Prescription renewals have become so ingrained in office-based practices that many physicians may overlook the opportunity to streamline the process to save time and increase efficiency. In fact, most practices renew prescriptions for an arbitrary number of refills, generating unnecessary work for physicians and their staff.
In an episode of the “AMA Moving Medicine” podcast, AMA Chief Experience Officer Todd Unger is joined by Marie T. Brown, MD, a geriatric and internal medicine specialist at Rush University Medical Center, in Chicago, who talks about synchronized prescription renewal and how providing 12-month prescriptions during annual visits can save time for both physicians and patients.
Unger: Dr. Brown, can you tell us a little bit about yourself?
Dr. Brown: Sure, and thank you for inviting me. I'm an internist and geriatrician here in Chicago, and I have had the honor and privilege of taking care of patients over 30 years, some are still patients of mine and I've had, again, the opportunity to take care of them and their family for over 25 years. I finished training at Rush University, and then began work at an FQHC, a Federally-Qualified Health Center, called Mile Square.
After that, my colleague, Dr. Janet Forbes, and I, moved down the bus line and opened a small private practice in Oak Park, Illinois, where we continued to serve the patients in the suburbs as well as on the Near West Side of Chicago. About five years ago, I joined the Rush University faculty, where I'm now an associate professor. So, it's been very interesting to provide care in three different settings. The one constant is that I've had the opportunity to care for the same patients in each of those settings, and that brings me great joy.
Unger: Well, we're so happy to have you here today, and to talk about annual synchronized prescription renewal. So, let's start off with a basic question. What is it?
Dr. Brown: Great question, and actually Dr. Christine Sinsky began doing this and discussed it probably almost 10 years ago. It is taking your chronic medications that patients would be on lifelong, and picking one visit—perhaps their annual physical, or a time of the year, maybe near their birthday—when you fill all of their prescriptions for 90 days, with four refills. So, you are filling the prescriptions once, all at the same time, and then not again for at least a year. Now, duration of prescriptions varies by state. Some states are 12 months, some are 15, some are 18, and a few states are two years.
Unger: What are the advantages of annual synchronized prescription renewal on your practice?
Dr. Brown: Once you begin doing annual synchronized prescription renewal—perhaps you would start tomorrow after listening to this podcast—you won't see the benefit for six months. But I've had the opportunity to share this with many clinics, and, in fact, six months from tomorrow, if you start doing it tomorrow, in six months you will see half the number of refills coming in. So, think about the number of phone calls that go down by half, the number of faxes coming in from the pharmacy, the number of patients calling, and your inbox goes down by about 50–90%, we've seen. And the work of the physician is decreased by an hour a day, and perhaps by a nurse can be two hours a day in a busy clinic.
Now, you continue to see the patient as often as you need to. You may see the patient every month, you may see the patient every three months, but you're only spending the time and the enormous number of clicks in the EHR and e-prescribing—you're only doing that once a year.
So, during that one visit, it's an opportunity to look at what you can synchronize, so they all come due on the same day. I actually write a note, in the note to pharmacy free text, requesting that the pharmacist cancel all prior prescriptions and synchronize so they all come due on the same day.
Some of the retail pharmacies are recognizing that synchronizing the medicines is very important—that, for patients to come in three different times during a month because their medicines come due on three different days, is not very patient-centered and is a negative effect on adherence. Any obstacle we can remove is going to improve adherence.
Once you are more efficient with your time, the patients who are likely to miss an appointment are generally patients who are struggling with other problems as well—maybe mental illness, maybe transportation, maybe housing insecurity.
So, the time for that nurse or your team members—rather than responding to refills for patients who are adherent, and talking to every retail pharmacy across the city—that person's excellent clinical skills and communication skills are better served reaching out to those few patients who might have missed an appointment—address some of their other problems, which are usually present, and bring them into the office. We don't want to punish our whole panel of patients because a few patients would miss their appointment. …
I used to give a medicine for six months because I wanted that patient to come back for a lab test. A typical example is a diuretic. If they don't come back for a lab test, I would worry that their electrolytes would be abnormal and hypokalemia.
However, I have a way to now have the time to find out if a patient misses the appointment, and if I'm really concerned, I might fill four of their medicines and maybe not their diuretic, to make sure that they come back. But the risk there is that they're going to take their other medicines, but they're just not going to take their diuretic for a month or two and then their blood pressure will be out of control.
So that's the advantage for the office. You can save an hour or two a day. The person on call and off-hours is not responding in an emergency fashion to somebody who's at a retail pharmacy just looking for a refill, so it's really nice for your colleagues who cover for you, and for you when you're on call. The advantage for the patient is that they don't have to sit at the retail pharmacist, waiting for a call back from your office. You're not interrupted during the routine day to do something that is not an emergency, does not need your skill set and takes you away from thinking about the patient in front of you.
Nurses and medical assistants appreciate it, again, because they're not taking phone calls from an angry pharmacist or an angry patient waiting for a refill. And the patients appreciate it because they don't have to worry about whether they're going to have refills or not. And once they get into the habit of once a year, they're very appreciative and, if you can get them synchronized, which takes work and working with our pharmacists, they're saving three or four visits a month, and they appreciate that time saving. Or, if they're the caregiver, they're not leaving work to pick up a refill numerous times over the course of 90 days, but rather only once.
Unger: Can you really save that much time each day? One to two hours sounds like a lot.
Dr. Brown: You can, and I really did it myself. But think about a hypothetical scenario where the practice has a thousand patients with chronic illness. On average, five medications per patient. If you think about it, each patient makes two calls per prescription, per year, where the pharmacy calls or the relative calls, and that interrupts the flow of the office. The result of that one minute or two minutes can be 300 hours of physician and staff time spent on prescription renewals per year, and that can be cut in half.
When I talk to my colleagues about this, we are trained as physicians to always think of the exception. If a patient comes in with a headache, we're trained to think the worst, and we do a history and a physical until we make sure it isn't a brain tumor or a stroke or a subarachnoid hemorrhage. When somebody comes in with chest pain, we make sure they're not having a heart attack or a dissecting thoracic aneurysm. We do a history and a physical to make sure it's not.
When you think about these sort of efficiency approaches, you want to take off your doctor hat and put on your industrial engineering hat, the efficiency expert hat. Often, a physician will share with me that it won't work for this patient or that patient, and we think of those challenging patients who will not come back for their appointment or have other issues.
And I say to that physician, "That's correct, and I don't do this for absolutely everyone, but if you do it for 80% of your patients, instead of saving two hours a day, you'd only save an hour and 45 minutes," and that makes everybody smile. It doesn't work for everybody, and you might want to phase it in so that you do it for medicines that don't need monitoring, until everybody gets comfortable with that.
There's one organization with eight clinics that began doing this and taking care of all the refills in one place, and the messages not going directly to the physician or the provider for refills. In one week, they found that there were 500 prescriptions that they were able to turn from three months or six months to one year, and 130 prescriptions that were automatically sent by the pharmacist unnecessarily because the prescription had already been sent a few weeks prior. And this is another tremendous opportunity where we can work with our pharmacists to make sure we don't have these automated calls and connect the prescription to the prior prescription so that unnecessary, wasteful work is not done at the office.
Unger: How do you get started with this process? How do you roll it out?
Dr. Brown: Well, the first thing that a physician could do, if they're going to do this themselves, is start tomorrow. A colleague of mine started after he heard me talk about this at the organization, and sure enough, six months later, he found that he was going home 30 minutes earlier and his inbox was empty. They brought it to their organization, across the organization, the pharmacy and therapeutics committee, and discussed it. Got the buy-in from the nursing staff, the pharmacy staff, and decided which medicines were appropriate and everybody felt comfortable doing in a year's supply, and which ones … were not. …
And then they put some standing orders in place. So, if the patient hadn't been seen in six months or a year, they weren't eligible for a full year. But then there was a smaller number of people that they would reach out to, to make sure that that patient came in.
You develop standing orders, education amongst your organization. Decide and listen to the people who do the refills, because they're going to come up with some very good perspectives about where there might be problems or exceptions that we want to pay attention to.
So, it can be rolled out yourself, tomorrow, or you can begin to have a conversation across your organization through pharmacy and therapeutics, or amongst your colleagues, and develop some standing orders that are pretty simple, that your colleagues are comfortable with. You'll have to wait six months, but I expect that you'll be very happy with the time saved. …
Unger: You mentioned reaching out to other colleagues. How do you inform the pharmacies about this change that you're making?
Dr. Brown: I e-prescribe all of our medicines, and there is a free-text box that says, "Note to pharmacy." And during that annual physical or that annual comprehensive review, I will put a note in there that says, "Please synchronize all medicines so they come due at the same day, every 90 days, for one year. Cancel all prior Rxs." I'm hoping that will communicate what we're trying to accomplish here. Some physicians write, "Do not fill until patient calls," or, "Place on hold."
I think, since pharmacies and pharmacists vary around the country and they're an intricate part of improving medication adherence and unburdening the patient, a call to your top three local pharmacies that you use and ask them, "What would you like me to put?" And hopefully, it's just a few keystrokes, so that they understand what the goal is.
In e-prescribing, I use autocorrect, so that I actually have this message set up, so I just write S-Y-N, the first three letters of synchronize, and the whole message comes out. And that saves me a tremendous amount of time, because we couldn't possibly write this free text for every single prescription, for every single patient. That would not be a good use of our time.
Unger: What if a patient only requests a renewal for one medication?
Dr. Brown: Well, unfortunately, that is what most patients do. And then the next time they see you, they will ask for a refill for another prescription. Or, in between, they will call because they've run out of a third medication. I take that opportunity, if I have time that day, if I'm going to refill one, I'm going to share with the patient, "Let's try to get these all coming due, so you only have to go to the pharmacy once every 90 days, and I'm going to refill them for a whole year."
So, if you have time, you can take that opportunity to get them all synchronized. Again, communicating that to the pharmacist and canceling all prior prescriptions takes some effort, and a conversation with your local pharmacist is probably the best way to approach it. But, if the patient understands what you're trying to do, they're very appreciative and they want the prescription for a whole year, and they only want to go to the pharmacy once every 90 days.
Unger: Do you have any final thoughts you would like to share?
Dr. Brown: I was surprised about two things. One, I had been using the six-month prescription as a way of holding the patient hostage, forcing the patient to come in to see me. I was surprised that that was not necessary. I saved so much time, truly an hour to two hours a day, that if a patient missed an appointment, we had plenty of time to have the team reach out to them and find out what else was going on.
I also was surprised that the patients appreciated it so much. Patients appreciated that they had half the hassle, and it improved adherence and was a very efficient way to get back to what I want to do. It was a very efficient way and allowed us to get back to what we went into medicine to do, which was be challenged by new patients' concerns, develop a differential diagnosis or build that trusting relationship.