Before I began my pharmacy informatics career, I worked as a clinical pharmacist conducting medication therapy management drug reviews for senior patients. I recall vividly how almost every one of them would express some level of confusion regarding their current medication regimen. One patient even described it as a puzzle she had to solve several times a day.
The fact is, for patients with accompanying diseases—diabetes and hypertension, for instance—medication management is complex.
Senior patients rarely arrive at their doctor’s office or pharmacy with just one compartmentalized illness that can be treated with one medication 1, 2. This results in a number of medication bottles—a major contributing factor to the puzzle patients must solve. Some bottles are full, some empty, and some are partially full. For many patients, correctly discerning between medications they are meant to take and medications the prescriber intended to discontinue proves to be difficult.
Some patients told me about their own creative solutions, or self-implemented medication management “systems.” These ranged from marking an “X” on the bottle to label a discontinued medication, to using different color highlighters to indicate “currently taking,” “sometimes taking,” or “not taking,” to merely tearing pieces off the label. The rest reported relying solely on their memory. In even more tenuous circumstances, some patients were causally told just once at the end of a routine visit to discontinue a medication. In scenarios like these that rely on the patient’s memory, the potential for that patient to inadvertently continue taking a medication that their physician intended to discontinue is very real and very concerning.
As part of American Pharmacists Month, it’s important to take a moment and acknowledge the essential role pharmacists play in managing a patient’s drug therapy, and serve as a point of contact to help patients make sense of these complexities. But sometimes, the puzzle is quite challenging for pharmacists to solve as well. While the pharmacist has more information and can leverage their pharmacologic and therapeutic background to interrogate medication dispensing histories to understand the patient’s current regimen, key pieces of the puzzle may still be missing or unclear.
So, where are all of the pieces to the puzzle? And in a digitized society, why is it even a puzzle in the first place? Can we deliver better information to pharmacists—we call it actionable intelligence—to improve prescription accuracy and patient safety?
It starts with the provider’s decision to stop or change a therapy. He or she needs to declare this intent clearly and conspicuously to communicate to all other stakeholders involved in the patient’s care, including the pharmacist who may be miles away. The significance of this step is critical. The entire healthcare team and patient need to be exactly aligned and clear on when a medication is to be stopped or changed. If this step is missed or misinterpreted, the picture starts to become fragmented into separate puzzle pieces.
Luckily, in the age of health information technology and e-prescribing, tools exist today to support and refine this process and facilitate direct and precise communication.
The NCPDP SCRIPT CancelRx transaction is currently available for EHR and pharmacy technology vendors to implement. The CancelRx transaction communicates an electronic message to the pharmacy when the provider discontinues a medication in the EHR system. Providers can enter notes in that message to indicate why the medication was discontinued, giving the pharmacist more information to correctly complete the puzzle.
For far too long, this critical functionality has been severely underutilized. In light of this fact, Surescripts, the nation’s most trusted and capable health information network, has led the healthcare industry in promoting CancelRx, and identified its increased implementation as one of our Critical Performance Improvement (CPI) initiatives.
As a result, CancelRx utilization has skyrocketed this year, increasing almost 200% over 2016.
EHR vendors are rapidly enabling this functionality, driven in part by Meaningful Use requirements. Pharmacy technology vendors are also picking up their pace in response. However, we need all sides to commit to this initiative, because it has the potential to reduce adverse drug events related to patients taking unnecessary medications, including many that are high-risk or “high-alert.” In fact, an analysis of cancelled medications via the CancelRx transaction during August 2017 revealed that 8% were for medications on the Institute for Safe Medication Practices’ (ISMP) List of High-Alert Medications in Community/Ambulatory Healthcare. Of these medications, most were of opioids (35%), oral hypoglycemic agents (32%) and insulins (17%).
Because of the increased adoption of the CancelRx transaction along with other quality improvement measures, this year, we are on track to eliminate 50 million possible instances where a pharmacists needs to seek clarification in order to accurately fill a prescription. I am excited by these results, along with the many other opportunities for our industry to develop and evolve. I’m hopeful that this progress predicts the industrywide adoption of other high-value functionalities and transactions, including Structured & Codified Sig, RxChange and electronic prior authorization.
As an informatics clinician reflecting on this growing momentum, and in talking with industry leaders about the value of the CancelRx transaction, I am encouraged by knowing that this technology exists. CancelRx continues to solve the puzzle, enhance processes and workflows, and ultimately improve patient care.