Today’s topic will not be new to the pharmacists that read this forum. The purpose today is to give pharmacists a chance to share this information with providers and patients with the hope of increasing the awareness of some of the more challenging aspects medication therapy management: how to reconcile medications when the pharmacy doesn’t know a change has occurred.
Let’s look at a scenario that came up today. We received a call from the hospital looking for a current medication list for a patient who was being admitted. This is fairly routine: medication reconciliation is a staple of the admit and discharge process from hospitals. During the call, the pharmacist doing the reconciliation questioned one medication we were providing: they recalled reading a clinic note that referenced the medication being discontinued. Our records did not show this change.
Often, the patient’s own pharmacy is the last to know when a change is made, and sometimes, we are never informed of changes. How can this be? Many hospitals and doctors give the patient a post-visit summary. This might include changes in how they are to take a medication, new medications to start, and old medications to stop taking. Sometimes the patient will share this with their pharmacy. This is ideal, and we train and encourage our patients to provide us with a copy when they receive one so we can reconcile their medications on our side as well.
If the patient doesn’t share this, some of the changes will still become apparent. For example, a new medication will result in a new prescription being sent to the pharmacy. In the other scenarios, though, there isn’t any communication of the changes made back to the pharmacy. The change may eventually come to light when the patient requests a refill early or doesn’t need a refill when we expect. Both of these scenarios depend on the pharmacy being very proactive.
Independent pharmacies like ours are proactive. We leverage Medication Synchronization (MedSync) and make calls to patients a week or so before they are due to get refills to ask about changes and confirm what needs to be filled. Changes may become apparent at this point. Pharmacies that do not have these types of program may completely miss these changes.
When a pharmacy packages patient medications, the lack of communication could result in changes not being made promptly. There really should be a better way to communicate. As it turns out, there is. SureScripts has supported the CancelRx transaction for quite some time now.
The CancelRx message is a message to the pharmacy to discontinue one or more prescriptions that the prescriber previously sent. This message, when used, alerts the pharmacy of changes that they otherwise might not be alerted to in a timely manner. Unfortunately, some providers don’t use this message, or their electronic health record (EHR) doesn’t support the message.
This message is not without its own caveats. We routinely receive CancelRx messages from providers to cancel the old Rx at the same time we receive a new Rx for the same item. If the doctor, however, forgets to send the new Rx, the medication might be instead be just discontinued. Today we received a host of CancelRx messages for seizure medications without new prescriptions following. This resulted in a call to the provider to ascertain their intent.
It should be apparent by this point that communication between the patient, prescriber and the pharmacy is exceedingly important. With our without the CancelRx message, the pharmacy needs to be in the loop on any changes being made. The patient can help by providing their after-visit or discharge summaries to the pharmacies promptly. The prescribers can make judicious use of the CancelRx messages, as well as other communication avenues.
The pharmacy has a job in this as well. The pharmacy should be documenting and providing regular feedback to the prescriber, including the current list of medications. Every message, SOAP note, and request that our pharmacy sends to a provider includes a current medication list as we have it documented. This includes supplements and medications that may come for other providers. This helps close the loop of communication between the provider(s), patient, and pharmacist.
The take-home lesson today: Patients — provide your pharmacy with a copy of the information you receive from your visit or hospital discharge. Prescribers — be sure to communicate changes not only to the patient and their caregivers, but also to their pharmacy. Finally, pharmacies need to provide feedback to the providers, both with respect to current medications and supplements the patient is taking as well as any issues, side effects, or concerns the patient voices to the pharmacy staff. In short: Make Every Encounter Count!