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One critical, yet inordinately annoying part of outpatient care is the task of refilling medications.

Through the course of our day, countless requests for refills come in through telephone calls to the practice, as well as portal messages through the electronic medical record. How many hours a day do you think we each spend refilling chronic medications for our patients? And how many hours do you think it takes our patients to get their refills from their primary care doctor or their specialist? There has to be a better way.

Informing the Patients

I think that part of the duty of prescribing medications for patients should come with a detailed session with them about how to get their medications refilled at our practice, what the policies are, what we pledge to do, what they will agree to abide by, and how to make sure this process goes smoothly for all of those involved.

One of the easiest ways to get refills is by using the patient portal, where the patient can select a medication on their list, and send a refill encounter request to the prescriber who sent it in last. This is often problematic, as sometimes we send in a refill for coverage for one of our partners who is out that day, and then the next refill will come to us. Similarly, sometimes our patients can't reach one of their specialists, and will request one of their medicines from our practice, and we sometimes refill as a courtesy. This opens us up for future refill requests from them the next time they need it.

Just recently, we had a bad clinical outcome occur where a patient had been routinely requesting and receiving refills from our practice for a medicine that was not prescribed by us originally. In addition, the patient had not been coming in, and had been receiving other medications that interacted with the one that they were requesting, from some outside providers.

Looking back at the original refill request when this all got started, the patient had been advised that they would receive a 1-month supply of this medicine and then were told that after that they needed to receive it from the original prescriber, a subspecialist who was managing this condition. Unfortunately, due to people being overwhelmed by the number of messages they receive, the next month the same request came in, and someone looked back and saw that the patient had received it the month before, and so unwittingly just continued to refill it -- on and on over 2 years.

This ended up being bad for the patient, and is a bad way to practice medicine, so we need to make sure that the right checks and balances are in place so that no matter what, refilling medicines does not harm our patients. I think there should probably be more definitive ownership of medications within the electronic record, so that all of those looking can quickly and easily know who the prescriber is, and what their intention about refills is going to be moving forward.

Built-In Checklists

One of the features that I do love in our electronic medical record that goes along with medication refills is a series of checks that the system does, to ensure that safe prescribing, as much as possible, is allowed with really just a click of a button. For instance, for thyroid medication, the system will check to see that a patient has had a normal TSH in the lab within past few months, has had an appointment with the provider in the past year, and/or has an upcoming scheduled appointment.

Another example is ACE-inhibitors, which includes checks for normal creatinine and normal potassium done recently in our lab, a normal blood pressure, and previous and future appointments with the practice scheduled. If all of these conditions are met, I don't need to go digging around in the chart to make sure I want to refill it, I'm happy to do it pretty much with the click of a button in most situations.

I would love to see even more of these rules built for medication refills, so that with a quick glance each provider can see that it's safe to refill a medication based on their practice, and once medication-specific or condition-specific rules have been satisfied. We need to do a better job of labeling medicines as one-time prescriptions, such as for pain medicines for an acute injury or oral steroids for an asthma exacerbation, or whether medications are chronic and should be refilled routinely when requested by patients when certain criteria are met.

And the next generation could be clinical practice guidelines and protocols, that can send patients down dose escalation or de-escalation pathways, if they answer that they have been compliant with their medications and their blood pressure has consistently been below goal to increase a blood pressure medication dose, or if lipids are not at goal, to recommend increasing the statin dose. This all makes sense, and this is how we want to be able to safely prescribe medicines for our patients.

Refining the Rules

As we've started to build out a new off-site call center for our practice, that will combine with a number of other practices, we need to develop and refine these rules so that they can work equally well with a telephone operator who answers a patient's request for refills when they aren't active on the portal. First off, they should offer everybody the opportunity to enroll in the portal, and should help them do so if they can.

One of our least favorite messages is "Refill all medicines." Oftentimes, a quick look through the chart would see that the patient has refills on many (if not all) of their medicines, and that many medicines are not prescribed by our practice. Specific details should be gotten from the patient about what medicines they need.

I got a message just the other day: "Steroids. To pharmacy." Huh? Not on chronic steroids. No reason to need steroids. Which pharmacy?

If a patient hasn't had an appointment at our practice in a timely fashion, they should be notified that a brief interim refill amount may be sent to the pharmacy at the discretion of the provider, and further refills would be contingent on coming in for an actual appointment with their primary care provider for appropriate physical exam, monitoring, and blood tests as needed.

We want to make this easy for patients, easy for providers, and as safe as possible, with as little margin for error as we can comfortably create. We need to build a system where patients can reach us during the day and quickly and easily get the medicines they need, so they don't have to call the answering service at 1:30 in the morning requesting a refill of their allergy medications.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 番茄社区, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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