Recently, I was at a multidisciplinary meeting to discuss how pharmacists and prescribers can work more effectively together to identify patients with certain risk factors and ensuring that they receive appropriate drug therapy. As I discussed our continuous medication monitoring process (CMM), the prescribers in the room indicated that they were not familiar with pharmacists in their communities doing anything like what I was describing. Sadly to say, their own experiences going to a pharmacy as a patient did not help my argument. The other providers described the situation, that is all to common, that they seldom talked to a pharmacist and if they did, they had to wait 25 minutes. Now I realize that this may not be the actual case, but we have to remember that their perceptions are their realities. After some heated discussion about the roles of pharmacists and turf issues, I finally said to one of the physicians who was sitting next to me questioning how pharmacists can do what I was describing that he should change pharmacies and go to one that does provide clinical services.
Unfortunately as we have written in previous blogs, too many community pharmacies (chains and independents) have settled for a “strip-down” model of practice where there is little to no overlap between pharmacists and just enough technician help to ensure prescriptions can be filled efficiently–but little thought to clinical services. This “strip-down” model evolved out of profit motives and not what was best for patients and as reimbursements dwindled over the past decade, the “strip-down” model became even more prevalent and accepted. Because of this, patients, providers, and payers get mixed messages. They hear what I and others are talking about, but they experience something totally different when the go to a pharmacy. It is time to change the paradigm of community pharmacy practice.
The paradigm change that I am talking about will change the perceptions of all who come to a community pharmacy. First, we have to stop using the word “retail” when talking about community pharmacy as it gives a much different description then if you say community pharmacy. Secondly, pharmacists need to become interventionists identifying and resolving drug therapy problems, counseling an educating patients, consulting with other providers, and documenting their activities. Thirdly, pharmacists have to stop being passive in the dispensing functions. We need to make sure that we engage patients to collect information that will help us better manage their medications. Lastly, we need to make sure we have sufficient staff so that pharmacists are freed up to provide clinical services including CMM during the dispensing process.
For the past twenty something years we have been pushing community pharmacists to move from distribution functions to patient care. One would think, after all these years, that we would have a critical mass of community pharmacists providing ongoing clinical services. But given the response I received from the other providers at this meeting obviously they have not been exposed to it yet (and these providers were from around the country). We have to stop apologizing and making excuses for why we are not providing patient care services and just be doing it!
I was just on a conference call with a managed care organization (MCO) that will respond to a request for proposal (RFP) as our state shifts our medicaid administration to two or more MCOs. Unfortunately, the MCO that we spoke with today did not have any idea about the role of pharmacists as care providers. WHAT?!!!! How after all these years, with pharmacy’s movement from product distribution to patient care, can a managed care organization or payer not understand the value of pharmacists as clinical providers.
Part of the reason is because payers are not seeing this type of practice across the board. Also, not all pharmacists are practicing to the level of their degrees–identifying and resolving drug therapy problems, providing recommendations to prescribers, and documenting their activities. Lastly, payers may be looking at the wrong metrics when reviewing pharmacies (e.g. focussing on drug costs and not clinical parameters and patient outcomes, including health care spend).
As a profession, we need to do a better job of selling ourselves to payers and, in particular, our value to the health care team. Our value is that we have access to patients, we are able to identify and resolve drug therapy problems, we can ensure that patients are on safe and effective medications, and most importantly, we can make sure patients are achieving therapeutic outcomes–which will positively affect their total health care spend.
But all pharmacists also need to step up their efforts to develop and implement patient care services if they have not already done so. There is no money in product distribution because there is little value from patients and payers. The value statement is patient care, achieving health outcomes, and the unique role and knowledge of pharmacists to monitor and manage patients drug therapy. So, we need to make this the “norm” of pharmacy practice–not the exception.
Pharmacists, as a group, also need to be more vocal about the clinical roles to payers, legislators, and regulators. We cannot just sit on the sideline hoping that someone can figure this out–each of us has a responsibility to advocate for our profession–to reach out to payers and let them know what you are doing and the value you bring to their clients through your patient care services. If we do not do this, our profession will continue to experience the response that I experienced today–and that is getting old!!!
As co-owners of two community pharmacies, a compounding pharmacy, and a consulting company, my business partner and I have created practices that have developed and implemented value-added services. The services we have implemented include immunizations (flu, pneumonia, shingles and TDaP), health screenings, disease state management, medication therapy management, medication adherence program, medication synchronization services, consultations for CPAPs, ostomies and wound care, and continuous medication monitoring. Although I described these services as “value-added”, it is not the service in and of itself that is of value to patients, but rather the pharmacists’ knowledge and their ability to problem-solve for the patient. As I write this blog today, I am reminded of a statement made by one of my pharmacy colleagues when asked what makes a good pharmacist and his reply was “It’s about the therapeutics, stupid!”
My colleague was absolutely dead-on. We can offer many value-added services, but if pharmacists do not have the clinical knowledge and skills to ensure that patients are achieving their therapeutic outcomes with safe and effective drug therapy, then these services are just a shell with no real value. As our health care system moves to a value-based system and providers are evaluated based on their performance, then it will be those pharmacists who keep up with the literature, keep their knowledge current and relevant, and are capable of identifying and resolving drug therapy problems who will thrive in this new system.
Unfortunately, there is not an easy way for pharmacists to keep their knowledge current and it requires a lot of work and energy. It requires that pharmacist keep up with the guidelines, read and understand landmark studies, be involved in professional organizations, and apply their knowledge consistently in the practice setting. For some it may require some remediation, whereby they may need to take a series of courses on therapeutic topics that they need to further their understanding. But it does not end there, because to become comfortable with new knowledge, it is important that it is applied to everyday situations until it becomes entrenched in memory. Perhaps purchasing an updated therapeutics textbook as a guide will help, along with a case study workbook to apply new knowledge and therapeutic skills. Another approach is to connect with a faculty mentor who can provide you with reading material and cases to help you become a better clinician. Employers should invest in their employees and encourage them to attend local/state/national conferences, which would help increase their value as employees to better the practice. Even with employer support, it still is up to the individual pharmacist to read, assimilate, and apply new knowledge. In other words all of us need to become life-long learners.
At the end of the day, those pharmacists who keep their therapeutic knowledge current and relevant will be of great value to the health care system. More and more payers are recognizing the value of good and effective pharmacists in reducing total health care spend and improving patient outcomes. I am convinced that the future of our profession lies in our ability to affect patient outcomes, collaborate with other providers, and improve the bottom line of payers. Now is the time to prepare yourself for the this future which is coming fast and furious. It will all serve us well to remember our value to the system is all about our therapeutic knowledge and how well we can apply it to our patients!
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.
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.
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.
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:
Untreated indication
Need for additional therapy
Adherence
Dosing issues (dose too low and dose too high)
Unnecessary drug therapy
Adverse drug reaction (side effects and drug interactions)
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.
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
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.
[dropcap color=”white” background=”black” style=”rectangle” size=”big”]A[/dropcap]t Our pharmacies, we put a great deal of emphasis on performing clinical services while working on the dispensing counter and we call this process continuous medication monitoring (CMM). By this, I mean that the pharmacist, while verifying that the prescription was filled correctly, is also responsible for an in-depth look at the patient’s medication profile each and every time the patient has a prescription filled. To accomplish this, we have developed a software platform for our clinical pharmacists to work with while on the counter called PharmClin.
While the PharmClin package contains a comprehensive array of features including documentation for the clinical pharmacist, one of its core features is the patient profile. The single most important piece of information that a pharmacist has to make clinical assessments is the patient’s medication profile. The remainder of this post will look at the importance of the profile and how a logically formatted profile can aid the pharmacist in CMM on the fly.
A dispensing profile
Before looking at a clinically oriented profile, consider that a PMS (Pharmacy Management System) also maintains a patient profile. The user experience when trying to use most PMS profiles to perform CMM, however, quickly deteriorates. A Pharmacy Management System (PMS) is designed to facilitate dispensing. The PMS profiles are, therefore, optimized for dispensing activities, and not CMM. Consider a PMS like McKesson’s Pharmaserv below (click to enlarge).
Example Profile from Pharmacy Management System
This screen grab is fairly typical of most any commercial PMS in that it shows the history most current at the top. The level of detail visible, though is limited, and one has to select a prescription to see the previous dates (in the split window below). In all, the information visible is related primarily to dispensing.
This begs two questions: 1) what information displayed by the PMS do we not require when making clinical determinations and 2) what is missing that we would want to see? Taking these questions in order, our clinical pharmacists were less interested in:
Original Date (because it does not related to the first date the patient started taking the drug)
Refill number
Strength and form (because it is duplicate information)
Price
Facility
NDC
Coverage / Insurance
RPh and Tech
Keep in mind that almost all of these have significant value when considering the dispensing aspects of pharmacy, they just are not relevant to the most common clinical issues.
Our clinical pharmacists were interesting in seeing a few other details without having to drill down into the record. These included:
Days Supply
SIG or directions
Recent Refill Summary
A selective profile representing only the most recent therapies
Our clinical pharmacists were also interested in being to quickly spot
Specific therapeutic drug categories (e.g. those in the EQuIPP measures)
Drug interactions
Compliance Issues
A Clinical Profile
With this in mind, we pared our clinical profile view down to the following (for sake of comparison, this is the same profile as listed above): (again, click to view the image)
Example profile from a clinically based system
Besides some small differences in sorting and the scale size of the screen capture, the profiles represent the same exact data. One of the first things you might notice is that the profile is narrower (taking up much less space across the screen). The changes represent most of the important items on our clinical staff’s wish list for the profile.
Some things in this profile may not be initially obvious, but are exceptionally helpful to a clinical pharmacist performing rapid CMM on the counter. To simplify the profile , only the last three dispensing incidences for each given drug are displayed, and these are all displayed together, without respect to Rx number, NDC or other drug product changes. This saves the clinical pharmacist time as they do not need to hunt thru the profile. One advantage to this method is that the pharmacist can review compliance over the last three dispense occurrences quickly.
Other simplification were made to the profile. To reduce the amount of data to be interpreted, only the last 180 day are displayed, significantly reducing clutter in the profile. If a clinical situation requires a complete history, that option is available.
Another key difference is the addition of color. While the color-key is not visible in this screen capture, the drugs are color coded as follows:
Statins in GREEN
ACE / ARBs in RED
Diabetic medications in BLUE
Drugs listed as high risk (Beer’s List) in PURPLE
Drugs that precipitate drug interactions in ORANGE
All of the above color-coding relates directly to the current CMS 5-STAR rating guidelines, and allow our pharmacist to quickly make 5-star related determinations on compliance, high risk drugs, and drugs that are known to precipitate interactions.
Besides color-coding drugs that are known to precipitate drug interactions, the profile has drug interaction column that highlights any interactions flagged by the PMS. This column is kept minimal and does not show the details of the interaction by design. We decided that if we did not know what was going on, we could click to look, but for the most part, knowing that an interaction was flagged was enough for our clinical pharmacist to make their assessment. Interaction pairs are easy to spot this way. Drug – Alcohol and Drug – Food interactions sometimes create an ODD number of interactions, but after a bit of practice, spotting problems becomes very easy.
The profile above is not perfect, and has changed with time as we work thru our CQI process. One of the things that would be most helpful to us would be an accurate listing of medical conditions. Unfortunately, while PharmClin and our PMS do have the capability of entering this information, we often do not have documentation of actual diagnoses. For the purposes of “on the fly” clinical work, therefore, we use implied diagnoses, and the color coding is helpful in this.
I should point out that our clinical system does a lot more than just show the pharmacist a patient profile. The patient profile is important to start the process, but once the pharmacist has identified a problem, they have to document it efficiently. Once the pharmacist notes something worth documenting, they can document an intervention system for the next pharmacist or even write a quick SOAP note to send to the prescriber. Interventions and SOAP Notes can be flagged for follow-up.
Notes on PharmClin
PharmClin (patent pending) was developed as an in-house documentation tool for a clinically oriented retail pharmacy. The product currently integrates with McKesson’s Pharmaserv, but integration with other PMS vendors is being pursued. More details about PharmClin are available on the Innovative Pharmacy Solutions website. Web demonstrations can be arranged from that website.
[dropcap color=”white” background=”black” style=”rectangle” size=”big”]M[/dropcap]ore and more, we are hearing that MTM is the future of pharmacy. And while there is some truth with this statement, the reality is a lot more complicated.
MTM, as it has evolved under Medicare Part D’s parentage, is a poorly conceived service. The separation of the medication costs and the medical costs that exists within Medicare Part D gives PBMs (who manage the Part D benefit) little financial motivation to give patients access to the MTM service. This results in fewer MTM opportunities for community pharmacists. Additionally, many PBMs have brought significant amounts of MTM activities in house, using their own nurses or pharmacists to perform the minimum number of required by law. When local community pharmacists in the trenches do get an opportunity to perform MTM, they often end up spending far too much time completing the intervention and are reimbursed too little to cover their expenses. With the recent changes in Medicare Part D and CMS’ adoption of completed patient cases for comprehensive medication reviews (CMRs) as a performance measure for community pharmacies, this may potentially boost pharmacists access to MTM opportunities. Unfortunately, the amount of reimbursement for a CMR will continue to be a significant challenge unless pharmacists find a way to streamline their MTM processes.
The pharmacists approach to MTM needs to change. Consider that each refill picked up by the patient is an opportunity to assess the patient’s medication therapy, identify and document problems, and take action.
Today, pharmacists need to re-train themselves to complete MTM type activities in real time. This means upgrading their clinical knowledge, leveraging documentation systems, and optimizing workflows. Once pharmacists stop thinking about MTM as a sit-down encounter that takes more than 45 minutes, it opens up a host of possibilities.
Using a bite size approach to MTM allows the pharmacist to create, over the course of a few months, a complete medication therapy management description for a large number of patients. The pharmacist gradually collects and documents the information required in a traditional MTM encounter. This collection takes place on the counter, while checking prescriptions. This efficiency means that when a pharmacy is called upon to perform MTM services for a payor, they already have documentation and results in their pocket. The MTM intervention can be done in a matter of minutes.
It should also be point out that MTM does not need to exist only in the context of Medicare Part D. Pharmacists can look to group homes, assisted living centers, and others as potential MTM customers. Once shown the benefits of MTM groups and individuals often become quite interested in this service. Cash based MTM can become a real revenue stream for a pharmacy without requiring hours of desk time to complete.
[dropcap color=”white,” background=”black” style=”rectangle” size=”big”]O[/dropcap]ne of the most challenging issues facing pharmacist is what to do about high risk medications. Patients are often reluctant to stop using high risk medications and doctors are frustrated with a lack of options. All the while, pharmacies are being evaluated by Medicare since the adoption of a performance measure that looks at the number of patients on high risk medications. Approaching high risks mediation use is a lot like approaching a grizzly bear; you don’t know until after you approach it if it is a circus bear that juggles, or a wild, angry, and hungry bear.
Given the uncertainty involved, the approach taken is very important. While there is not one right way to approach high risk medication use with either the patient or the prescriber, this article will outline some guidances for pharmacists to consider when deciding how to initiate the conversation.
Preparation
Before venturing into the unknown, a few first steps are very helpful
Determine which prescribers are writing the larger share of high risk medications. This may require reports or other data extraction from the Pharmacy Management Software. Knowing who to deal with ahead of time allows one to better prepare.
Meet with select prescribers to discuss the issues. The goal here is to understand the issues and concerns the prescribers have about these medications. Be sure describe the Medicare Quality Measures and how both pharmacies and prescribers ratings are effected. Determine the level of engagement for these prescribers.
Prepare a standard procedure. When approaching a difficult task, it helps for every member of the pharmacy team to be on the same page. Standard procedures, including standardized phrasing for notes sent to prescribers and talking points when discussing the issues with patients or family members.
Start small. Working with the prescribers involved earlier, identify a small pool of representative patients to approach.
Being proactive. Resolving a drug therapy problem before it becomes a problem is a good approach for high risk medications. In other words, by performing continuous medication monitoring and identifying high risk medications before dispensing the first fill can be a better approach.
Be an evidence-based. There is plenty of literature that discusses the risks of high risk medication especially in older patients (>65 years old). Pharmacists have a more convincing argument when they know literature and can discuss the risks with patents and prescribers. But how this information is communicated can impact how it is accepted by others.
Be an interventionist. What is meant here is that if the pharmacist identifies a patient on a high-risk medication, then it is important that the pharmacist take action to try to resolve this drug therapy issue.
Intervening with the patient
As health care providers, pharmacists sometimes get the cart ahead of the horse. Before making any recommendation to the patient, it is important to..
Explain why the pharmacy is looking at the medications. Speak in terms of safety risk / benefit and overall outcomes.
Strive to understand the patient’s situation. It is tempting to simply state that one should not be taking a given medication due to overall risk. Instead, ask questions to help identify how important this medication is to the patient and how they feel about the associated risk(s).
Involve the patient in the decision on how to proceed. As a pharmacist, don’t forget that it is the patient that will have to deal with the consequences of any change in their drug therapy. Offer several options on how to proceed and seek imput from the patient. Success is more likely if the patient is involved in the decision.
Initiate the plan. Decisions at this point can run the entire spectrum from the patient being unwilling to considering any changes to a willingness to try a variety of options. How to proceed from this point will hinge on your conversations with the prescriber(s) earlier.
Document the plan. It is is unrealistic to expect a pharmacy to drop high risk medication to zero. Even a failure to effect a change, if documented, is a success.
Follow-up. Do not forget to schedule follow-up with the patient. This is an especially important action item if any changes were made. This should also be documented in the patient record. If no changes were made, follow-up should still be scheduled for the purpose of revisiting the discussion at a later date. Six months or 1 year are reasonable intervals for this type of follow-up.
Ultimately, patient willingness to consider changes depends on a number of factors. For patients that are resistant to changes, follow-up at a later date is important. With time, the pharmacist’s understanding of the patient’s motivations will increase, leading to new opportunities to change behavior.
[dropcap color=”white” background=”black” style=”square” size=”large”]T[/dropcap]he pharmacist has access to their patient’s refill history. With the history, the pharmacist can assess medication persistence, which is something a prescriber cannot readily assess.
Consider the following scenario: while performing final verification and doing Continuous Medication Monitoring (CMM) you notice that the patient does not appear to be taking one of their medications correctly. The patient appears to be taking roughly half of all scheduled doses. As the pharmacist, you decide to approach the patient in order to correct this compliance issue.
Before making this intervention, however, consider that you really know very little about the situation. While your data shows non-compliance, there are many possible explanations and only one of them is the patient being unwilling or unable to take the medication as prescribed.
Before approaching the patient, consider some of the possibilities. The following is representative of issues we have seen, but is certainly non exhaustive.
Samples. Yes, there are still samples being handed out by physicians. If the patient is on a name brand drug, this is certainly a possibility.
Mail order or another pharmacy. As pharmacists, we generally are not fans of this type of pharmacy, but the possibility that the patient has another source.
Prescriber – Pharmacist communication. It is fairly common in our practices to have the prescriber send the patient a letter of follow-up after an office visit. Often, the prescriber makes changes to the patient’s drug therapy in these letters but fails to include the pharmacy in the correspondence. The patient may be taking the drug correctly, but the pharmacy doesn’t know it (yet)
Medication hoarding. Often I find patients will have acquired massive stockpiles of their medications. Once they have done this, their apparent compliance starts to fall.
Drug side-effects or adverse events. The patient will be the first one to know if a medication effects them in an undesirable way. The patient may self-adjust their dose to avoid these effects. They do not always think to share this with the prescriber or the pharmacist.
Therapeutic goals. Related to the self-adjusted dose for ADRs, patients often adjust their dose themselves based on how they feel. As crazy as this might seem, the patient is often justified. Many patients I have seen over the years have adjusted their blood pressure and cholesterol medication doses themselves without letting anyone know. The prescriber often assumes that the dose being taken is what they prescribed. What matters here is that the patient is attaining the goals the prescriber and patient have established.
True Non-compliance. The patient cannot or will not, for one or many reasons, take the medication as prescribed.
Understanding that there are many different possibilities for the refill pattern being observed necessarily impacts the approach used. Instead of asking the patient why they are not taking their medication as prescribed, one needs to enter into a fact finding mission.
One approach that we have found useful in our practice is the use of open ended questions. Typically we explain what we have noticed and then ask the patient to fill us in on any changes. For example:
“We noticed that your refills for this medication were often late. We are often the last to know if the prescriber made any changes. How are you taking this medication now?”
By taking blame for “not knowing” about any possible changer, we have tried to make the assessment less confrontational. Generally, this tactic helps illuminate the underlying reasons for what we have observed. Most of the time, a good reason actually exists for the late refills.
Once the reason is understood, the appropriate action can be planned. Often, the persistence data is a false-positive for a compliance issue, and the pharmacist only needs to document the reasons for the late fills. If there is are true obstacles to compliance, the pharmacist can further intervene and help coach the patient to improve compliance. Of course, this too should be documented. Lastly, the pharmacist needs to schedule a follow-up to re-assess the patient. Our practice typically re-evaluates the patient’s compliance (even false positive cases) in 90 days.
Pharmacies and pharmacists have a unique opportunity. Our businesses bring our patients to us regularly. This means we can see and interact with them at a minimum of several times a year and often several times each month. Pharmacists need to make every one of these encounters count.
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.
