One of the pleasures of aging is to see the things that we use in our everyday lives, evolve. The Twentieth Century was perhaps the most exciting time to bear witness to, as technology evolved at a dizzying rate, changing almost every aspect of our lives. In the area of Pharmacy, we have also seen massive changes in technology, affecting almost every aspect of our job. We are even receiving electronic prescriptions from most prescribers.
Although many aspects of the practice of Pharmacy
have changed, one may argue for good or bad, there are other areas that have not. Within the last 10-15 years, we have seen the Physician’s office change as well. Since our business is so firmly linked to theirs, many changes that we have seen are a result of their evolving practices. One example might be the advent of Mid-Level practitioners which, in some instances, has enabled a sole physician to double or triple their patient visits. Some physicians decide to do this to make up for shrinking numbers of insurance companies whose reimbursements were fairly generous and whose formularies were lenient. In addition, the caliber of office personnel, in my opinion, has declined to such an extent that sometimes I have to carefully ask to speak to a “Member of the Clinical Staff”, in the hopes that I will reach the ears of at least an LVN or maybe an RN.
With the advent of more stringent formularies, an increasing number of Prior Authorizations and an increase in the average number of medications per patient, communication between Prescriber and Pharmacist
has become frustrating, overly automated, poorly audited and this, I believe has contributed to the number of medication errors. If a Pharmacy called a Doctor twice a week for something important, he/she would probably receive a little more priority than we currently do. On the other hand, if the Prescriber communicated more effectively in the first place, many “Nuisance” calls could be averted, leaving more time for important ones.
This leads me to one item that has not really changed since its conception, The “Prescription
”. What is it? What could it be? What else could one use this small piece of paper, or data for, to make life easier and safer?
Many aspects of it have changed, including its data entry and its route of transmission. However, the actual INFORMATION included on it has not changed at all. A few days ago, during a busy day in the pharmacy, I was presented with a prescription that required me to ask several questions before I could dispense it. The prescription was for a very strange dose, contained two drugs that had a level 1 interaction and was for a lady that was 95 years old. The issues were so obvious that it made me wonder what was going on in the mind of the person writing the prescription. This Doctor must have known all the "Red Flags", but did not feel it was necessary to write a few words on the prescription, indicating that he was aware of the interaction and specifying what the prescription was for. Perhaps he did not realize that we monitor these things. In this instance, one drug was Simvastatin at 80mg and the other drug could have raised its levels. The Prescriber could have written a note to the effect that “He was aware of the interaction but would monitor Liver Function and watch for Myopathy.
We routinely see many prescribers use drugs for conditions that they are not indicated for, in doses that are not approved etc. Sometimes, there is a good reason for this. In many instances, the medical community will adopt the use of a drug before the FDA has approved it. In this instance, the Prescriber should write what the medication is to be used for so that we know AND can counsel the patient properly. A male patient that comes with a prescription for Clomiphene, an Estrogen blocker, may puzzle a pharmacist who then has to call. However, if the physician wrote that it was for gynecomastia or to counteract the aromatization of Testosterone in HRT, it would be easier.
The” Prescription”, is simply a system that communicates information from a physician to a pharmacist. It is not limited to just the name, strength, amount and directions. It can include other information. As Pharmacists, we are called on to counsel patients about their medication. One of the key components of this is communicating what the medication is for, Unfortunately, in most instances, we do not have detailed information on what the patient has been diagnosed with, Most of us have become experts in looking at a profile and deducing what their diagnosis is but it is a rather "Backwards" way of doing it. An example might be a new prescription for Gabapentin. During counseling, the patient asks what the drug is for. Although it was originally intended to be used for seizure disorders, it has many other uses, some approved and some not. In this instance, a quick look at their profile might show a muscle relaxant and Voltaren gel. You deduce that the patient has a musculoskeletal complaint and that the Gabapentin is for pain. Perhaps the patient's profile showed Phenytoin, in which case it could be for seizures or, perhaps it showed an anti-viral and you assume that it is for post-herpetic pain from shingles.
Another example might be a Beta-blocker. The patient could have high blood pressure, arrhythmia, tremor or headaches. Without a drug profile to give you a clue, it is hard to know.
At this point, you might think that the best course of action is to ask the patient. However, this depends on many other variables. In elderly patients, the condition may not be communicated to the patient, or a care-giver may be picking it up. In many areas that I work, there is a large language barrier and many prescribers just hand patients the prescription with little or no information. It then falls to us to paint a picture that we can use to communicate. I just do not feel comfortable dispensing something new to the patient and telling them to take it when they do not know what it is for. Lastly, some patients will question your credibility when you ask them what they are taking the medication for. You are the pharmacist, don't you know?
interact or are inappropriate in certain ages or in medical conditions. The point is that the prescriber should indicate on the prescription as much information as possible to let the pharmacist
know that he/she appreciates that the prescription may be unusual and that it would probably initiate a phone call. Sometimes this may not be possible, especially since the patient will be able to see what is written but in many cases, a few words would really help.
On many occasions, I have worked in severely indigent areas. In some instances, I have been amazed with the knowledge of prescribers regarding Medicaid formularies and various discount plans and manufacturer assistance programs. On other occasions, I have been flabbergasted with how a prescription for a $200 drug can be written for a patient who has to walk to the pharmacy and has no money to pay. If it isn’t on Medicaid, they are simply going to pass. Sometimes, the patient does not have Medicaid, which incidentally does cover some really pointlessly expensive drugs. In these cases, when I am taking a verbal prescription, I often ask what “Plan B”, is, no pun intended. I ask them if we can use drug X if drug Y is not covered or is too expensive. Then I have some wiggle room to get them on their therapy without breaking the Piggy Bank or languishing for days while we call the office and they try to get the Prescriber to try again.
I have sometimes seen prescriptions written with “Or”, such and such a drug if this one is not covered. It just makes sense.
I know that the prescribers are busy too but too often do they leave out vital information only to leave us to deal with their office staff to try and resolve an issue, with the patient often staring us in the face.
Darius Randeria, RPh, BPharm, MRPS
VP Staffing AHS PharmStat