The Refill Encounter: Managing Medications the Modern Way

\r\nHe has published in several medical journals, including recent research on use disparities in telehealth visits & effective community outreach interventions to encourage COVID vaccination. His weekly MedPage Today column, \u201cBuilding the Patient-Centered Medical Home,\u201d focuses on improving patient care.<\/p>“,”affiliation”:””,”credential”:”MD”,”url_identifier”:”fp4223″,”avatar_url”:”https:\/\/assets.medpagetoday.net\/media\/images\/author\/Pelzman_330px.png”,”avatar_alt_text”:”Fred Pelzman”,”twitter”:””,”links”:null,”has_author_page”:1,”byline”:”Contributing Writer, MedPage Today”,”full_name”:”Fred Pelzman”,”title”:”Contributing Writer, MedPage Today, “,”url”:”https:\/\/www.medpagetoday.com\/people\/fp4223\/fred-pelzman”,”bluesky”:””}]” categoryimage=”https://assets.medpagetoday.net/media/images/articles/Pelzman_icon_120px.png” categoryimagealt=”Building the Patient-Centered Medical Home”/>

I vividly remember my first day in outpatient clinic as an intern more than 30 years ago, when my patient told me they needed refills for all their medications. In his incredibly thick paper chart was a list of medications, handwritten, some partially crossed out, others duplicated. We went through them and figured out what he was actually taking and needed. There were also a couple new medications he needed based on his visit that day.

I presented the patient’s case to the supervising attending and told her about the medications. She handed me a thick prescription pad and said, “Fill them all out and bring them back to me to sign.” It took me a couple tries since I’d never written a prescription before, but eventually they were all ready. I then gave them to the patient.

This whole process added another 15-20 minutes to our visit. So, by the end of the day, that very first day, I was several hours behind, and don’t think I’ve ever caught up.

I remember another patient I saw in clinic during my residency who came to see us about overwhelming fatigue. He brought in all his prescription bottles, one of which had been filled at the pharmacy as diphenhydramine (Benadryl) 50 mg twice a day. But the handwritten scrawled prescription he had gotten, which we recovered from the hospital pharmacy, was for Benazepril 50 mg twice daily.

So, instead of controlling his blood pressure, he was just exhausted. But of course, his allergies weren’t bothering him at all.

When I first moved back to New York and joined my practice, one of the joys of the electronic medical record (EMR) we were using at the time was a prescription writer; it was amazing how much time that saved. Typing a medication name, selecting a dose, filling out the sig line, number to be dispensed, and refills, and that was it.

With our current EMR, things have gotten even more sophisticated: adding a diagnosis code, crosschecking against allergies and medication interactions, highlighting dangerous classes and medicines based on the patient’s age or comorbid conditions, and more.

The modern way to prescribe and dispense medications from the clinic is dramatically better than it had been, but there are still problems.

Right now, our EMR in-baskets are bombarded daily with multiple requests for refills, some from our current patients, some are refill requests of patients we supervised, some from patients we’ve never met, some for medications we don’t prescribe to them.

These refill encounters come in as phone messages, patient requests via the portal, and add-ons to a message that might contain multiple parts, including a medical complaint and a request for a referral along with the refill request.

Chaos.

Managing a patient’s medications safely and effectively requires a lot of thought and care, and there are multiple opportunities for mistakes. It’s one of those areas where the Swiss cheese model of medical errors is holier than usual.

Far too often, we see medications prescribed that maybe shouldn’t be, and sometimes those that definitely shouldn’t be.

We get refill requests where the patient hasn’t been seen in 1, 2, 3, or more years, and often a covering provider will just reflexively refill these medications.

Mental health medications are often prescribed for a 90-day supply with three refills, and there have been cases where we look back and no actual mental health care has been accompanying these medications.

Medications that were prescribed by a specialist and refilled once by us as a courtesy, now forever linked to our name and license.

One of my least favorites is “patient requests all of his medications be sent to the pharmacy,” and someone blithely sends everything — even medications the patient may not be taking, duplicates inadvertently left on their medication list, and medications that need more intensive monitoring.

Every provider has different rules about how they refill medications.

I’ve heard some say the maximum amount they’ll give somebody is 90 days without seeing them again or at least checking in. There certainly are high-risk medications for which too liberal prescribing can potentially be dangerous, such as anticoagulants and steroids.

If I give a patient a short course of a new medication, or start them on something that requires monitoring, I want that to actually be adhered to.

If someone has not been seen in 2 years and I get a request to send in a year’s supply of their medications, I tell my team, “Let the patient know that once an appointment has been scheduled an interim refill can be sent.”

For other patients, I freely prescribe a year’s worth of refills for their chronic conditions.

We want to make sure we do this right, that we safely prescribe and refill and monitor medications, while optimizing the efficiency and convenience of being able to get refills from our practice. Setting standards and policies, putting alerts that might tell someone no further refills are allowed before the patient is seen, things like this could go a long way.

Technically, the patient is only able to request a refill from their prescriber who last sent it in, so they can’t click the button and send it to me when it’s prescribed by their neurologist, dermatologist, ophthalmologist, or cardiologist.

But sometimes they tell the staff I need refills of all these medicines, someone queues them up, and a covering provider co-signs it — then it just bounces back to us from then on.

We suggested that medications be assigned not only to a provider, but to a practice, so that all ophthalmologic drops go to the ophthalmologists, and if a neurologist is prescribing your antiepileptic drug, then it really can’t be prescribed by a patient’s gastroenterologist.

It may be tough to align all these different rules, all these different practice patterns, plus adding in all the vagaries of insurance coverage and formularies and how many refills patients are allowed. And don’t get me started on controlled substances.

But as these things continue to evolve, I hope that we can tweak the systems so that we are less prone to errors when it comes to prescribing medicines, maintaining them, and stopping when appropriate.