A key factor in performing continuous medication monitoring (CMM) is knowing the indication of each medication a patient is taking. Sometimes this is easy to decide, and other times it can be challenging. The important step, however, is documenting the information once it is known. This article will discuss strategies and workflows that we use to collect and document diagnosis information.
Certainly of Diagnosis
When documenting a diagnosis in a patient record, it is important to state the level of certainty associated with the diagnosis. For example, the indication for some drugs is often easy to guess. Statin medications (HMG-CoA reductase inhibitors) are rarely used for anything except hyperlipidemia. We refer to the pharmacists best guess for the indication as a inferred diagnosis. Sometimes a pharmacist may consider a likely indication but recognize that the possibility exists that the medication is being used for something else entirely. An example of this might be the drug metformin. While this medication is used primarily for diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes), it can also be used “off label” for Polycystic ovary syndrome (PCOS). In the case of a female patient without other evidence of diabetes in their profile, assigning a diagnosis of PCOS would be recorded as a suspected diagnosis. When the indication is specified explicitly, either by the prescriber or on a prescription, the diagnosis would be considered confirmed.
Diagnosis Source
Similar to the documentation of the certainty of a diagnosis, it is important to note the source of the information in the patient record. We use three categories to refer to the source of a diagnosis.
- Pharmacist — This is used to indicate that the pharmacist, using clinical judgment, has assigned a diagnosis based on their knowledge of therapeutics.
- Patient — indicated that the patient has identified the diagnosis
- Prescriber — is used when the prescriber has stated the diagnosis
A Diagnosis Workflow
At our pharmacies, CMM is performed at the final verification stage of the prescription workflow. After the pharmacist verified that the new prescription or refill has been filled with the right drug and is labeled correctly, they evaluate the profile a look for potential or real drug therapy problems. The clinical workflow screen displays the diagnosis associated with the drug being checked. If no diagnosis is specified, the system may suggest possible indications for the drug (see Figure 1 below). The pharmacist can assign an inferred indication to the patient quickly at this point. Here, the source of the diagnosis would be the pharmacist and the certainty would be marked as inferred. If a new prescription includes diagnosis information, this too can be added to the profile with the appropriate source and certainly indicators.
If a diagnosis is uncertain, the pharmacist has the opportunity to engage the patient when the mediation is picked up. At this point, the pharmacist could create an intervention (Figure 2) and flag the prescription for counseling, including a note (Figure 3) to clarify the diagnosis with the patient. When the patient arrives, the pharmacist has the opportunity to consult with the patient and determine if the inferred or suspected diagnosis is correct. Information received from the patient can then be used to further update the pharmacy record.
Often, a patient confirmed diagnosis is sufficient for the needs of the pharmacy. Sometimes, however, the patient may not be a reliable source. In these cases, the workflow should include a method to send a short SOAP note to the prescriber requesting clarification of the diagnosis (Figure 4). Once this information is returned, the diagnosis information for the patient can be completed.
Collecting accurate, relevant patient drug-diagnosis combinations is an important step in the CMM process. Leveraging the patient at the point of sale is yet another example of making every encounter count.
