Asynchronous Prescribing: A Primary Care Divorce and the Basis for Medication Irreconciliation

The Disease Management Care Blog welcomes this essay from a physician colleague.

When I first started in practice, face-to-face “medication reconciliation” was built into my drug prescribing.  The prescriptions were written by hand at the time of the clinic visit and each one, including the dosing and their purpose, were discussed with the patient.  New prescriptions by physician-specialists were noted during the time of the initial history taking, meds that the patient stopped on their own and the reasons why were reviewed, intolerances to recently prescribed meds were discussed, allergies were updated, and side effects were explained.  Prescriptions were written for one month supplies and enough refills were given until the next encounter.  They were then handed to the patient.  If there was a problem, I could count on my patient to notify me right away.

As time went on, things changed.  Thanks to how many pharmacy benefits plans are run, mail order prescriptions are now typically given for ninety days with four refills.  I think of this as medication irreconciliation.

While ninety days may look like a good idea, for the primary care physician, this was the beginning of a divorce between medication prescribing and the clinic visit.  Face-to-face medication reconciliation is no longer synchronized with the doctor visit.  Since this now asynchronous disconnect allows patients to skip appointments and continue medications, many physicians no longer

1) perform frequent medication reconciliations and

2) use the reconciliation process to monitor their patients.  

This problem is greatest for those diseases that require more than annual visits.  Instead of using the medication reconciliation process to follow complex hypertensive, hypercholesterolemic or diabetic patients every three months, one-on-one appointments, because of skipped appointments, are now happening annually.   This has made it difficult to schedule other appropriate preventive interventions such as testing, preventive screening and immunizations such as flu shots and other timely care.  

This was the reason that primary care often wrote prescriptions that were only good until the next encounter.  As Reaganites like to quote “Trust and Verify”.

It doesn't stop there.  What has finalized the divorce between the drug and the visit is the new auto refill program being used by many pharmacies (examples are here and here).

Thanks to auto refill, the patient and physician are even more disconnected with each other.  Under this system, expired refills prompt automatic refills requests that are not patient or physician initiated.  I have found in my practice that these auto refills are often for discontinued medications.  What’s worse, I have also received refill requests from pharmacy benefit managers that have apparently opened expanded operations in the afterworld for deceased patients. Humorously, one note attached for the deceased patient’s request stated that he was expecting to pick it up at 11 am on Thursday.

I am not the only one who has noticed this (here and here).

This divorce between face-to-face visits with my patients and medication prescribing has made the problem of “medication irreconcilation” even worse. It’s now necessary to reconcile each and every prescription asynchronous with the office encounter.  This may be efficient for the pharmacy providers, but it is disastrous for primary care and dangerous for patients.  For many primary care physicians, the best time to reconcile medications is when all parties are present.  During a traditional office visit, patient labs and tests are reviewed, vital signs are taken, the history is updated and an exam is performed.  That’s the perfect time when all the appropriate medications for an appropriate length of time should be prescribed.

Thanks to the divorce, accurate reconciliation has become at times impossible.  Physicians can’t use clinic visits to query their patients about new developments in their care or new prescriptions by other providers.  New doses can’t be reviewed, compliance can’t be discussed and patient concerns can’t be addressed. 

This divorce between prescribing and seeing the patient has become grounds for irreconcilable differences.  It sure was easier when it was the other way around.