Medication ManagementSave Time by Simplifying Your Prescribing and Refill Process

1. Describe seven key steps to implement an approach for efficiently managing medications

2. Explain how to improve the efficiency of the prescription prior authorization process

3. Share medication management tools and resources to implement in your practice

Chronic conditions that require long-term medication therapy affect more than 133 million Americans.¹ More than half of all Americans take four prescription medications each day and get their prescriptions from several health care providers.² 75% of patients also regularly take at least one over-the-counter (OTC) medication.²

Managing the care of patients who take multiple medications creates a conundrum for the already overburdened clinician: During a brief visit, how do you reconcile all medications, ensure that patients are taking them as prescribed, and fill or refill medications efficiently? This module details STEPS you can take to help optimize processes you can use for medication management.

The goals of medication management are to:

• Reduce medication errors.³

• Improve patient safety.

• Promote better outcomes.

• Ease clinician workload.

• Mitigate burnout by addressing aspects of medication management that overburden the clinician.

1. Adopt Annual Synchronized Prescription Renewals and Standing Orders to Prescribe Efficiently

2. Create an Accurate List by Reconciling Medications

3. Carefully Review the Medication List to Identify Opportunities to Deescalate Therapy

4. Determine if the Patient is Adhering to Their Medications

5. Streamline the Prescription Drug Prior Authorization Process

6. Leverage Your Electronic Health Record (EHR) to Confirm Refill Data and Save Time

7. Coordinate With Your Pharmacy Colleagues to Sustain Your Efforts

You can save up to two hours every day by writing prescriptions for medications that treat chronic conditions so that the patient receives a 90-day supply filled four times a year.⁴ The shorthand for this is “90 x 4.” This approach is also known as annual synchronized prescription renewal because all of the patient's prescriptions for chronic conditions are renewed at the same visit.

Annual prescription renewals for stable medications can occur whenever there is an opportunity. Some practices routinely renew all prescriptions for the maximum duration during an annual comprehensive care visit. Patient visits will still occur at the same frequency, but refills are addressed once per year.⁴

This may seem intuitive, but you'd be surprised to find that many practices don't have standard processes for synchronizing and standardizing recurring patient prescriptions and lab orders. Eliminating frequent prescription renewals is the first step to improving how you and your team manage medications for your patients.

Standing orders are another mechanism to simplify and streamline prescribing. With a quick glance at a printout, your team will be able to determine which medications they can prescribe for 90 days without contacting you for approval.

More than one million Americans are harmed by medication errors each year, and one way to reduce medication errors and promote patient safety is to know what medications patients take and when.^6,7

Medication reconciliation is “a process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system.”³ Asking open-ended questions during this process can help you capture medications prescribed by other health care providers, as well as determine if the patient is self-prescribing OTC medications.⁷

With team-based care, medication reconciliation can be performed by other team members as allowed by state regulations and organizational guidelines. An MA is qualified to perform this task, but whether they can reconcile within the EHR is specific to state guidelines covering their scope of work.⁸ In some instances, the physician may also perform medication reconciliation, but this is not the best use of time with the patient.

A “Plan Forward” approach may help the task feel less daunting, so consider starting reconciliation during pre-visit planning by sharing a printed medication list with your patients when they arrive in the waiting area. Many patients and their families find it easier to look at a printout of a paper medication list while the team is looking at the same list on the computer. For new patients, it is helpful to start this process on the phone prior to the appointment and add a reminder to bring in all medications.

There are several other touch points where this task can be initiated, such as:

• Over the phone on the day prior to the visit by the medical assistant, especially if the patient is new or recently hospitalized. If the patient is unsure of their medications, obtain their permission to contact a family member or the patient's pharmacy.

• During the interval between visits by an embedded or affiliated pharmacist who has access to the patient's medical record.

• Before the visit by the patient in the patient portal (note: the team will need to set up reminders for patients).

• With a pharmacist at the local community pharmacy if a patient brings a printout of their medication list from their patient portal.

Techniques for medication reconciliation include coordinated review with an affiliated or embedded pharmacist, home health or nurse care manager, which is helpful but not necessary if these individuals are not regular members of your care team, and “brown bag” review.

Quiz Ref IDA brown bag review is where a patient brings in all their prescription medications, OTC medications, vitamins, and supplements, including those they do not currently take or that were prescribed by another doctor.⁹ To make this easy for your patients and your team, consider these approaches:

• Offer a reusable bag. Give patients a reusable bag with your practice name and logo on it to take home, put their medications in, and then bring back to their visit. You may also want to print “Bring All Your Medications” or “Put Your Medications in Here for Your Next Visit with ‘X' Practice” on the bag. As soon as your team sees that, they'll be prompted to perform the review at the start of the visit.⁹

• Use a template in your EHR. Include prompts and fields that need to be filled in, such as discrepancies in the dose the patient is supposed to take vs the dose the patient is taking.⁸

• Remind everyone. Include a note on the patient's appointment card, reminder email, alert in the patient portal and mention it during calls about the appointment. For your team, mark or highlight in the EHR that there will be a brown bag review at the next visit. You could consider calling out the number of patients on the schedule planned for medication reconciliation during the daily team huddle to help the team prepare.⁹

• Be appreciative. Thank the patient or caregiver for taking the time to go over medications with the team to improve their health care.

For more information on conducting brown bag reviews, check out this resource from the Agency for Healthcare Research and Quality: Tool 8: Conduct Brown Bag Medicine Reviews.

Adverse drug events, unwarranted polypharmacy, suboptimal treatment regimens, incorrect or inadequate dosing, drug-drug interactions, and adherence should all be considered when looking for opportunities to deescalate or adjust therapies.¹⁰ Think back to the findings of the previous two STEPS when adjusting therapy, as well as if you are adding or subtracting medication.

For example, the standard approach with geriatric patients is to follow Beers Criteria^® published by the American Geriatrics Society.¹¹ There are many other reasons to adjust or de-escalate therapy that will be dependent on individual patient characteristics. Additionally, deprescribing may be warranted for some patients with polypharmacy.

The following algorithm covers some general considerations for the order and mode of deescalating or deprescribing¹²:

Figure 3 is adapted with permission from JAMA Intern Med. 2015;175(5):827-834. Copyright © 2015 American Medical Association. All rights reserved.

It's hard to determine in the general population, but estimates suggest that one in five medications frequently prescribed to older patients are inappropriate or unnecessary.¹²

Often patients hide their nonadherence for fear of being “shamed,” made to feel foolish, or simply because they want to please their physician. If this has happened to the patient in the past they may be very reluctant to tell you their true medication-taking behavior.¹⁷ In that case, you may escalate therapy needlessly which can lead to unnecessary costs, extra time spent, and potential harm to the patient if they suddenly become adherent, such as when they are admitted to the hospital.

As you cover the previous STEPS and discuss how and when your patients take medicine, it is important to ask about their medication-taking behavior in a non-threatening, blame-free way. You can incorporate routine questioning about adherence outside of medication reconciliation by asking about factors such as cost of the medication or the number of doses per day, and whether these are barriers for your patients. Patients may have good reasons for not taking their medications and should be reassured that they can share their true medication-taking behavior without fear of being admonished.

Scheduling a “lunch and learn” session to review the STEPS Forward™ Medication Adherence module and to watch videos depicting how patients perceive nonadherence may be helpful for your team.

Prior authorizations (PAs) can negatively impact both patients and physician practices. Physicians report that PA can lead to care delays, treatment abandonment, and negative clinical outcomes.¹⁸ PA consumes significant resources: practices report completing an average of 31 PAs per week per physician, with this workload consuming an average of 14.9 hours—almost two business days—per week of physician and care team time.¹⁸

Given the associated disruptions in timely care delivery and practice workflow, improving PA process efficiency can benefit your practice. There are several different approaches that you and your care team can take to ensure that your patients receive the medications they need when they need them. Streamlining practice workflows to reduce the number of “touches” required for PA and opportunities for PA automation can save your patients and your team time.¹⁹ See the downloadable “Tips and Resources to Alleviate Prior Authorization Burdens” for additional direction on how to apply these techniques to your daily workflow.

Quiz Ref IDYou can put your EHR to work for you by creating customized commands that allow the user to quickly insert standard text for commonly used phrases/verbiage, thereby improving the efficiency of documentation, ordering, and prescribing. Leverage your knowledge of your patient panel to create defaults and set preference lists. These functions could be created with the help of a pharmacist or on your own based on your assessment of the most commonly prescribed medications, dosages, and instructions used in your practice.

Even if your practice doesn't have an embedded or organizational pharmacist, there are actions you can take to improve your working relationship with local pharmacists and pharmacies. As you embark on the process of improving how medications are managed, you may consider hiring a consulting pharmacist for a short time.

Simplification, standardization, and automation can help you manage your patients' medications more efficiently. The components of a successful intervention to improve medication management include adjustments to practice workflows, creating and streamlining processes for reconciling medications, ensuring that you're using your EHR to its full potential, and having open dialogues with your patients about adherence and with your pharmacist colleagues about how to make the process easier for everyone. A little time invested into the aspects outlined here will help you reduce the burden on you and your team and promote joy in medicine.

Journal Articles and Other Publications

• Brown MT. Practical ways to address physician burnout and improve joy in practice. Fam Pract Manag. 2019;26(6):7–10. PMID: 31714045. https://www.aafp.org/fpm/2019/1100/p7.html