Questions that a structured medicines review may seek to answer are as follows:
(a) Whether a prescribed medicine is appropriately indicated for a patient
(b) Whether medicines are being prescribed at the correct dose and frequency for the indication
(c) Whether there are significant side effects with any medicine
(d) Whether there are any significant drug interactions or drug sensitivities that may be giving rise to side effects
(e) Whether what is referred to as “ polypharmacy ” (the accumulation of therapy due to inappropriate overuse of drugs or inappropriate treatment of side effects) can be reduced
Structured medicines reviews have grown in their importance during recent years, and their significance is subject to some controversy. While it has been claimed that medicines reviews can improve health outcomes, some studies have failed to demonstrate the cost-effectiveness of pharmacist-performed medicine reviews. 20
The role of the medicine review came to the fore in the UK NHS following the publication of the UK government National Service Framework for the Elderly 21 in 2001, which recommended that every patient over 70 years of age on four or more regular medicines should receive a medication review every 6 months. More recently, a structured medicines review, the medicines use review (MUR) has been introduced as a new service in the English community pharmacy contract, and is now a feature of community (retail) pharmacy in the UK, although implementation has by no means been widespread.
Hospital pharmacists have traditionally provided feedback to prescribers about appropriate use of medicines in a reactive manner; however, in the UK, comprehen- sive medicines reviews in hospitals, in a proactive manner, are still not being carried out consistently across a range of specialties and geographical locations 22 .
Since EP systems will have a clear and accurate record of the medicines prescribed for a patient, together with proactive and reactive decision support tools, EP systems have the potential to support healthcare professionals in conducting patient centred, structured medicines reviews.
An EP system might have medicine review functionality as part of the pharmacy workflow, or alternatively, as a separate module within the application. The outline functional flow for medicines reviews might be as follows:
(a) The reviewer selects the patient record for review. There is a facility for the patient’s consent to the review to be recorded.
(b) The system will then display the profile of currently prescribed medicines for that patient.
(c) The system would then guide the reviewer through a structured review process.
For each prescribed medicine on the profile, the system would advise the reviewer of any significant clinical checks (drug interactions, drug – disease interactions, sensitivities, duplicate therapies), and would direct the reviewer to
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EP Systems and Patient-Centred Medicines Reviews 107
any appropriate care plans or clinical guidelines for treatment. The likely sce- nario is that these decision support tools used in the medicines review process would be driven from the same decision support database used by the EP sys- tem for proactive decision support at the point of prescribing.
(d) For each medicine, the system would also prompt the reviewer to ask the patient relevant questions for each medication. Responses from the patient would then be entered into the system.
(e) The information from the review would then populate a predefined medicine review form, which may be a healthcare provider standard format document.
The system would prompt the reviewer with suggested recommendations to the prescriber, either to be included on the medicine review form as they stand, or to be overridden by the reviewer on the basis of their clinical experience.
(f) The completed medicine review form would then be routed to the prescriber and would be displayed for action by the prescriber when the patient’s record is next accessed.
It is anticipated that the medicine use review functionality would be operated by the reviewer on a wireless laptop PC or palm PC, so that they can conduct the review interview with the patient at their bedside on the ward, or in an outpatient clinic situation. As with medicine administration functions, a PDA would not be adequate for this application due to the small screen size.
One of the problems that has been noted in the use of medicine reviews so far, especially in the community situation, is the effective communication of medicine review information from reviewers (usually pharmacists) to prescribers. One of the advantages of an EP system facilitated medicines review process in hospitals is that it is possible for the review process to be designed and implemented in consultation with, and taking into account the needs of, both prescribers and reviewers. In this way, the process will be acceptable and relevant to all stakeholders, and is more likely to be used effectively. Furthermore, the recommendations of the medicines review are available directly to the prescriber in electronic form, thus reducing the possibility of the review not being available to the prescriber. Future, more sophisticated systems might offer functionality to link medicine review recommendations to prescribing routines. Then, if the prescriber accepts the recommendations of a review, by clicking on the relevant parts of the review form, new or amended prescriptions are automati- cally generated, which must then be authorised by the prescriber.
An EP system can therefore facilitate a closed-loop process for medicines review, whereby a review is initiated with an accurate prescribing history for a patient, and conducted in a structured and consistent manner, with inputs from the system’s decision support tools. Specific and well-defined recommendations are then made to the prescriber and, if the prescriber chooses to accept the reviewer’s recommendations, the recommendations are then implemented by the EP system in an accurate and consistent manner. The process can then be repeated with future reviews in an iterative manner (Fig. 6.2 ) .
It is clear that, due to the use of decision support tools at the point of prescribing, electronic prescribing will lead to more rational prescribing at the outset,12 which will
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obviate some of the issues that present in medicines reviews at the current time.
However, the extent to which electronic prescribing affects subsequent medicine reviews has not yet been fully elucidated. In any case, there is an important role for healthcare professionals in conducting patient-centred medicine reviews, in order to identify ongoing issues with side-effects, compliance and other aspects of phar- maceutical care (e.g. inhaler technique). The “ closed-loop ” review process, which can be supported by an EP system, will support health professionals as they develop this part of their professional practice and may improve patient outcomes relating to these reviews, thus clarifying the controversy concerning the efficacy of medi- cine reviews.