Doing Medication Reviews in GP Practices

Noshi IqbalLead Pharmacist

Clinical Training & DevelopmentSeptember 2007

Medication Reviews – where did it all start?

� There is considerable published evidence on:� issues associated with medicines� benefits of medication reviews

� Paper in Am J Hosp Pharm (1992) –effects of pharmaceutical care on quality of patient care in an ambulatory-care clinic

� Many other papers from 1999, 2001, and so on about medication reviews conducted by pharmacists in GP practices (BMJ)

� NSF for Older People: all people over 75 yrs to have all meds reviewed annually, and for those taking four or more meds to have a six-monthly medication review (2001)

Key Features of ‘Room for Review’� Greater patient and carer involvement in

medication review as a route to partnership in treatment decisions and medicine taking: � Concordance

� Guide focussed on the practice of medication review in primary care with the needs of older people, & people with long term conditions particularly in mind

� There are practical issues for the NHS in relation to capacity and staff time to undertake medication review and meet NSF and other targets:� Using skills of different healthcare professionals –

pharmacists

The need for medication reviewMedication review is an important component of

medicines management:� Medication review milestone in the Older People’s NSF� Medication reviews are specifically mentioned in two

sections of the GMS contract: � a medication review is recorded in the notes in the preceding 15

months for all patients being prescribed four or more repeat medicines (standard 80%; medicines 5 indicator)

� a medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines (standard 80%; medicines 9 indicator)

� The importance of medication reviews is further highlighted in a number of areas of the GMS contract including, epilepsy, asthma, CHD and hypertension. Over 300 points are achievable by reviewing medication.

What is a Medication Review?

� ‘A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medicine-related problems and reducing waste’

Room for Review, Nov 2002

Suggested principles of a medication review� All patients should have a chance to raise

questions and highlight problems about their medicines

� Reviews should seek to improve or optimise impact of treatment for an individual patient

� The review is undertaken in a systemic way, by a competent person

� Any changes resulting from the review are agreed with the patient

� The review is documented in the patient’s notes

� The impact of any change is monitored

Why Medication Reviews are important� Providing patients general information

about their medical condition and treatment

� How to take medicines properly� Medication options (alternatives)� Patients personal beliefs and preferences

(helps concordance)� Concerns about medication discussed

Potential target patient groups� At risk of medicines – related problems

� Taking 4 or more medicines every day� Recently discharged from hospital with complex meds (e.g. TB

drugs)� Receiving medicines from more than once source (hospital clinic

& GP e.g. dermatology)� Significant changes to medication regimen in past 3 months� Taking medicines requiring special monitoring (e.g. DMARDs,

warfarin), wide range of side effects (e.g. NSAIDs), or narrow therapeutic range (e.g. digoxin)

� Where non-compliance is suspected or known to be a problem� Special needs

� People with learning difficulties / communication difficulties� Older people / residents in care homes� Physical problems e.g. arthritis, inability to swallow� Mental states e.g. confusion, depression, anxiety� Literacy or language difficulties / ethnic groups

What patients want from medication reviews

� General information about the medical condition & treatment� Confirmation of ‘what medication are on & why’

� How to take pills properly� What to take & how much

� Medication options � Alternative formulations to aid compliance

� Personal beliefs & preferences� Concerns about medication

� Adverse drug effects

Levels of Medication Review

This is what we should read code as XaloW –‘medication review done by pharmacist’

This is what we should read code ‘medication review done’ (‘seen by pharmacist’ code can also be added here)

Level 1 – Prescription ReviewCommunity MURs� Reviews done without access

to the patient’s clinical notes and do not often include a review of the full repeat prescription (e.g. go by what the patient or pharmacy PMR says)

� Compliance issues, dose & pack optimisation, resolving quantity problems & generic switches can be dealt with at this level

� MURs are an integral part of the Pharmacy Contract – each MUR attracts a £25 fee (paid by PCT to the Pharmacy)

Level 2 – Treatment Review‘Medication review done by pharmacist’� These reviews are done by pharmacists (or GPs) but

without the patient� Medicines can be reviewed in the context of the patient’s

medical condition, history & treatment� Review relies on formal record rather than patient’s own

account of the medicines they take� Dose adjustments, removal of unwanted items, effect of

medicines on pathology (e.g. DMARDs & FBC, ACEIs & renal function), adverse effects, reducing likelihood of drug interactions

� Optimising medicines use (changing dosage forms for residents with swallowing difficulties), checking compliance, minimising waste by calculating quantity actually required per prescription interval

� Identify patients who need a face to face review

Level 3 – Clinical Medication Review

Face to face with patient� At this level medicines will be examined in the context of the

patient’s condition & the way they live their lives – listening to the patient’s views & beliefs about their medicines, understanding their medicine taking behaviour, & taking full account of their preferences in any decisions about treatment

� Objective evidence e.g. BP; peak flow done� A check to ensure the patient understands how to take

medications (inc. storage conditions)� Requirements for any additional support (e.g. dosettes,

repeat dispensing, collection services by local pharmacy)� The review should conclude with a summary of the

agreement with the patient about the treatment & an explanation of what will happen next (e.g. date of next review)

Recording Medication Reviews� Pharmacists are well recognised as

being experts in pharmaceutical knowledge and communication skills

� Conducting medication reviews (with or without patients) is an important opportunity for pharmacists to establish the concept of partnership between patients & health professionals in relation to medicines

� It is imperative that this valuable support that we provide to our practices gets recorded & fed back to the PCT

� We all have a responsibility to record this information on our practice timesheets & emailed to Hab before the end of each week so that data can be recorded

Using SystmOne to do Medication Reviews

Medication Reviews in SystmOne

� Mostly done when ‘reauthorising’ medication for another 6 months

� The read code ‘XaloW’ should be used� Clinical reports can be created for patients

on ‘x’ number of medicines which can be used to do medication reviews on patients records when have time after other daily duties

Reauthorising medication as part of a Medication Review� Before reauthorising medication for

another six months, the following sections must be viewed in the patients record:�Quick Glance�Summary & Family History�New Journal�Recent issues & repeat template�Communications�Pathology

Quick Glance Note the last time BP, BMI & smoking status was checked, check to see if information is present / absence here

Check if patient is allergic to any medication

See if there are any important recalls e.g. diabetes review

Check the last three consultations in the patients record

Summary & Family History

Check the summary of the patients medical conditions (listed in date order here)

Check for any relevant family history

New JournalBy clicking on the ‘custom’ yellow cup, the new journal window can be maximised

The highlighted section above is expanded providing more information such as blood results, letters & prescriptions issued

Recent issues Check if any important medication has been issued as an acute – some drugs may be being titrated

By changing the option to summary, a list of every drug ever issued appears

By right clicking on a drug and selecting issue history, a detailed record appears for that drug

Repeat template

Clicking on this bar will arrange drugs in alphabetical order

The number of repeat medication the patient is on

The date when the medication was last issued

The date when a medication review due

Number of issues left

Date when next supply of medication due

Issue duration

Frequency of issues

Date medication started

Person authorising medication

Communications Look through recent letters to see if there has been any change in medication, or medical condition

Pathology

This screen gives info on the management of the results i.e. whether the patient needs to be informed

Expanding this + sign gives an option to view trends in the pathology

Results in pink are abnormal; green are OK

Clicking the BP button brings up a graph with recent BP readings

Clicking the data tab will list all the BP readings with dates ever done

Reauthorising MedicinesRight click each drug turn by turn and click on ‘reauthorise / restart’

Ensure that all details entered on this page e.g. issue duration, review date quantity of drug all match with other drugs – ‘synchronise medicines

BEFORE

AFTER

Read coding� After all the medication have been reauthorised, ensure

that each medication has a correct read code assigned to it. If a read code is missing, check the diagnosis box, new journal and communications sections to find the appropriate read code or the date for the diagnosis (which can then be read coded)

� Sometimes may have to look in paper records tofind the diagnosis to read code

Diagnosis box

Read codingClicking here will

bring ‘link diagnosis to repeat template’

box

Clicking here will bring ‘record new coded entry’ box

Consultation� An entry needs to be made

in the consultation� Some practices will have

templates where this entry can be made

� After the consultation is written, this needs to be read coded ‘medication review done by pharmacist’ or XaloW

If a read code is not known by value, free typing the word will

bring a browser up

The finished record The finished entry in the new journal

Putting Medication Review into practice

� Select patients via Clinical Reporting (ask Hab to show you)

� Discuss with GP which patients need to be seen (complex drug treatments, chronic disease patients, etc)

� Develop good working relationships with the local community pharmacists who can check compliance via MURs if time is limited to see patients (e.g. if do surgery half day)

Where to obtain further information

� National Prescribing Centre website www.npc.co.uk

� CPPE training packs on Medication Review

� Room for Review (pdf version available –ask Noshi)