Marie T. Brown, MD, discusses challenges, benefits, and strategies for streamlining medication management.

Q: What problems do health care professionals encounter when it comes to medication management?

A: One real challenge is having the time to talk with our patients to discuss why they need to take a particular medication—or medications. This includes talking about how long they'll be on medications, as well as the side effects, risks, and benefits associated with each medication.

For example, one of the most common and most effective type 2 diabetes medications is metformin, which is very safe and inexpensive. Finding the right metformin titration regimen is important. Many providers and patients are often not familiar with the gastrointestinal (GI) side effects associated with metformin and don’t understand that the GI upset will resolve, usually in 7 to 10 days, in most patients. Unfortunately, what usually happens is that, after 2 or 3 days with GI issues, a patient will stop taking metformin, and then resume taking the medication once the side effects resolve. The problem is that their body restarts the process of adjusting to metformin, and the GI symptoms return. These patients may never take the medicine for the 7 to 10 days and get to the point when the GI symptoms disappear. Tell your patient that if they take a “drug holiday” and skip metformin for as brief a period as 2 to 3 days, once the metformin is restarted, the diarrhea may return.

Another challenge is that, according to the Centers for Disease Control and Prevention, nearly a quarter of Americans are taking three or more prescription medications.¹ Different medications may be prescribed by different providers. Most people with diabetes have additional chronic diseases, such as high blood pressure, cholesterol, and depression, which can further complicate medication taking behaviors, or medication adherence.

Q: What are some of the benefits of streamlining medication management?

A: The benefits of streamlining medication management are myriad. With an efficient process, you can save up to 2 hours a day—or 10 hours a week—for your team. With that additional time, you can develop relationships with patients more effectively, so that you can begin to uncover medication nonadherence, which is often hidden. Achieving optimal medication-taking behavior is a collaborative process of communication and understanding between patients and their health care team.

Change is difficult, but stress to your team that streamlining medication management will save time for everybody—medical assistants, physicians, nurses, receptionists, and patients. Patients will spend less time waiting in the pharmacy. The medical assistant will get home on time. Nurses will spend less time refilling medications by phone and will be able to spend more time in direct patient care. And for the practice, the number of phone calls can diminish by 50 percent. Patient satisfaction increases and opportunity for medical errors decreases.

Team members can spend time developing relationships with patients, encouraging adherence, and building trust. That brings more joy to the practice, which is one of the goals.

Q: What are some efficient ways to streamline medication management?

A: There are several approaches health care providers can take. This includes:

• Annual prescribing. Annual prescribing is the most important way to streamline medication management, especially for patients with chronic conditions. In most states, you can refill a medication for 12 months, though some states allow refills for 15 months or 2 years. For example, you might prescribe 90x4 (90 days with 4 refills) or 30x12.

   

  With annual prescribing, you continue to see the patient as often as needed—usually every 3 months for a patient with diabetes. There will be some patients for whom annual prescribing may not work, but the vast majority of patients like this change.
  

   

  I made the change from prescribing chronic medications for 6 months (90x1) to annual prescribing (90x4), and found it was the most powerful intervention that I’ve ever experienced. I was hesitant to change because I thought patients wouldn't return for their appointment. I was using the prescription to “hold them hostage,” so to speak. It was unnecessary, and very few patients didn’t return for follow-up visits. With the hour or two a day freed up by annual prescribing, you and your staff have time to do outreach to find those patients who've missed an appointment.

   

• Synchronizing prescriptions. Synchronizing prescriptions so they all come due on the same day of the year is also critical. When prescribing medications for chronic conditions, I now write in the pharmacy notes: “Synchronize all prescriptions so they come due on the same day each year and are refilled on the same day every 3 months.” Some pharmacies will help patients synchronize their medications. A patient on six medications shouldn’t have to go to the pharmacy six different times; they should only have to go once every 3 months.
  
  
• Reducing the patient’s pill burden. To support medication adherence and reduce pill burden, providers should try to make sure patients can take all their medications once a day. Some pills may be taken on an empty stomach, while others need to be taken with food. Different medications need to be taken once, twice, or three times a day. This can be very confusing for the patient. If patients can take all of their medications once a day, this simplifies the regimen and increases adherence. Providers also should inform patients that, for generic medications, the size and color of pills may change with each refill.

   

• Encourage brown bag reviews. A brown bag review means asking the patient to bring all their medicines—even medicines from other providers, medicines they’re not taking, and over-the-counter medicines—to each visit. Medication reconciliation can begin during pre-visit planning the day before a visit or in the waiting room before a visit. Medication reconciliation involves the team, not just the health care provider.

   

• Utilizing Electronic Health Records (EHRs). In EHRs, you can add the indication to the directions on the prescription label. Indication prescribing helps patients understand what a medicine is for—lowering sugar, lowering cholesterol, lowering the blood pressure, and so on. Before a patient’s office visit, my receptionist prints out a list of the patient’s current medications from the EHR. At check-in, the receptionist gives the patient the medication list with instructions to review the list in the waiting room, which saves an enormous amount of time in the exam room. It is much easier for a patient to review medications listed on a piece of paper they are holding than try to view the computer screen over the shoulder of the provider or try to remember all their medications.

Q: How can health care professionals and practices efficiently assess a patient’s medications and medication taking behaviors?

A: Patients often hide behaviors associated with nonadherence. In addition, if a patient has admitted in the past to not taking a medication as prescribed and was admonished by their health care provider, that patient is probably going to be reluctant to share their true medication-taking behavior.

The most important thing we can do as clinicians is to create a blame-free environment. Initially, this will take time, but in the long run, it will save hours per patient. For example, if you assume a patient is taking the first- and second-line diabetes medicines you’ve prescribed, you may add another medicine that is costlier and requires pre-authorization. However, the additional medicine may be unnecessary; the problem may be that the patient isn’t taking the full or daily dose of the diabetes medicines already prescribed.

Once I began to understand this and work collaboratively with patients to find ways to improve their medication-taking behavior, I rarely need pre-authorization for an additional drug. So, instead of spending the hour getting a pre-authorization for another medication, I spend that time helping the patient improve their adherence.

Q: Where can health care providers find resources on streamlining medication management?

A: The American Medical Association (AMA) STEPSforward™ modules can help with streamlining medication management. Topics include synchronizing prescription renewal, improving medication adherence, and a team-based approach to managing diabetes.

What tips or insights can you share around streamlining medication management? Tell us below in the comments.