Describe seven key steps to implement an approach for efficiently managing medications
Explain how to improve the efficiency of the prescription prior authorization process
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.
Adopt Annual Synchronized Prescription Renewals and Standing Orders to Prescribe Efficiently
Create an Accurate List by Reconciling Medications
Carefully Review the Medication List to Identify Opportunities to Deescalate Therapy
Determine if the Patient is Adhering to Their Medications
Streamline the Prescription Drug Prior Authorization Process
Leverage Your Electronic Health Record (EHR) to Confirm Refill Data and Save Time
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.
Use this tool to streamline your medication refill process.
What are some benefits to extending prescription duration from six months to one year, and having a nurse or other care team member take on this process?
There are many benefits, including:
Satisfied patients who aren't waiting for refills
More efficient practice workflow
Fewer interruptions for the physician
Reduced need for second requests by pharmacists
Greater time and money saved overall
Which states allow prescriptions to be written for one year? Do any states allow for longer than a year?
Eight states and the District of Columbia have no time limits on prescription refills, and two states (South Carolina and Wyoming) allow prescription refills to be written for two years.5 The remaining states allow refills to be written for a duration of one year, with the exceptions being 18 months in Iowa and 15 months in Idaho and Maine.5
Are pharmacies implementing synchronization programs?
Yes. Some pharmacies have programs a patient can enroll in that synchronize prescriptions to save patients time and reduce the number of trips to the pharmacy for refills. Let your patients know that this may be available to them.
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.
What does a brown bag review entail?
During the brown bag review, it is essential that you let the patient tell you what they know about their medications. Correct and clarify medication instructions in plain language. Ask what they are taking the medicine to treat and when they are taking the medicine.9 One approach is to use the teach-back method commonly used in health coaching. Sometimes, it is most helpful for them to show the dose they take each time. Is it one pill? Two pills? At what time of day?
Update the medication list as you review. When complete, make sure the patient gets a copy.
Do I need to schedule a visit dedicated to reconciliation if I have a complex patient with polypharmacy and numerous chronic conditions?
You can if you want, but this is not necessary. If a portion is done during pre-visit planning or before the physician enters the exam room, the process goes quickly.
For some patients, the best approach is to have reconciliation coincide with their Medicare Annual Wellness Exam/Visit (AWE/AWV).
How should I approach medication reconciliation if my patient sees multiple providers and some are outside of my network?
If your patient sees multiple health care providers, assume that there may be duplicate medications. A brown bag review is invaluable for gathering information if this is the case. Another helpful tip is to check to see if your EHR has a screen to review outside medications to add or remove from the medication list. Some systems have this functionality.
How do I keep the medication list up to date after I've finished reconciliation?
Before every visit, correct or update the medication list during pre-visit planning. Establishing protocols, such as consistent use of generic vs. trade names for prescriptions in the medication list, scripted prompts or questions that are guided by the layout of your EHR, and having the same team members perform reconciliation whenever possible will help improve this process.
Have a list of common trade and generic names handy for the person reconciling so that they can easily convert to the preferred terminology in your practice.
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
How could standing orders help me adjust and/or deescalate medications?
During medication reconciliation, develop a list of medications that should be reviewed to determine if each is still necessary. These medications might include high-dose vitamin D, hormone replacement therapy, proton pump inhibitors, laxatives, anxiolytics, bisphosphonates, or pain medications.
What other steps or processes can help me with deprescribing?
This table describes a 5-part deprescribing protocol that may be helpful.12
Figure 4 is adapted with permission from JAMA Intern Med. 2015;175(5):827-834. Copyright © 2015 American Medical Association. All rights reserved.
Why is it useful to include the indication on a patient's prescription?
Including this information, often termed “indication prescribing,” can help your patients better understand their treatment and thus adhere to your recommendations. For example, when starting a diuretic, you would include the generic name, the dose, and a note in words the patient can understand, such as “Take one every day to control your blood pressure.” This would appear on the after-visit summary as well as the pill bottle. This method bridges the gap in patient education to help them better understand the purpose and use of their medications.
Indication prescribing is especially important as the shape and color of generic medications can vary each time they are refilled. Include a note on the bottle if labs are needed at set intervals. For example, patients on thyroid medication require a thyroid function lab test every year. The pharmacist will then have another opportunity during each refill to be sure the patient hasn't missed a lab test.
However, be aware of sensitivities that patients may have about certain information being visible on their bottles. For example, exercise caution with indication prescribing with treatments for mental health issues and substance abuse. It's always a good policy to discuss these potential sensitivities with your patient.
Are some patients better candidates than others?
You don't need to adjust or deescalate therapy with every patient. We suggest starting with a cutoff, for example, any patient over the age of 75 on 10 or more medications.
Who should determine which medications to adjust, deescalate, or deprescribe?
Your team can help you identify which medications you could consider. You could send a list of patients that fit the criteria to a pharmacist for evaluation or involve a pharmacy student. If that's not an option, a nurse practitioner or physician's assistant may be able to assist you. If they recommend reducing the dosage or eliminating a therapy completely, have them loop back with you. For some medications, such as anti-depressants or anxiolytics, suddenly stopping can result in withdrawal symptoms.
How should I tell patients to dispose of unused medicines?
The Food and Drug Administration (FDA) offers detailed guidance on proper medication disposal.13- 15
You may find it helpful to have some printouts of the fact sheets from the FDA website on hand to pass out.13 If you advise your patient to dispose of unused opioids, take-back programs are the preferred method to safely dispose of these medications.16
For a user-friendly roadmap to medication disposal, check out their Drug Disposal Options infographic.
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.
Use this sample scripting to more effectively communicate with patients.
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.
Use this tool to assist in streamlining the PA process.
What are the benefits of electronic PA for prescription drugs, and how can I learn more about this process?
Standard electronic PA (ePA) technology for medications allows you to complete the PA process within your EHR, as part of the e-prescribing workflow. This process saves you and your care team time, as well as prevents patients from arriving at the pharmacy only to find that a prescription can't be filled due to an unmet PA requirement.20
To learn more about prescription ePA, visualize this workflow, and find out how to implement this technology in your practice, watch this three-part video series.20
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.
How can I use smartlists or preference lists to be more efficient?
Many physicians don't realize that these lists could include medications. Use these lists to save time prescribing time and better manage medications.
What does a typical smartlist or preference list look like?
Take the time up front to set up a smartlist or preference list of the typical dosing for the most commonly prescribed medicines.21 This includes indication prescribing and directions to the pharmacist.
Think about the first-line drugs for diabetes and hypertension, then build a preference list. When you type the medication, it automatically populates in the list within your EHR–or you can select medication, dose, and directions from a dropdown.
What are some common defaults for refills?
Your refill defaults will follow your smartlist or preference list. Once you've determined that a medication is safe for annual prescribing, you can set this as default for chronic medications (90 x 4).
How do I discontinue a medication or dose or start a new prescription without disrupting the schedule for the remainder of the prescriptions?
When discontinuing or starting a new prescription, we suggest adding “discontinue (d/c) prior dose” in the note to the pharmacy to keep prescriptions synchronized. This can be automated in your EHR with the CancelRx (formerly CanRx) e-prescribing function. CancelRx inactivates the old prescription and prevents the pharmacy from dispensing it, which can happen if refills remain.22,23
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.
Can pharmacists manage medications for me?
Yes, Medicare Part D plans reimburse pharmacists for reviewing medicines as part of medication therapy management (MTM) services.24
How do I let pharmacies know to stop automatic refill requests?
The pharmacist needs to be made aware that you are getting refill reminders on the old prescription schedule. This can happen for annual prescriptions (90 x 4) in addition to those that the patient may have filled monthly. In your note, consider putting “cancel all prior” to stop reminders from being sent.
What are some ways to engage a pharmacist to support my efforts to streamline PAs?
Here are some ways you can engage pharmacists:
Embedded pharmacists could be delegated responsibility for completing PAs on behalf of physicians.
Some states allow pharmacists to directly submit PA requests. This works best if the pharmacist has access to EHR/clinical data.
Pharmacists can help coordinate the PA process—especially if the prescription cannot initially be filled–and contact the patient when the PA is approved and the prescription is ready. Also, the practice can contact the pharmacy when the PA is approved so the pharmacy knows to reprocess the claim.
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.
90 × 4 is one of the easiest, most impactful ways to change how you manage medications.
Incorporate medication reconciliation into existing workflows when you can to save time and effort.
When you see your patient is not at goal, investigate medication nonadherence.
When there's no getting around the need for a prior authorization, streamlining the number of touches could make the process easier.
Automation in the EHR can be your friend–use this functionality to confirm refills.
Collaborate with your colleagues to make medication management easier.
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
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Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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