You are now reading Part II:
1. Challenges with the "refreshed" MedsCheck program
2. Potential improvements
3. Conclusion and what to do next
A History and Criticism of the Old and New MedsCheck Program
This is a two-part series, with Part I focused on:
You are now reading Part II:
I received a lot of email responses when we asked for your comments and opinions regarding the new Medscheck program in Ontario.
There was a lot of overlap in the sentiment, so I will try to summarize:
A few submissions were short:
Others were longer:
I also read submissions which were even more detailed, which I will try to succinctly summarize with their own quote:
This first section will lay out the major challenges that I (and others) have noticed about the new MedsCheck forms, followed by specific improvements that can (and should) be made to maintain the integrity of the MedsCheck program while reducing workload for pharmacists.
Challenge #1 - Number of Pages Printed
There are too many pages being printed. Do not confuse this with the next point regarding the tediousness of the paperwork. I am referring specifically to the physical number of pages that are being printed for every MedsCheck. Excluding the additional paperwork required to complete a MedsCheck Diabetes, there is a minimum 8 (eight) pages of forms to print out and fill out for a MedsCheck Annual.
Even if some fields can be automatically filled by a dispensary software, the forms represent a sub-optimal use of real estate space and the large number of pages represents a mental roadblock for pharmacists completing the forms.
Take for example the first page of the Pharmacists Worksheet and how much physical space is required to just print the pharmacy's contact information:
Or look below at the amount of space required to indicate the source(s) of information consulted to complete the MedsCheck:
Similarly, half a page is dedicated just to selecting the patient's characteristics that contribute to the need to conduct a MedsCheck:
Using a form's real estate efficiently will reduce some of the stress involved in filling it out.
Challenge #2 - The Forms Ask Tedious Administrative-Style Questions
The MedsCheck forms resemble a health insurance questionnaire more than a form used to organize medications and improve clinical outcomes. In fact, my real estate forms used for purchasing/selling/leasing homes can be shorter.
For example, the "Patient Information" section of the Pharmacists Worksheet asks for too many identifiers:
Why is all of this information necessary to identify the patient? Is the pharmacy expected to mail the patient a Christmas card and the postal code is very helpful to Canada Post?
For the vast majority of patients receiving this service, he or she will already be a patient of the pharmacy and their information will already be stored in the pharmacy's computer system. The necessity to re-type or re-write or re-print this information when it can be easily verbally confirmed, is confusing. Patient contact information is already located on the Personal Medication Record. Its presence on the Pharmacist Worksheet is redundant.
Similarly, on the Pharmacists Worksheet, look below at how much information is needed about the pharmacy where the MedsCheck is being done:
I have asked myself again and again why this information is needed at all to identify the pharmacy on the Pharmacists Worksheet.
No one is sending carrier pigeons to contact the pharmacy
An auditor presumably already knows the location of the pharmacy he/she is auditing. In this present time, all one needs to find a pharmacy's address is a Google search and the pharmacy's phone number, and if the internet is down, just pick up the phone and call the pharmacy directly. The full address here serves practically no purpose to anyone. Pharmacy contact information is already listed on the Personal Medication Record and so address information on the Pharmacist Worksheet is redundant.
Challenge #3 - There Are Glaring Redundancies In The Forms
As previously mentioned, pharmacists are writing the same things twice (or more).
In the Patient Acknowledgement of Professional Pharmacy Service form, this is what the "Patient Information" section looks like:
Now look at the "Patient Information" section found on the Pharmacists Worksheet:
Finally, look at the Personal Medication Record:
Seeing triple? That's because you are.
It's the same information that has to be entered three times on three separate forms. Software may be able to auto-populate this data, but it is unreasonable to expect every pharmacy to have the software to do this job. There are easier, less tedious, ways to identify a patient.
Challenge #4 - The Forms Request Some Information That Is (In My Opinion) Not Clinically Relevant
On the Pharmacists Worksheet, the form expects pharmacists to identify every single drug as a prescription medication, over-the-counter medication or natural health product:
I've stared at this section and wondered who is this information intended for? This knowledge of a drug being Rx/OTC/NHP has no inherent clinical value whatsoever.
Improvement #1 - Reduce The Number Of Pages Being Printed
I am suggesting better usage of the forms' real estate. This will be less harmful for the environment, but also represents less of a psychological roadblock for the pharmacist when fewer pages are printed out.
On the Patient Acknowledgement form and Pharmacists Worksheet, reduce the patient information to just First and Last Name and Telephone Number. Do the same for the Personal Medication Record but keep the Date of Birth and Address as an extra patient identifier. Thus, the Address only appears once, on the most important document, the Personal Medication Record. The same principle should apply to the "Pharmacy Information" section that appears in three separate forms.
Primary Care Provider information should be displayed in full on the Personal Medication Record, but can be reduced to just First Name and Last Name and Designation in the Pharmacists Worksheet.
Simplify "Sources Consulted" section from this:
Improvement #2 - Simplify The "Clinical Need For Service" Section Of The Pharmacists Worksheet
Right now it looks like this:
From a clinical perspective, if I have already written or typed notes into the box "Why are you [the pharmacist] conducting this MedsCheck service?", I should not have to re-do my work by checking off boxes right underneath my paragraph.
These characteristics serve as a good screening tool for pharmacists when considering a patient for a MedsCheck but have little to no clinical value while the MedsCheck is already being conducted.
Lastly, from an audit perspective, more than half of these characteristics are not even related to the criteria for conducting the MedsCheck anyways. These characteristics can be removed from the Pharmacists Worksheet and can be placed into an optional patient screening tool form that can be used by pharmacists, students, technicians and staff to identify patients in need of a medication review.
Improvement #3 - Add/ Move Clinically Important Sections
Add an area on the Personal Medication Record to illustrate any Drug-Related Problems (DRP's) that were resolved at the time of the MedsCheck (e.g. "pharmacist advised patient to stop magnesium tablets due to diarrhea"), or cannot be resolved at the time (e.g. "further thyroid level testing required").
Add "Other Medical Conditions" on the Personal Medication Record. While it may seem obvious that the "WHY I TAKE IT" section would include the patient's condition(s), not every medication condition is treated with a medication (e.g. mild depression treated with cognitive behavioural therapy).
Move "Lifestyle Information" section from the Pharmacists Worksheet to the Personal Medication Record. It has a much greater chance of being seen and/or addressed by other health care providers if it's on the Personal Medication Record.
Improvement #4 - Remove "Rx/OTC/NHP" Questions From Worksheet
As explained above, this section that must be completed for all medications does not provide clinical benefit and should be removed.
Improvement #5 - Properly Incentivize MedsCheck Foll0w-Up
As it stands, the MedsCheck Follow-Up service requires the exact same paperwork as the MedsCheck Annual service but at less than half the reimbursement.
I propose two solutions:
I am optimistic that there can be improvement to the MedsCheck program that provides a clinical benefit to patients while also reducing the paperwork burden of the pharmacists that complete them. While I acknowledge the problems of the past MedsCheck program, a comprehensive medication review can help a patient better understand their medications and help the pharmacist identify potential drug therapy problems.
If you agree with any of the above suggested improvements, I highly recommend that you email the Ontario Pharmacists Association and link this article. The CEO of the OPA is a Co-Chair of the Pharmacy Council. The Pharmacy Council "provides advice and recommendations to the Minister and the Executive Officer on building and sustaining a strong positive working relationship between the Government of Ontario and the pharmacy profession". The interim CEO of the OPA right now is Allan Malek (firstname.lastname@example.org).
It is important that you let your voice be heard, whether you are an OPA member or not.