsVISN 15 West Orbit - Day 30 Rxs

**20,823**

**14,022**

**Notes:**

VISN 15 implemented prior approval template Q2FY05 – total number of Rxs has decreased from 21,000 per quarter to about 14,000 per quarter.  Although not shown on this graph, the number of ACE inhibitor number of prescriptions has stayed static while HCTZ has increased

## ARBsVISN 15 West Orbit - Total Cost

**$244,886**

**$104,556**

**Notes:**
ARB total cost per quarter has decreased from about $140,000 per quarter or about $560,000 annually.

## Clopidogrel and AggrenoxVISN 15 West Orbit – Day 30 Rxs

**$244,886**

**24,020**

**14,438**

**1,111**

**3,649**

**Notes:**
Clopidogrel conversion began Q4FY06

## Clopidogrel + Aggrenox VISN 15 West Orbit - Total Cost

**$1,907,468**

**$1,337,282**

**Notes:**
Total cost of Plavix + Aggrenox combined has decreased $600,000 per quarter for a total cost avoidance of approximately $2.4M annually.

## Benefits

- Providers and patients receive immediate feedback
- Saves time – request, documentation, and order all in one process
- Proactive
- Improved reporting of allergies/ADRs
- Promotes evidence-based guidelines
- Improved drug utilization and expenditures

## Quality Assurance

- Data validated in over 90% of patients prescribed ARB through prior approval template

## Auto-Scripting with use of Procomm Plus software

- San Diego VAMC developed process
- Procomm Plus - terminal emulation software (allows computer to talk to program and execute (like KEA-term))

**Notes:**
After gaining the leadership support for the project, we wanted to implement it in an efficient manner to realize savings immediately.  

## Target Drugs

- Therapeutic interchanges due to newly negotiated contracts, newly designated preferred agent in a class, etc.
- Quick switchover required
- Prescription characteristics easily defined or standardized
- Blanket discontinuations

## Process

- Drug search report
- All patients
- Other reports of patients to eliminate
- Combine reports in Access for final eligible list
- Export final list of patients into Excel spreadsheet for data manipulation

## Excel Report

**Notes:**
Excel file of all patients to be converted to alternate drug/Rx (column headings match Access report template)
We pull data through a canned report in VISTA that gives us all patients on a particular drug for an designated time period, use Access to get it down to unique patients
Cross reference report with other reports that we may need (ADR reports, other drugs that may interact, or other information that would exclude a patient from eligibility for the conversion)
Final report of patients to be converted, then we assign column headings and auto-fill those with the information needed for new prescription entry

## Access ReportProgram

## Access ReportOutput 

## Procomm Plus Program Language

## Procomm PlusRun Program

## Proventil HFAKansas City VA – Day 30 Rxs

**Notes:**
Conversion from Levalbuterol to Proventil HFA began at KCVA March 2007.

## Proventil HFAKansas City VA – Total Cost

**$15,579**

**$11,941**

**Notes:**
Cost has decreased for the Kansas City VA alone by $3600 per month, approximately $42,000 per year.  

## QuinineKansas City VA – Total Rxs

**Notes:**
Discontinuation of quinine undertaken Feb. 2007  - immediately dropped from 240 to 6 Rxs and have seen none thus far for 3QFY07.

## Efficiency

- Workload savings
- Manual process estimated at 50-60 Rxs per hour (~ 1 minute per Rx)
- 300 new prescriptions in 30-60 minutes (~6-12 seconds per Rx)
- For 2000 prescriptions, estimate time savings of ~30 hours
- Discontinued 400 prescriptions in <30 minutes (quinine)
- Procomm Plus software costs ~$120 per copy

**Notes:**
Estimated time savings includes difference in time to perform manual entry and also excludes report/program setup time, estimated to be 4 hours for this project

## Questions?