Author: Randy McDonough

Randy McDonough is co-owner of Towncrest, Solon Towncrest, and Towncrest Compounding Pharmacies. He is also co-founder/co-owner of Innovative Pharmacy Solutions. He oversees Towncrest Pharmacy’s clinical services including MTM services, wellness screenings, immunizations, and adherence services. He is responsible for development, implementation, and quality assurance for all aspects of the clinic and services. He is board certified in geriatrics and as a pharmacotherapy specialist. Randy has published and presented extensively on the subject of pharmaceutical care and MTM in the community pharmacy setting. In particular he is recognized for his efforts in developing and implementing patient care services. He has co-authored a book on pharmaceutical care and has written chapters for several other texts. He has presented nationally and internationally on pharmaceutical care, MTM services and Performance Measures in the community pharmacy setting. He currently writes a column for Pharmacy Today titled “MTM Pearls” Randy is a member of the American Pharmaceutical Association, National Community Pharmacists Association, American Society of Consultant Pharmacists, American College of Clinical Pharmacy, and the Iowa Pharmacists Association. He has served in various roles in these organizations. His areas of interest include community-based outcomes research, pharmaceutical education, diabetes education, disease state management, student development, and the development of patient care initiatives in the community pharmacy setting.

Writing Effective Communications to Prescribers

Over the years I have been asked by many pharmacists why Towncrest Pharmacy gets such a good response from physicians and other prescribers when we send them a SOAP note and recommendations.  My response to them is that it took having many conversations with different physicians, creating easy to use physician communication forms, and learning how to write succinct, clinically relevant notes that matter to physicians.  This experience has helped me to develop a set of criteria that I use to teach pharmacists, residents, and pharmacy students on how to write an effective SOAP note.

Criteria for Physician Communication.

  1. Keep it succinct and clear.  It is important that our SOAP notes are not lengthy nor convoluted.  The information needs to read easily and be understandable.  By using the SOAP note format (S = Subjective, O = Objective, A = Assessment, and P = Plan) pharmacist create a note in a format recognizable and understood by prescribers.  Subjective information is information that the patient has told you, objective information is something that was measure (e.g. labs, vitals, etc), assessment is the pharmacists evaluation of the subjective and objective information to identify potential or actual drug therapy problems (DTPs), and the plan is the pharmacists recommendations to resolve the DTPs.  It is important to keep the SOAP note to one page, if at all possible, and include an updated medication list.
  2. Provide the prescriber with information they do not have.  What I mean here is that pharmacists need to look at their patients and their drug therapy with a critical eye.  Pharmacists need to be asking themselves how their patients are taking their medications, if they are adherent, if they are achieving their therapeutic goals, and if they are experiencing any adverse drug reactions (ADRs) including side effects and drug interactions.   By systematically reviewing each medication in this way, pharmacists can communicate information to physicians that may be otherwise unknown to them.
  3. Describe the problem.  The assessment part of the SOAP note is where pharmacists use their critical evaluation skills to identify the drug therapy problems that patients may be experiencing.  The categories of drug therapy problems that we use to describe the problem is what has been used extensively in the literature including:
    1. Untreated indication
    2. Need for additional therapy
    3. Adherence
    4. Dosing issues (dose too low and dose too high)
    5. Unnecessary drug therapy
    6. Adverse drug reaction (side effects and drug interactions)
  4. Provide concrete recommendations to prescribers.  Over the years I have learned provide recommendations that are answered with a yes or no by theprescriber.  Also, I make it clear on the form that I use thatprescribers understand that the recommendations become a prescription if approved and signed by the physician.  For example, I recently provided the following recommendation to aprescriber.
    1. Patient is taking both sertraline 25 mg QD and trazodone 150 mg QD. She has a PMH signficant for dementia with behavior disturbances, depression, and anxiety.  Her last depression evaluation indicated minimal depression.  Due to concerns about CNS ADRs with trazodone, can we attempt a trial reduction of her trazodone to 100 mg QD, #30 tablets, 11 Refills?  _____Yes  _____No
  5. Be evidence based.  It is important that pharmacists keep current with their therapeutic are are aware of the literature to support their recommendations.  This does not mean that you have to cite a particular study, but it does mean that you are able to do this if questioned and challenged.  If prescriber become confident in your knowledge and clinical skills they will more likely become more accepting to your recommendations.

Knowing and applying these criteria will help community pharmacists impact their patient’s care and help to develop collaborative working relationships with prescribers.  It is our responsibility to ensure that our patients medications are safe and effective, but we need to effectively communicate with other providers if we are to be successful in helping our patients.

Compliance and Persistence in Continuous Medication Monitoring (CMM)

There has been a lot of interest lately in Medication Synchronization programs as a way to improve a pharmacy’s EQuIPP measures, especially as they related to measures of Proportion of Days Covered (PDC). While there are a number of possible ways to implement Med Sync, it is important to not lose site of the actual goals of therapy.

For years, mail order pharmacy has touted cost savings based on the supposition of improved patient compliance. As it turns out, these assumptions were often flawed due to the disconnect between the billing / shipping of the product and the patient actually taking the medicament. Indeed, automated refills of any nature, including mail order or Med Sync programs, will show improved compliance (based on claims data including the day supply and dates of refill), magically augmenting a pharmacy’s performance with respect to PDC.

While many pharmacies would be thrilled to improve their PDC related measures, making an investment in Med Sync appealing, the real story is both more interesting and harder to document.

The more important measure, and one that is not adequately measured by EQuIPP or other PDC style metrics, is the rate the patient takes their medication correctly. There is a subtle, yet important difference between these. The PDC is based only on claims data, which comes from the information written on the prescription. The latter is a combination of the instructions given to the patient by the prescriber directly (which are often at odds with those written) and the patient’s willingness or ability to follow thru with these directions.

Many Pharmacy Management Systems will flag early or late refills for the pharmacist or technician to follow-up with, but in reality these are difficult to leverage. For example, If a patient with 100% compliance to the prescription’s directions, picks up meds four our or five days early over the course of a few months (simply out of convenience), they could easily be 2 or more weeks late on the current refill without actually being out of medication. A calculation looking at 3 to 6 months of the dispensing record gives a more accurate picture of the patient’s compliance and persistence in taking their medication.

One of the tools we use daily in our pharmacy is Continuous Medication Monitoring (CMM). Each time we refill any medication for a patient, we carefully look at the entire patient profile. For each prescription in the patient’s profile, a persistence score is calculated over time using the total number of days dispensed (corrected for future days) versus the actual days passed. While this can be done manually, our software automatically flags any prescriptions showing any drop.

When we notice an unexplained drop in persistence for any medication, we can approach the patient to inquire if anything has changed. Quite often, any changes in persistence are explained not by the patient’s inability to follow the regimen prescribed, but by new instructions given to them by the prescriber that have not been communicated to the pharmacy.

Thru the use of CMM, these types of issues can be addressed with the patient at the counter. From there, the prescriber can be approached to provide a new prescription with updated instructions. In the end, compliance was not the problem, but communication between practitioners.

As you consider implementation of a Med Sync program, be sure to keep in mind that compliance and persistence are more than just claims data. Be alert for evidence of changes, and “Make Every Encounter Count” when you have the patient in front of you.

The Stripped Down Model of Pharmacy Practice

What does a pharmacist do? The answer to this question depends on who you ask, with patients, health care providers other pharmacists, PBMs and insurance companies offering a wide array of responses.

Maybe a better question to ask is this: “What is a pharmacist paid to do?” Based on reimbursement from Pharmacy Benefit Managers (PBMs), pharmacists are only paid for the product they dispense, and then, only the most inexpensive generic medications. Many times, pharmacies are not even receiving a dispensing fee for their work, let alone a professional fee for services rendered.

In other words, over the past 20 years, pharmacy has evolved into what we call the “Stripped Down Model” of pharmacy practice. This model has become the de facto prototype for pharmacies in the United States. Unfortunately, a low-cost model is not synonymous with patient care and lower overall healthcare costs.  Pharmacists concentrating only on dispensing the correct medication to the patient are doing little to improve patient outcomes and healthcare quality and, in fact, may easily be replaced by automation or less expensive providers.

This shift to a volume driven profession is not optimal  for patients or the health care system, and all of us are all to blame for this. Pharmacists have precious extra time to perform patient care services in many practices for a variety of circumstances including  pharmacy management emphasizing metrics of wait time and volume to their staff, patients wanting their medications to be cheap and fast, and PBMs and Insurance companies wanting to maximize profits and their bottom lines.

The Stripped Down Model doesn’t really use a pharmacist, and in truth as mentioned previously,  pharmacists can potentially be replaced by robotics or technician based dispensing models, creating additional savings for the “system” thru mitigation of expensive pharmacist salaries.

…the profession of pharmacy needs to work to create a network of truly high performing pharmacies and pharmacists.

While I believe that the above scenario is possible, I see another direction for pharmacy. Despite the oppression of this stripped down model, pharmacists across the country still work to apply their clinical skills and make interventions on behalf of the patient. Pharmacists can and are impacting healthcare by decreasing costs and more importantly improving patient outcomes.

Even Medicare is starting to understand, with the new emphasis on quality indicators. Pharmacists and pharmacy performance are about much more than prescription volume. It is the patient outcomes that matter.

As the paradigm of pharmacy changes, the emerging model should leverage the pharmacist for what they can do. In other words, a model that pays pharmacists to care for patients through appropriate mediation management. Pharmacists should be financially recognized for ensuring that patients are using safe and effective medications in the most cost-effective way so that they achieve optimal therapeutic outcomes.  In the coming days, weeks, months and years, the profession of pharmacy needs to work to create a network of truly high performing pharmacies and pharmacists. Pharmacists will need to work to become recognized for what they do and they will need to be paid to do it.

Pharmacists will need to “make every encounter count” with their patients!