Prescription Medication Management

Primary Care Prescription Medication Management When Patients See Other Health Professionals

Print This Post Print This Post

 

In the primary care setting, many of our patients receive some healthcare services from providers outside of our practice. The entire concept of primary care is that our patients contact us first and we coordinate care with other professionals who may or may not have independent prescribing licensure. Ideally any prescribing and monitoring of medication in that setting is negotiated between professionals with the patient involved or at least informed of the plans. Unfortunately, that ideal is often not achieved because of poor communication between busy providers who may not know one another’s capabilities and limitations. Seeing the patient asynchronously also complicates communication. The National Academy of Science’s Institute of Medicine (IOM) publications consistently identify prescription medication errors as the most significant patient safety risk in the US and failures in communication as a major source of these adverse outcomes. (1,2,3) Evidence to guide clinician prescribing behavior in the setting of multiple providers tends not to be derived from controlled trials, but rather programmatic interventions. Most of the literature of systematic approaches to prescribing describe interventions studied in institutional settings where clinical care teaming and interprofessional communication has been practiced for decades.

The only uniform regulation of pharmaceutical prescribing at the national level is that of the US Drug Enforcement Authority (DEA) which licenses individuals to prescribe any of a list of controlled substances, most of which are central nervous system depressants. The US Food and Drug Administration (FDA) labels pharmaceuticals either as requiring the prescription of a licensed health care professional or dispensable without prescription. FDA does not specify what professions or qualifications within those professions have prescribing authority; that is determined by licensing agencies within each individual state. All the states have health professional licensure boards or committees which advise the state legislature on what professions should have medication prescribing authority and how health professionals should interact. For example, nurse practitioners and physician assistants in some states require the supervision of a licensed doctoral level professional or have limited formularies for independent prescribing. In several states, psychologists with additional training in pharmacology are allowed to write prescriptions for some medications. This requires us to know the current regulations for our practice. In addition to statutory limitations, all health professionals have limitations of knowledge and experience with the thousands of FDA labelled drugs and devices, the FDA approving new drugs/devices daily, labeling instructions changing, and some being restricted or even withdrawn every day.

Here are a few of my personal ground rules for prescribing in a coordinated care setting:

When our practice is primarily involved in managing a patient’s problem without initial involvement of outside professionals, I will write medication prescriptions only for individuals who have had at least one in-person visit to our practice. I write refill prescriptions only for patients whom we plan to see again. I want to be assured that our patients understand the potential benefits and risks of the medications and that they understand that the prescription medication is only a part of their treatment. If they work with professionals outside our practice for this problem or any other we ask them to mention that we are their source of primary health care.

When our practice requests a consultation from or referral to a professional who prescribes medications, I try to let them know in advance if I would like them to prescribe and handle any refills for the specific problems for which I seek their input. Any necessary monitoring must also be negotiated. For example, if a psychiatrist prescribes an atypical antipsychotic, I may order and evaluate results of the hematologic and metabolic laboratory testing. If I do not feel competent to evaluate the results {like blood levels of certain drugs, viral genotypes and viral load, or specialized immunologic tests), I request that the prescribing professional receive those results and make any necessary decisions involving them. I do ask that I be kept informed of any recommendations, especially if it requires any change in my treatment of that patient.

If a patient in our practice sees a health professional without prescribing authority (either as a result of our referral or their own choice), I request that the patient keep us “in the loop”. Our practice is in a large metropolitan area and we may not have any previous relationship with the other health professionals. I try to communicate to each professional outside our practice that, if they would like us to prescribe any medication or referral for diagnostic or therapeutic procedure for any of our patients that they are seeing, they contact us first to discuss their suggestion before sharing that suggestion with the patient. If the patient tells me “so and so suggested that you give me fill-in-the-blank”, I want to know the context of that discussion. I will then discuss with the patient my rules for prescribing under these circumstances. If I am prescribing, I certainly need to be informed of any adverse effect of whatever I prescribe, but I may or may not be able to evaluate the benefits as well as the other professionals involved. If the requested intervention is something I am not comfortable doing, I inform the patient and the other consulting professionals that it is not within my normal scope of practice and I try to find a resource for that intervention with whom we can all work together.

The Affordable Care Act directs the Federal Center for Medicare/Medicaid Services (CMS) to develop an Accountable Care Organizations (ACO) program to reward coordination of professional services for individuals insured under their Federal programs. Participation in one or more ACOs is currently voluntary for providers who receive “fee for service” reimbursement from Medicare. “Comprehensive Primary Care Initiative” (CPC) is an experimental program funded by CMS for primary care practices which provides coordinated care fulfilling requirements similar to the prescribing model I have described above. Other third party payers are also employing ACO models. Further discussion on how primary care practices can get paid for the additional time and effort necessary to coordinate care with both prescribing and non-prescribing health professionals is beyond the scope of this article.

The communications and documentation involved are more complex in coordinating primary care with other health professionals, but it is necessary if we all want to get the best possible outcomes. Interoperable electronic health records are evolving slowly, but promise to make these tasks easier in the future.

Charles Sneiderman, MD, PhD, DABFP
Medical Director, Culmore Clinic
Falls Church, VA

 

References:

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine (IOM). Washington, DC: National Academies Press, 2000. http://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system

2. Committee on Quality of Health Care in America; Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001. http://www.nap.edu/catalog/10027/crossing-the-quality-chasm-a-new-health-system-for-the

3. Committee on Integrating Primary Care and Public Health, Institute of Medicine (IOM). Primary care and public health: exploring integration to improve population health. Washington, DC: National Academies Press, 2012. http://www.iom.edu/reports/2012/primary-care-and-public-health.aspx

 

Published November 16, 2015