Sometimes I lament that, as a pharmacy owner, I don’t get to spend as much time on the prescription counter working with patients anymore. I still enjoy the challenge of working on the counter and working with patients, and every day I spend in this capacity I see examples of how pharmacists bring real value to healthcare. I also regularly find examples demonstrating the importance of taking time with each patient to be a clinical interventionist. I wanted to share a recent encounter I had the other day, because it emphasizes one of the core tenants of the Thriving Pharmacist: making every encounter with the patient count.
Today, while doing routine CMM (Continuous Medication Monitoring), I noticed that a medication had not been filled in several months. Our clinical checking system (PharmClin) helps our pharmacists easily spot these types of problem in two ways. First, the system calculates compliance (as a PDC — percentage of days covered). When the PDC drops below a pre-set level (around 75%), the software creates an alert for the pharmacist. It is important to note that this is done for all medications each time the patient record is visited and without regard the the medication(s) being filled and checked on a given day. The second feature of PharmClin that is immensely helpful is the ability to document if problem (like compliance of a medication) has or has not already been addressed. It also allows the pharmacist to set a follow-up date for re-evaluation of the issue.
In the case today, this medication had dropped to a compliance rate of 75 percent three months ago. The PDC was low due to one late refill, the pharmacist note on that date indicated that we would continue to monitor the compliance and revisit it in 3 months. It is not uncommon compliance to rebound, and 90 days is a reasonable amount of time to observe and re-assess. Today the software once again alerted me to the compliance issue (the three months had now elapsed). Given both the worsening PDC and the previous course of action (simply to monitor), I generated an intervention and attached it to one of the prescriptions being picked up today. The note simply asked if the dosage of this medication had changed or if this medication had been discontinued. The pharmacist speaking with the patient at the register would then be able to collect any important details (why, side effects, ineffective etc.).
When the patient arrived this morning, the technician (seeing the intervention tag) called me over to the counter to speak with the patient. During the course of discussion, I was able to ascertain that while the medication was indeed working for him, he was not currently taking it due to a drug interaction. Not seeing any drug interactions noted in his profile, further inquiry was made. It turned out that the patient was receiving a mediation from the local university teaching hospital. This medication (Harvoni) did indeed have an interaction with the medication in question.
At this point, I was able to speak to the patient about the importance of a single pharmacy home, and making sure that that pharmacy home has a complete profile. As it turned out, the patient had simply assumed that we would know what the other pharmacy dispensed. If a new medication was prescribed that also interacted with Harvoni, we very likely would not have been aware of the potential for an interaction. After the patient left, I added Harvoni to his profile for inclusion in future screening during our CMM activities.
The intervention that I had with the patient today was not uncommon to pharmacy. Pharmacists around the country take the initiative to be clinical interventionists. It doesn’t take board certification, a residency, or a fellowship to be a successful interventionist. It takes a sound workflow and an desire to think and ask questions. The biggest difference for me, though, is the documentation being done by our pharmacy. Documentation, like the previous note and the alert for a follow-up, allows the pharmacist to continually refine the clinical picture for each patient and the plan of care. Software is an important part, and can enable the pharmacist perform and document meaningful CMM activities.
