Refill alerts on a medication list - help reduce unnecessary work

What if the doctor and patient took care of all the necessary work at a visit for managing chronic disease?

Disclosure: I hate getting calls and faxes for refill requests. It seems totally avoidable. I’m not winning this battle.

It’s fairly common for primary care physician offices to get dozens of phone calls or faxes a week about medication refills.

It might be about a patient I just saw last week.
• These calls take time and money: mine and the staff.
• This is unreimbursed work.
• I get whiney about it.

If there is a discrepancy between the pharmacy (or patient) request and my records, it gets a lot worse.

Then calls go back and forth, trying to reconcile the difference, and the outcome is not always satisfactory.

So, what can we do about it?

How about adding a little alert to the medication list?

• Don’t make me think (that is, don’t make me “sort by last refill date”, figure out the interval since last refill, count the meds and remember their names), just show me!
• Dark red (or gray) could mean “due for refill in <3 months”.
• Pink (or lighter gray) could mean “due for refill in <6 months”.
• These intervals (3 and 6 months) match the numbers for “frequency of diabetic lab tests” and “limit on controlled substance refills”.

With this information right in my face, it would be easy to see if, and which, medications need to be refilled today. That avoids an extra call for the patient, an extra fax/call or two for my staff, and a headache for me.

That makes me happy!

(special thanks for the idea to Phil Vinyard at University Physicians Family Medicine Clinics)

How should drug interaction warning screens look?

Most clinicians I know suffer from "alert fatigue". I don't mean they feel tired from too much caffeine.

I mean, they are tired of EHR software crying wolf with too many drug interaction warnings. Embattled users simply dismiss all drug interaction warnings without reading them. Mild or theoretical interactions should be suppressable by individual user preference, as a default setting.

This is a significant patient safety issue.

If I am relying on my software to warn me about serious drug interactions, then the warnings about milder or dubious interactions are annoying, distracting false alarms. I need to be aware of serious interactions, so I can adjust therapy.

Here's another problem: I get warned that drug A interacts with drug B. I dismiss the warning. Then I immediately get warned that drug B interacts with drug A. I know that!

Worse yet, if I then change the dose of drug A, I get warned all over again. We need smarter systems now, geared to what fallable, imperfect, tired human users need, and geared to keeping patients safe.

Here is a modest proposal of a way to display drug interactions.

Note that the key findings are in the middle, the drug names are prominent, the severity level is great big number, and user pref settings are right there.

Are you still taking Prozac?

Reviewing the medication list is a routine part of the visit for patients with chronic visits, or those needing refills. This is often not such a simple task. The tools we have are flawed in the world of EMR's. They improve on the written list by making changes dynamic and instantaneous. They make doing refills much simpler.

Many med list modules are limited and assume a fairly black and white reality: The doctor ordered it. You took it. You got better.

The real world is more chaotic and variable. We need systems that allow adding qualifiers, to cover circumstances like these:

1. I cut it back to one a day, so I wouldn’t run out before this appointment
2. The pharmacy switched me to the one covered by my insurance
3. They stopped that when I left the hospital. Should I still be taking it?
4. I'm not taking it yet. I plan to get that medicine this Friday, when I get paid.
5. I went to get it, and the copay was $75! So I didn't get it.

So the modern medicine list needs to accommodate the vagaries of the real world. Here are some of the features needed in an ideal EMR medication module:

The basics (you can skip over this section!):
1. name of drug (generic and brand name)
2. dosage and form
3. when and how taken (in patient-friendly language, and large-enough font for age)
4. purpose (the reason, not the ICD-9 description)
5. start and stop dates
6. quantities
7. number of refills
8. refill dates
9. who prescribed it

Other predictable features that are needed, but rarely present today:
1. Danger signs (e.g. symptoms to report promptly)
2. Monitoring required (e.g. periodic lab)
   
3. Notes about side-effects, dose adjustments, food-drug or drug-drug interactions to be alert for.
   

Weird events that are harder to describe:
1. I ran out ____ days/weeks/months ago.
2. I was about to run out, so I reduced the dose by ____% about ____ days/weeks/months ago.
3. I thought it was causing me problems/wasn't working, so I reduced/increased the dose.
4. I forget a lot of doses, especially the evening ones.
5. I ran out of the Nexium, so your nurse gave me some Prevacid samples, and my sister had some left-over Protonix she gave me for a couple weeks.

Can you think of other weird events to consider in the ideal med list design?

Notes:
For a model med list, see: Med List (a Microsoft Word document) from the Massachusetts Coalition for the Prevention of Medical Errors. It includes a number of helpful features to promote safety and clear communication.