Q. Do you have any tips to help community pharmacists perform more effective medication reviews?A. Considering that publicly funded, community pharmacy-based medication review programs are relatively new in Canada, it is understandable that many pharmacists are unsure how to best provide this service. If you graduated from pharmacy school when I did, you were not originally trained how to perform a medication review. If you graduated more recently, but have not provided this service, you may feel equally uneasy.It is important to provide high-quality medication reviews, primarily to ensure that we optimally improve the health of our patients. Additionally, our profession may only get one chance to capitalize on this opportunity we’ve been provided. If we perform these medication reviews poorly, we may lose the service permanently, which will not be good for our patients or our profession.I would be happy to suggest some tips, based on my experience working with a primary care team and managing a Medication Assessment Centre in our pharmacy school.Tip #1: If you cannot do it well, don’t do it at allIt is possible to do more harm than good if you are not prepared to provide a high quality service. One physician told me that he shreds faxes from certain pharmacies without even reading them, because of previous experiences with poorly-performed medication reviews by these pharmacists. This is obviously not the response we are looking for.Resist the temptation to jump into this service until you are sure that you’re ready. If you need a skills upgrade, there are courses you can take to improve your competence and confidence (Tip #8). Also, ensure that you have the protected time and a private/quiet space in which to perform the reviews properly.Tip #2: Respect patient privacyMedication reviews should not be performed over the counter where patients pick up prescriptions. Use your private consultation room or take the patient to a semi-private area that is well out of earshot of other people. Older patients will also appreciate a chair, since these reviews can take 30-45 minutes.Tip #3: Pick the right patientsJust because a patient is eligible for a medication review from a billing perspective, it doesn’t necessarily mean they require the service. Use your professional judgment to identify the highest risk patients who will benefit the most from the service. Some provinces require patients to be taking only three medications to be eligible for billing. Hopefully pharmacists are not focusing on young women taking birth control and a couple of acne medications, instead of elderly patients taking 10 medications.Tip #4: Resist the urge to fix everything in one visitIt is generally impossible to address all of the drug therapy problems in a complex patient in a single visit. Considering the fees that are available for this service in most provinces, it is also difficult to justify spending more than 30 minutes per consultation.If you have a complex patient, use the initial appointment to collect a thorough history (see Tip #5) and address only the most urgent problems. Stay within your time limit and plan to address the non-urgent issues one at a time during multiple subsequent follow-up visits. Slowly develop a comprehensive care plan over time that eventually addresses all of the patient’s issues. This is how family physicians manage complex patients, and while perhaps not optimal, it is the only way to be thorough, maintain quality, and pay the bills in a fee-for-service environment.Tip #5: Get a thorough history before making recommendationsPoor quality medication reviews are often caused by pharmacists making recommendations without having the patient’s entire story. It is imperative to collect a thorough history before making any recommendations. This usually includes: medication list, problem list, detailed history of the management of each problem, allergies, social history, and adherence assessment. Often you must collect additional information after the patient interview is complete (e.g., lab and diagnostic tests, specialist consults, hospital discharge summaries). This may be time consuming, but if you skip this step you risk making uninformed recommendations that will harm your reputation—and possibly the patient.You’ll often need information from the patient’s chart. In my experience, few physicians refuse this request if you follow these rules: refrain from asking for too much information, which can be time-consuming for staff; avoid asking for information that is available elsewhere (i.e., electronic databases); explain exactly why you need the information; and include a ‘consent to release medical information’ form, signed by the patient.Tip #6: Communicate recommendations clearly and conciselyMake sure your physician letters are clear, concise and easy to read. Recommendations should stand out from the rest of the letter (perhaps using bold or underlined font) and should be followed immediately by a brief rationale for each suggestion. It is not necessary to use full, grammatically correct sentences. I use bullet points in my letters to make them easier to read. Long letters written in a narrative style can annoy physicians.Tip #7: Follow up on your recommendationsOne pharmacist told me that most of her recommendations never get implemented. This should not happen. I would estimate that more than 80% of pharmacist’s recommendations should be accepted, if you are doing this well.I always discuss my recommendations with the patient and sometimes I even provide them with a copy of the letter that will be faxed to the physician. Then I ask the patient to make a specific appointment with their physician to discuss the recommendations. This ensures that the patient plays an active role in their care and it also makes sure that the physician reads and considers your suggestions. When you fax the letter, let the physician know that the patient will be making an appointment in the near future to discuss the letter.I phone the patient a few weeks later to see what happened. Often they have lots of questions about changes that were made and you can identify any recommendations that were missed or ignored. Tip #8: Use resources for helpThere are plenty of resources to help you, so don’t try to manage this on your own. Join the Primary Care Pharmacists Specialty Network (contact the Canadian Pharmacists Association or Canadian Society of Hospital Pharmacists), which gives you access to hundreds of experienced pharmacists who can provide advice about difficult patients (or physicians!). Consider the ADAPT Education Program (www.pharmacists.ca/adapt) to expand your skills and confidence. I have also posted five videos to my YouTube channel (www.youtube.com/user/mrpharmacistderek) that provide examples of how to perform a medication review. Finally, don’t forget about your local drug information centres, which can be used to answer therapeutic questions that you cannot find quickly. These people are there to help you, so it is a shame if you do not take advantage of the service.Please continue to submit your Ethics and Issues questions to derek.jorgenson@usask.ca. Derek Jorgenson is an Assistant Professor with the College of Pharmacy and Nutrition, University of Saskatchewan and a pharmacist with the West Winds Primary Health Centre in Saskatoon.
