Drug monitoring system serves as communications link between physicians and pharmacists
A Computer-Based System for Screening Outpatient Drug Utilization
At the Medical University of South Carolina Family Practice Clinic, a computerbased system designed to monitor outpatient drug utilization has been established as a subsection of a developing comprehensive medical record system. The clinic, which is located within the Family Practice Center, comprises a large outpatient practice designed as a teaching model for the 43 residents in training in the Family Practice Program. 1 The patient population provides a sample of the community surrounding the medical center with known demographic , social and medical characteristics-a training model largely lacking on most medical center campuses. The pharmacy subsystem has been under development and revision for approximately three years. 2 It has been fully operational in the Family Practice Center pharmacy for approximately one year . The average work load is approximately 100 prescriptions a day. The primary function of the pharmacy-teaching senior pharmacy students-places greater demands on the system than might seem apparent from the prescription volume alone. A nearly identical system services six pharmacies located in the surrounding community. This more realistic environment serves to establish the practicality of many of the system concepts. Each of these pharmacies also serves in a training program for pharmacy students.3
PHARMACY OPTION: NEW PRESCRI PTIONS
The Computer System Virtually the entire medical record of the Center's 6,000 patients is stored on the computer. Appropriate security measures provide limited access to data where complete access is not required or would invade the patient's right to confidentiality . Located within the center is a dedicated PDP-15 computer" with 48,000 words (48K) of core storage and three movable head disk drives providing 60,000,000 bytes of mass storage . Approximately 24 cathode ray terminals (CRTs) are located throughout the center, linked to the computer by lines with a communications rate of 120 characters a second (1,200 baud) to most locations, a few locations being serviced at slower rates when appropriate . All medical records are computer printed for a back-up paper system. The operating system, MilS, "" is a derivative of MUMPS (Massachusetts General Hospital Utility Multi-Programming System), an interactive system for information pro• Digital Equipment Corporation, Maynard, Massachusetts. •• Medical Information Technology, Cambridge, Massachu-
setts.
82
PATIENT ID : DOE, JANE DOE, J ANE C 950950 ••. 0K? Y (YES) MEDICAI D PATIENT DRUG NAME : DILANTI N MEDICAID FORMULARY DRUG INTERACTS WITH ALCOHOL I NTERACTION IN BODY TO REDUCE EFFECT OF DI PHENYLHYDANTOIN ( PHENYTO I N). REF:429 NO I NCOMPLETE PRESCRIPTIONS ADD TO PROF ILE? Y (YES) PRESCRI PTION DATE: JULY l O PRESCRIPTION: l OOMG CAPS N90 ND3 R3 SI G: 3 PO QAM DOCTOR : B RX NUMBER: 38l STRENGTH: l OOMG FORM : CAPS NUMBER PRESCRIBED: 90 SI G: 3 PO QAM #REF ILLS: 3 NUMBER PER DAY : 3 RX NUMBER : 38l DOCTOR : B OK? Y (YES)
BEING FILLED NOW? l
PRICE: $3 . 00 # DI S: 90/
ON DATE: T
PATIENT INFORMATION MAY CAUSE DISCOLORATION OF THE URI NE OR FECES (6) TAKE DIRECTLY BEFORE, WITH, OR AFTER MEALS TAKE WITH FOOD OR MILK (lO) FILLED BY :
JDJ
cessing on small computers developed at the Massachusetts General Hospital. MilS incorporates a dedicated interpretive programming language and a time-sharing system. The latter partitions core into 1,000 word segments, a size made practical because of the density of interpretive code. Because information processing is essentially a disk-bound application it provides less competition for the central computer (CPU) than would be the case in a general purpose time-sharing system . This balance allows good response time despite the overhead of processing interpretive code . Rationale The system rationale is best understood by considering two features which we feel are generally true of health care delivery out of the hospital.
0038l DOE, JANE C TAKE 3 CAPSULES BY MOUTH EVERY MORNI NG DILANTIN l OOMG #90 REFILLS 3 DUE SEP l 2, 75 JDJ AUG l 3, 75 Label resulting from sequence.
jl 1IIalllily llIrartirl' l}IJ,arlllacy COLLEGE OF PHARMACY
PHONE 792 · 3451
No .
000976
DO :::.JANE C TAK::: I TA3!..ET EVE~Y
MuS C
CHARLESTON
D' . .:L8
S
C
lY'WUrh
J"A()RN I J-i(]
DILANT I N 300MG #30 DJ E 5=P 12,
2 REF I L L S
DIS P By_14[)~I_ _ _ 'D AT~.U '::;
13 .
75 75
Sample of computer typed labels. Figure 1 - New Prescription.· A new drug, Dilantin, is entered into the patient's profile through this sequence which notifies the pharmacist of the Medicaid status of the drug and patient, an alcohol-drug interaction 6 and pertinent educational information for the patient. The label is printed in a quantity determined by the response to " Being filled now?" Note that the computer interprets the pharmacist's shorthand into clear English on the label. 'In thiS and all subsequent examples, text typed by the pharmacist has been underl ined. Names of real patients are concealed while prescribers are ident ified only by initials to retain confidentiality of info rm atio n.
I. The practice of medicine in the outpatient situation is greatly based on pharmaceutical intervention in disease processes. A small number of diseases-hypertension, diabetes, coronary artery disease, congestive heart failure, chronic lung disease, chronic renal disease and the common infectious diseases-account for a tremendous bulk of the morbidity in any outpatient practice . These disease processes, along with minor injuries and psychiatric problems such as depression and anxiety, account for a substantial fraction of all visits to the physician. Except for trauma and the acute infectious and psychiatric diseases, these disease processes are almost invariably chronic . The primary modality of therapy for all of these conditions in the majority of patients is pharmaceutical. Thus, millions of patients, many of them elderly, regularly need potent phar-
Journal of the American Pharmaceutical Association
By Mark L. Braunstein and J. D. James
DOE, JANE C OPD#
950950
UNIT#:
DRUG PROFILE
DIPHENYLHYDANTOIN (PHENYTOIN) FORM: CAPS JUL 10, 1975 (DILANTIN) STRENGTH: 100MG NUMBER PRESCRIBED: 90(90) SIG: 3 PO QAM # REFILLS: 3 NUMBER PER DAY 3 RX NUMBER: 381 DOCTOR: B D(SEP 12, 1975) F**(AUG 13, 1975) 3 REFILL(S) LEFT Figure 2- Drug Profile. This drug profile is composed only of the drug prescribed in Figure 1. The prescription itself is followed by the prescription history. The letters F, Rand 0, respectively, represent original dispensing, renewals and the date on which the next renewal is due. One star (*) indicates an early renewal; two stars(**) indicate a late dispensing or renewal.
macologic agents for the control of disease processes which will often remain with them for the rest of their lives. II. The physician in an outpatient setting is in a much weaker position than is his hospital-based colleague to closely supervise his patient's drug therapy. The ambulatory patient is free to influence his clinical course in a number of ways which can be difficult to detect routinely and, indeed, which often go undetected. 4 -(a) The patient may not have the prescription dispensed or he may obtain less medication than was prescribed (often because of financial reasons). -(b) The patient may take too much or, more commonly, too little of the prescribed agent. The physician may be able to detect either problem but, in general, his opportunity comes substantially after the problem could have been detected by a pharmacist. Far too often the failure of drug compliance manifests itself through a patient's appearance at the office or emergency room-his particular disease out of control-in need of hospitalization. -(c) The patient may take drugs which may interact or interfere with each other. Most of the common problems of this type are well known but with the tendency of patients to obtain health care from multiple sources, the physician, even if he is knowledgeable of common interactions, may have incomplete data for ruling out such a problem. 5 -(d) The patient may erroneously obtain a medication to which he is known to be allergic. The use of proprietary names and the availability of many "combination" drugs make the patient subject to this possibility even if he is aware of the exact nature of his allergy. In our clinic approximately one prescription order per month is discovered for an agent to which the patient has a known allergy. -(e) The patient may receive duplicate prescription orders or prescription orders for medications with essentially the same
Vol. NS 16, No.2, February 1976
action. In the case of drugs with a potential for abuse or with a low therapeutic index, these situations could develop into serious problems. -(f) The patient may not understand the proper use of the drug. All of these possibilities are screened for by the computer in the family practice pharmacy using stored drug profiles and stored data bases as the basis for detecting problems.
The Pharmacy System A typical entry sequence is carried on as an interaction between the computer and the pharmacist at a CRT with a slave printer for making labels (Figure 1, page 82). The pharmacist generally is able to conduct this process in no more time than he traditionally took to type a label, and in substantially less time when multiple labels are required. In return he receives computer typed labels and is able to provide a service to the patient which both he and the patient regard as valuable. As prescriptions are entered and processed, a profile is built with information about the original prescription and about its
PHARMACY OPTION: REFILLS PHARMACY ID: F FOR DATE: T RX NUMBER:-381 DILANTIN 100 MG MORE THAN 48 HOURS BEFORE DUE DATE OK? Y (YES) NUMBER OF LABELS: 1 # DIS: 90(90)/ PATIENT INFORMATION MAY CAUSE DISCOLORATION OF THE URINE OR FECES (6) TAKE DIRECTLY BEFORE, WITH,OR AFTER MEALS TAKE WITH FOOD OR MILK (10) FILLED BY:
JDJ
00381 DOE, JANE C TAKE 3 CAPSULES BY MOUTH EVERY MORNING DILANTIN 100MG #90 REFILLS 2 DUE SEP 12, 75 JDJ AUG 13, 75 Figure 3- Renewal. This short sequence renews Dilantin. The computer screens for an early or late renewal. The prescription number, if not known, can be obtained through the drug profile for that drug.
renewal history. This information constitutes the basis of the patients's drug profile. It contains all of his prescription information as well as the history of each prescription (Figure 2, above left). Renewals become a simple procedure with most of the necessary information already stored (Figure 3, above). However,
Mark L. Braunstein
Mark L. Braunstein, MD, is assistant professor of family practice in the Department of Family Practice and director of the Computer Project at Medical University of South Carolina. He earned his BS from Massachusetts Institute of Technology, his MD from the Medical University of South CarOlina, and served as a medical intern at Barnes Hospital in St. Louis, Missouri.
J. D. James
J. D. James, BS, is the chief pharmacist at the Family Practice Center at Medical University of South Carolina, and associate at the university's college of pharmacy. He is a past president of the South Carolina Pharmaceutical Association and an active member in various other professional associations.
83
A Computer-Based System for Screening Outpatient Drug Utilization
the time of prescription dispensing and renewal, provide data for discovering additional problems (Figure 4, below) . Weekly reports are printed listing all patients who returned at an inappropriate interval for a
this process provides an important warning of possible noncompliance . Significantly late renewals often indicate definite under-medication . The stored patient drug profiles, built at
PHARMACY OPTI ON : NEW PRESCRIPTIONS PATIENT ID : DOE, JANE C DOE, JANE C 950950 .•• 0K? Y (YES) MEDICAID PATI ENT DRUG NAME : PANMYCIN MEDICAID FORMULARY DRUG TETRACYCLINE ALREADY PRESCRIBED JUL 16, 1975 STRENGTH : - 250MG - ATT FORM: CAP NUMBER PRESCRIBED : 40 (19) SI G: 1 QID # REFILLS : 2 NUMBER PER DAY : 4 RX NUMBER : 82000 D(JUL 27, 1975) R"' (JUL23 ,1975) F,b"(JUL 23 , 197 5) INTERACTS WITH DIPHENYLHYDANTOIN JUL 10, 1975 STRENGTH : 1 00MG SI G: 3 PO QAM # REFILLS : 3 D( SEP 1 2,1975) R*(AUG 13 , 1975) INCOMPATIBLE WHEN ADMI NISTERED PRECIPITATE FORMATION .
Future Research ( PHENYTO IN) FORM : CAPS NUMBER DISPENSED:90 ( 90) Our interest extends beyond screening . NUMBER PER DAY : 3 RX NUMBER : 381 F**(AUG 1 3,1975) 2 REFILL (S) LEFT The physiCian should be studied along with I N SAME SOLUTION BECAUSE OF PROBABLE his patient. Patient populations are readily
INTERACTS WITH MAALOX JUL 23, 1975 STRENGTH : FORM : SIG : 1 CC QD # REFILLS : 1 NUMBER D(JUL 27 , 1975) F( JUL 23, 1975) 1 INTERACTION I N BODY TO REDUCE EFFECT REDUCED ABSORPTION OF DRUG . NO INCOMPLETE PRESCRIPTIONS . ADD TO
NUMBER DISPENSED: 4 (4) PER DAY : 1 RX NUMBER : 91456 REFILL(S) LEFT OF TETRACYCLINE . PROFILE?
(NO)
~
Figure 4-Drug-Drug Interaction. A prescription for tetracycline elicits warnings about its interaction with Dilantin (an IV problem of interest only in the hospital) and its interaction with Maalox.7 The computer indicates all drug-drug problems including agents the patient is currently using.
JUL 1 , 1 975 --- ,ELOUISE : TJB ( ENCEBRIN) ---, RICHARD 0: GCJ (A PC WITH CODEI NE 1 GR) --- ,JOHN : JCM (PHENYLEPHRI NE) ---, JOSEPH : JS (DIAZEPAM) --- ,JEREMY : DAM (DIMETAPP) ---,LERETTA L: GM (DEL STAT) --- ,DEBORAH T: GHK (SELSUN) ---, PEGGY LEE: JLD (LIBRAX ) - -- ,NATHANIEL JR : GCJ (POLYVI-FLOR) JUL 2, 1 975 --- ,HARY NELSON : PG (NATALINS) ---, WILHELMINA: RMC (PHENOBARBI TAL) --- ,WILHELMINA : RMC (DI PHENYLHYDAN'ID IN - - PHENYTO IN ) ---, PAMELA DENISE : MLC (OVRAL) Figure 5- Drug Monitoring. A long list of renewals due on specified dates but not obtained by the time of the printout.
84
renewal or who did not return at all (Figure 5, below left) . In the Center all prescription orders are written on a duplicating pad with the pharmacy receiving a copy. Family Practice patients are free to use any pharmacy so it is necessary that a complete profile of prescription medication is kept. In addition, virtually every pharmacy in the area is provided with postcards on which it records the prescription number and the amount dispensed when it dispenses one of the Family Practice Center prescriptions. The postcards are returned to the Center and the information is entered to keep the drug profile current. Thus , the screen can be virtually complete for prescription orders that have been written in the Center whether or not they are dispensed there .
DATE 7/1 2/ 74 11/ 14/72 6/17/74 1/ 3/75 5/3/72 2/6/75 2/4/74
ACTIVE
5/9/75 11/7/73
X
8/ 7 /75 1/21/75 6/19/75 8/26/74 1 0/20/72 6/26/73 10/23/ 73
X
X X
X X X
X
identified based on their use of a particular drug in the past or at present (Figure 6, below) . Groups can be subdivided by physician . For example, when one looks at the rate at which a peer group of residents in the Center prescribed Diazepam, the most commonly used minor tranquilizer, one finds a marked and significant resident specific difference. In the group under study. a percentage of each resident's practice utilizing or having recently utilized
PATIENT DOCTOR FRANCIS RMC DAM JAMES E. SR REBECCA E JJC REBECCA TUTEN GCJ MEL FSF STEPHEN IH REBECCA S GCJ 1 00 PTS SEARCHED LUCY MF MARY SMS 200 PTS SEARCHED JOHN G JHK SALLYE RUTH LED ANNA EMS MYRTLE RSS NANCY GM LEROY SMS ELLA LED 300 PTS SEARCHED
Figure 6- Drug Search. A listing of all patients with a history of using a particular drug (Metahydrin in this case). Note that patients currently using the agent are indicated " X" under active. The computer searches all patients' profiles and indicates its progress after scanning 100 profiles.
Journa l of the American Pharmaceutical A ssocia tion
Braunstein and James
the drug varied from a low of 2.5 percent to a high of 12.7 percent. Additional analyses were unable to demonstrate any significant variation in age or sex among the practices under study (these were the only stored factors which correlated significantly with the chance of a patient being on the drug). Surprisingly, 'there also was no reciprocal tendency for residents to utilize other minor tranquilizers if they were low utilizers of Diazepam. Last, there was no chance increase in the diagnosis of anxiety in the practices high in Diazepam utilization (when the practice morbidity indices were searched). Indeed, there was a slightly negative correlation between these two factors suggesting that at least some of the residents who were low utilizers of the drug had a high number of patients with the diagnosis most commonly associated with its use. Perhaps the
heavy orientation toward the behavioral sciences in the Family Practice program has suggested an alternate means of therapy to this group of residents. It is too early to make any meaningful inference from the data-in most cases, records are complete for one or two years. It is probable that very few interesting questions concerned with drug therapy are answerable without a larger sample than we have so far collected.
Improving Patient Compliance (Continued from page 76)
tient feedback scheme in which the patient is required to verbalize his understanding to the pharmacist. At the time of dispensing, the patient should be encouraged to state in his own words the important points regarding his medication and the potential consequences of noncompliance. This pharmacist-patient intervention involves time but has been demonstrated to significantly improve patient compliance. For each drug that the patient receives, he should understand the directions for taking the medication, proper storage and handling, and the consequences of noncompliance. The patient should be taught to recognize the symptoms of side effects whenever possible. The pharmaCist can affect the degree of patient compliance in self-administration of drugs. The quantity and quality of pharmacist-patient intervention at the time of dispensing can reduce self-administered medication errors providing a significant, productive and necessary health care service to the patient, while at the same time enhancing the pharmacist's health care role in the patient's eyes . •
bal information. It would appear that written drug information without verbal reinforcement was "counterproductive" to compliance. Factors IncreaSing Compliance Several factors that will increase patient compliance in self-administration of prescription drugs have been described in the literature. The patient must" of course, receive the drug. His drug use then can be monitored with patient record systems. Increased communication about the drug by the health professionals who come into contact with the patient improves compliance. Printed information, including calendars, improves compliance provided there is verbal reinforcement. Patient compliance is better when there are fewer doses prescribed per day although this does increase the significance of omitted doses. The pharmacist can foster patient compliance by determining that the patient understands, in his own words, why and how .he should take the prescribed medication. This can be accomplished through a pa-
Conclusion A rewarding effect of this system has been the increased communication it encourages between two members of the health care team in the center-the physician and the pharmacist. Increased surveillance of health care will have its greatest value when health professionals are able to deal with the problems which such moni-
References Med-i-Quiz Answers
1.
e
2. 3. 4. 5. 6. 7.
B A A, Band e B A and B
10. 11. 12. 13.
e
14.
8. 9.
Vol. NS 16, No. 2, February 1976
e e A, e and D B Band e Bande
e
1. Berry C., and Latiolais, C., "Misuse of Medications by Outpatients," Drug Intell. , 3, 270-277 (Oct. 1969) 2. Clinite, J., and Kabat, H., " Errors During Self Administration of Prescribed Drugs," JAPhA , NS9, 450- 452 (Sept
1969) 3. Stewart, R.B. , " A Study of Outpatients ' Use of Medications," Hosp. Pharm., 7, 108-117 (April 1972) 4. Sharpe, T., and Mikeal, R., "Patient Compliance With Antibiotic Regimens," Am. J. Hosp. Pharm. , 31, 479-484 (May 1974) 5. Rosenberg, S., " A Case for Patient Education," Hosp. Form. Mgt., 6 , 14- 17 (June 1971)
toring will uncover. It is hopetl that work such as this is assisting in the training of health professionals who will communicate and work together toward solving the difficult problems of delivering quality health care in the community. • References 1, Curry, H. B., Family Practice Residence Brochure, Medical University of South Carolina, Charleston, S.C. (1975) 2. Karig, A. W. , James, J. D., Braunstein, M. L., and Henderson, W. M., Am. J. Pharm. Ed., 38,161 (1974) 3. Golod, W. H., Karig, A . W., 'James, J. D., and Braunstein, M. L., Am. J. Pharm. Ed. , 38, 511 (1974) 4. Hulka, B. S., and Cassel, J. C., "The AAPF-UNC Study of the Organization, Utilization, and Assessment of Primary Medical Care," Am. J. Publ. Health, 63, 494-501 (June
1973) 5. Hussar, D. A., "Drug Interactions-A Review of the Mechanisms by Which They Develop," Hosp. Form. Mgt., 5, 16 (Oct. 1970) 6. Martin, E. W., Hazards of Medication, J. B. Lippincott Company, Philadelphia, Pa. 430-439 (1971) 7. Garb, S., Clinical Guide to Undesirable Drug Interactions and Interferences, Springer Publishing Company, Inc., New York (1970)
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;
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ways to put
your talent to work in the health ~eld
Put your talent to work in the health field. Our new booklet, "200 Ways to Put Your Talent to Work in the Health Field:' tells about careers for all kinds of people, with all kinds of interests, talents, and backgrounds. For a free copy, write National Health Council, Box 40, Radio City Station, New York, NY. 10019. A PIJbIic 5eNioe 01 TAs Magazine & The Adwrtising Council
85
m . '
A Computer-Based System for Screening Outpatient Drug Utilization
At the Medical University of South Carolina Family Practice Clinic, a computerbased system designed to monitor outpatient drug utilization has been established as a subsection of a developing comprehensive medical record system. The clinic, which is located within the Family Practice Center, comprises a large outpatient practice designed as a teaching model for the 43 residents in training in the Family Practice Program. 1 The patient population provides a sample of the community surrounding the medical center with known demographic , social and medical characteristics-a training model largely lacking on most medical center campuses. The pharmacy subsystem has been under development and revision for approximately three years. 2 It has been fully operational in the Family Practice Center pharmacy for approximately one year . The average work load is approximately 100 prescriptions a day. The primary function of the pharmacy-teaching senior pharmacy students-places greater demands on the system than might seem apparent from the prescription volume alone. A nearly identical system services six pharmacies located in the surrounding community. This more realistic environment serves to establish the practicality of many of the system concepts. Each of these pharmacies also serves in a training program for pharmacy students.3
PHARMACY OPTION: NEW PRESCRI PTIONS
The Computer System Virtually the entire medical record of the Center's 6,000 patients is stored on the computer. Appropriate security measures provide limited access to data where complete access is not required or would invade the patient's right to confidentiality . Located within the center is a dedicated PDP-15 computer" with 48,000 words (48K) of core storage and three movable head disk drives providing 60,000,000 bytes of mass storage . Approximately 24 cathode ray terminals (CRTs) are located throughout the center, linked to the computer by lines with a communications rate of 120 characters a second (1,200 baud) to most locations, a few locations being serviced at slower rates when appropriate . All medical records are computer printed for a back-up paper system. The operating system, MilS, "" is a derivative of MUMPS (Massachusetts General Hospital Utility Multi-Programming System), an interactive system for information pro• Digital Equipment Corporation, Maynard, Massachusetts. •• Medical Information Technology, Cambridge, Massachu-
setts.
82
PATIENT ID : DOE, JANE DOE, J ANE C 950950 ••. 0K? Y (YES) MEDICAI D PATIENT DRUG NAME : DILANTI N MEDICAID FORMULARY DRUG INTERACTS WITH ALCOHOL I NTERACTION IN BODY TO REDUCE EFFECT OF DI PHENYLHYDANTOIN ( PHENYTO I N). REF:429 NO I NCOMPLETE PRESCRIPTIONS ADD TO PROF ILE? Y (YES) PRESCRI PTION DATE: JULY l O PRESCRIPTION: l OOMG CAPS N90 ND3 R3 SI G: 3 PO QAM DOCTOR : B RX NUMBER: 38l STRENGTH: l OOMG FORM : CAPS NUMBER PRESCRIBED: 90 SI G: 3 PO QAM #REF ILLS: 3 NUMBER PER DAY : 3 RX NUMBER : 38l DOCTOR : B OK? Y (YES)
BEING FILLED NOW? l
PRICE: $3 . 00 # DI S: 90/
ON DATE: T
PATIENT INFORMATION MAY CAUSE DISCOLORATION OF THE URI NE OR FECES (6) TAKE DIRECTLY BEFORE, WITH, OR AFTER MEALS TAKE WITH FOOD OR MILK (lO) FILLED BY :
JDJ
cessing on small computers developed at the Massachusetts General Hospital. MilS incorporates a dedicated interpretive programming language and a time-sharing system. The latter partitions core into 1,000 word segments, a size made practical because of the density of interpretive code. Because information processing is essentially a disk-bound application it provides less competition for the central computer (CPU) than would be the case in a general purpose time-sharing system . This balance allows good response time despite the overhead of processing interpretive code . Rationale The system rationale is best understood by considering two features which we feel are generally true of health care delivery out of the hospital.
0038l DOE, JANE C TAKE 3 CAPSULES BY MOUTH EVERY MORNI NG DILANTIN l OOMG #90 REFILLS 3 DUE SEP l 2, 75 JDJ AUG l 3, 75 Label resulting from sequence.
jl 1IIalllily llIrartirl' l}IJ,arlllacy COLLEGE OF PHARMACY
PHONE 792 · 3451
No .
000976
DO :::.JANE C TAK::: I TA3!..ET EVE~Y
MuS C
CHARLESTON
D' . .:L8
S
C
lY'WUrh
J"A()RN I J-i(]
DILANT I N 300MG #30 DJ E 5=P 12,
2 REF I L L S
DIS P By_14[)~I_ _ _ 'D AT~.U '::;
13 .
75 75
Sample of computer typed labels. Figure 1 - New Prescription.· A new drug, Dilantin, is entered into the patient's profile through this sequence which notifies the pharmacist of the Medicaid status of the drug and patient, an alcohol-drug interaction 6 and pertinent educational information for the patient. The label is printed in a quantity determined by the response to " Being filled now?" Note that the computer interprets the pharmacist's shorthand into clear English on the label. 'In thiS and all subsequent examples, text typed by the pharmacist has been underl ined. Names of real patients are concealed while prescribers are ident ified only by initials to retain confidentiality of info rm atio n.
I. The practice of medicine in the outpatient situation is greatly based on pharmaceutical intervention in disease processes. A small number of diseases-hypertension, diabetes, coronary artery disease, congestive heart failure, chronic lung disease, chronic renal disease and the common infectious diseases-account for a tremendous bulk of the morbidity in any outpatient practice . These disease processes, along with minor injuries and psychiatric problems such as depression and anxiety, account for a substantial fraction of all visits to the physician. Except for trauma and the acute infectious and psychiatric diseases, these disease processes are almost invariably chronic . The primary modality of therapy for all of these conditions in the majority of patients is pharmaceutical. Thus, millions of patients, many of them elderly, regularly need potent phar-
Journal of the American Pharmaceutical Association
By Mark L. Braunstein and J. D. James
DOE, JANE C OPD#
950950
UNIT#:
DRUG PROFILE
DIPHENYLHYDANTOIN (PHENYTOIN) FORM: CAPS JUL 10, 1975 (DILANTIN) STRENGTH: 100MG NUMBER PRESCRIBED: 90(90) SIG: 3 PO QAM # REFILLS: 3 NUMBER PER DAY 3 RX NUMBER: 381 DOCTOR: B D(SEP 12, 1975) F**(AUG 13, 1975) 3 REFILL(S) LEFT Figure 2- Drug Profile. This drug profile is composed only of the drug prescribed in Figure 1. The prescription itself is followed by the prescription history. The letters F, Rand 0, respectively, represent original dispensing, renewals and the date on which the next renewal is due. One star (*) indicates an early renewal; two stars(**) indicate a late dispensing or renewal.
macologic agents for the control of disease processes which will often remain with them for the rest of their lives. II. The physician in an outpatient setting is in a much weaker position than is his hospital-based colleague to closely supervise his patient's drug therapy. The ambulatory patient is free to influence his clinical course in a number of ways which can be difficult to detect routinely and, indeed, which often go undetected. 4 -(a) The patient may not have the prescription dispensed or he may obtain less medication than was prescribed (often because of financial reasons). -(b) The patient may take too much or, more commonly, too little of the prescribed agent. The physician may be able to detect either problem but, in general, his opportunity comes substantially after the problem could have been detected by a pharmacist. Far too often the failure of drug compliance manifests itself through a patient's appearance at the office or emergency room-his particular disease out of control-in need of hospitalization. -(c) The patient may take drugs which may interact or interfere with each other. Most of the common problems of this type are well known but with the tendency of patients to obtain health care from multiple sources, the physician, even if he is knowledgeable of common interactions, may have incomplete data for ruling out such a problem. 5 -(d) The patient may erroneously obtain a medication to which he is known to be allergic. The use of proprietary names and the availability of many "combination" drugs make the patient subject to this possibility even if he is aware of the exact nature of his allergy. In our clinic approximately one prescription order per month is discovered for an agent to which the patient has a known allergy. -(e) The patient may receive duplicate prescription orders or prescription orders for medications with essentially the same
Vol. NS 16, No.2, February 1976
action. In the case of drugs with a potential for abuse or with a low therapeutic index, these situations could develop into serious problems. -(f) The patient may not understand the proper use of the drug. All of these possibilities are screened for by the computer in the family practice pharmacy using stored drug profiles and stored data bases as the basis for detecting problems.
The Pharmacy System A typical entry sequence is carried on as an interaction between the computer and the pharmacist at a CRT with a slave printer for making labels (Figure 1, page 82). The pharmacist generally is able to conduct this process in no more time than he traditionally took to type a label, and in substantially less time when multiple labels are required. In return he receives computer typed labels and is able to provide a service to the patient which both he and the patient regard as valuable. As prescriptions are entered and processed, a profile is built with information about the original prescription and about its
PHARMACY OPTION: REFILLS PHARMACY ID: F FOR DATE: T RX NUMBER:-381 DILANTIN 100 MG MORE THAN 48 HOURS BEFORE DUE DATE OK? Y (YES) NUMBER OF LABELS: 1 # DIS: 90(90)/ PATIENT INFORMATION MAY CAUSE DISCOLORATION OF THE URINE OR FECES (6) TAKE DIRECTLY BEFORE, WITH,OR AFTER MEALS TAKE WITH FOOD OR MILK (10) FILLED BY:
JDJ
00381 DOE, JANE C TAKE 3 CAPSULES BY MOUTH EVERY MORNING DILANTIN 100MG #90 REFILLS 2 DUE SEP 12, 75 JDJ AUG 13, 75 Figure 3- Renewal. This short sequence renews Dilantin. The computer screens for an early or late renewal. The prescription number, if not known, can be obtained through the drug profile for that drug.
renewal history. This information constitutes the basis of the patients's drug profile. It contains all of his prescription information as well as the history of each prescription (Figure 2, above left). Renewals become a simple procedure with most of the necessary information already stored (Figure 3, above). However,
Mark L. Braunstein
Mark L. Braunstein, MD, is assistant professor of family practice in the Department of Family Practice and director of the Computer Project at Medical University of South Carolina. He earned his BS from Massachusetts Institute of Technology, his MD from the Medical University of South CarOlina, and served as a medical intern at Barnes Hospital in St. Louis, Missouri.
J. D. James
J. D. James, BS, is the chief pharmacist at the Family Practice Center at Medical University of South Carolina, and associate at the university's college of pharmacy. He is a past president of the South Carolina Pharmaceutical Association and an active member in various other professional associations.
83
A Computer-Based System for Screening Outpatient Drug Utilization
the time of prescription dispensing and renewal, provide data for discovering additional problems (Figure 4, below) . Weekly reports are printed listing all patients who returned at an inappropriate interval for a
this process provides an important warning of possible noncompliance . Significantly late renewals often indicate definite under-medication . The stored patient drug profiles, built at
PHARMACY OPTI ON : NEW PRESCRIPTIONS PATIENT ID : DOE, JANE C DOE, JANE C 950950 .•• 0K? Y (YES) MEDICAID PATI ENT DRUG NAME : PANMYCIN MEDICAID FORMULARY DRUG TETRACYCLINE ALREADY PRESCRIBED JUL 16, 1975 STRENGTH : - 250MG - ATT FORM: CAP NUMBER PRESCRIBED : 40 (19) SI G: 1 QID # REFILLS : 2 NUMBER PER DAY : 4 RX NUMBER : 82000 D(JUL 27, 1975) R"' (JUL23 ,1975) F,b"(JUL 23 , 197 5) INTERACTS WITH DIPHENYLHYDANTOIN JUL 10, 1975 STRENGTH : 1 00MG SI G: 3 PO QAM # REFILLS : 3 D( SEP 1 2,1975) R*(AUG 13 , 1975) INCOMPATIBLE WHEN ADMI NISTERED PRECIPITATE FORMATION .
Future Research ( PHENYTO IN) FORM : CAPS NUMBER DISPENSED:90 ( 90) Our interest extends beyond screening . NUMBER PER DAY : 3 RX NUMBER : 381 F**(AUG 1 3,1975) 2 REFILL (S) LEFT The physiCian should be studied along with I N SAME SOLUTION BECAUSE OF PROBABLE his patient. Patient populations are readily
INTERACTS WITH MAALOX JUL 23, 1975 STRENGTH : FORM : SIG : 1 CC QD # REFILLS : 1 NUMBER D(JUL 27 , 1975) F( JUL 23, 1975) 1 INTERACTION I N BODY TO REDUCE EFFECT REDUCED ABSORPTION OF DRUG . NO INCOMPLETE PRESCRIPTIONS . ADD TO
NUMBER DISPENSED: 4 (4) PER DAY : 1 RX NUMBER : 91456 REFILL(S) LEFT OF TETRACYCLINE . PROFILE?
(NO)
~
Figure 4-Drug-Drug Interaction. A prescription for tetracycline elicits warnings about its interaction with Dilantin (an IV problem of interest only in the hospital) and its interaction with Maalox.7 The computer indicates all drug-drug problems including agents the patient is currently using.
JUL 1 , 1 975 --- ,ELOUISE : TJB ( ENCEBRIN) ---, RICHARD 0: GCJ (A PC WITH CODEI NE 1 GR) --- ,JOHN : JCM (PHENYLEPHRI NE) ---, JOSEPH : JS (DIAZEPAM) --- ,JEREMY : DAM (DIMETAPP) ---,LERETTA L: GM (DEL STAT) --- ,DEBORAH T: GHK (SELSUN) ---, PEGGY LEE: JLD (LIBRAX ) - -- ,NATHANIEL JR : GCJ (POLYVI-FLOR) JUL 2, 1 975 --- ,HARY NELSON : PG (NATALINS) ---, WILHELMINA: RMC (PHENOBARBI TAL) --- ,WILHELMINA : RMC (DI PHENYLHYDAN'ID IN - - PHENYTO IN ) ---, PAMELA DENISE : MLC (OVRAL) Figure 5- Drug Monitoring. A long list of renewals due on specified dates but not obtained by the time of the printout.
84
renewal or who did not return at all (Figure 5, below left) . In the Center all prescription orders are written on a duplicating pad with the pharmacy receiving a copy. Family Practice patients are free to use any pharmacy so it is necessary that a complete profile of prescription medication is kept. In addition, virtually every pharmacy in the area is provided with postcards on which it records the prescription number and the amount dispensed when it dispenses one of the Family Practice Center prescriptions. The postcards are returned to the Center and the information is entered to keep the drug profile current. Thus , the screen can be virtually complete for prescription orders that have been written in the Center whether or not they are dispensed there .
DATE 7/1 2/ 74 11/ 14/72 6/17/74 1/ 3/75 5/3/72 2/6/75 2/4/74
ACTIVE
5/9/75 11/7/73
X
8/ 7 /75 1/21/75 6/19/75 8/26/74 1 0/20/72 6/26/73 10/23/ 73
X
X X
X X X
X
identified based on their use of a particular drug in the past or at present (Figure 6, below) . Groups can be subdivided by physician . For example, when one looks at the rate at which a peer group of residents in the Center prescribed Diazepam, the most commonly used minor tranquilizer, one finds a marked and significant resident specific difference. In the group under study. a percentage of each resident's practice utilizing or having recently utilized
PATIENT DOCTOR FRANCIS RMC DAM JAMES E. SR REBECCA E JJC REBECCA TUTEN GCJ MEL FSF STEPHEN IH REBECCA S GCJ 1 00 PTS SEARCHED LUCY MF MARY SMS 200 PTS SEARCHED JOHN G JHK SALLYE RUTH LED ANNA EMS MYRTLE RSS NANCY GM LEROY SMS ELLA LED 300 PTS SEARCHED
Figure 6- Drug Search. A listing of all patients with a history of using a particular drug (Metahydrin in this case). Note that patients currently using the agent are indicated " X" under active. The computer searches all patients' profiles and indicates its progress after scanning 100 profiles.
Journa l of the American Pharmaceutical A ssocia tion
Braunstein and James
the drug varied from a low of 2.5 percent to a high of 12.7 percent. Additional analyses were unable to demonstrate any significant variation in age or sex among the practices under study (these were the only stored factors which correlated significantly with the chance of a patient being on the drug). Surprisingly, 'there also was no reciprocal tendency for residents to utilize other minor tranquilizers if they were low utilizers of Diazepam. Last, there was no chance increase in the diagnosis of anxiety in the practices high in Diazepam utilization (when the practice morbidity indices were searched). Indeed, there was a slightly negative correlation between these two factors suggesting that at least some of the residents who were low utilizers of the drug had a high number of patients with the diagnosis most commonly associated with its use. Perhaps the
heavy orientation toward the behavioral sciences in the Family Practice program has suggested an alternate means of therapy to this group of residents. It is too early to make any meaningful inference from the data-in most cases, records are complete for one or two years. It is probable that very few interesting questions concerned with drug therapy are answerable without a larger sample than we have so far collected.
Improving Patient Compliance (Continued from page 76)
tient feedback scheme in which the patient is required to verbalize his understanding to the pharmacist. At the time of dispensing, the patient should be encouraged to state in his own words the important points regarding his medication and the potential consequences of noncompliance. This pharmacist-patient intervention involves time but has been demonstrated to significantly improve patient compliance. For each drug that the patient receives, he should understand the directions for taking the medication, proper storage and handling, and the consequences of noncompliance. The patient should be taught to recognize the symptoms of side effects whenever possible. The pharmaCist can affect the degree of patient compliance in self-administration of drugs. The quantity and quality of pharmacist-patient intervention at the time of dispensing can reduce self-administered medication errors providing a significant, productive and necessary health care service to the patient, while at the same time enhancing the pharmacist's health care role in the patient's eyes . •
bal information. It would appear that written drug information without verbal reinforcement was "counterproductive" to compliance. Factors IncreaSing Compliance Several factors that will increase patient compliance in self-administration of prescription drugs have been described in the literature. The patient must" of course, receive the drug. His drug use then can be monitored with patient record systems. Increased communication about the drug by the health professionals who come into contact with the patient improves compliance. Printed information, including calendars, improves compliance provided there is verbal reinforcement. Patient compliance is better when there are fewer doses prescribed per day although this does increase the significance of omitted doses. The pharmacist can foster patient compliance by determining that the patient understands, in his own words, why and how .he should take the prescribed medication. This can be accomplished through a pa-
Conclusion A rewarding effect of this system has been the increased communication it encourages between two members of the health care team in the center-the physician and the pharmacist. Increased surveillance of health care will have its greatest value when health professionals are able to deal with the problems which such moni-
References Med-i-Quiz Answers
1.
e
2. 3. 4. 5. 6. 7.
B A A, Band e B A and B
10. 11. 12. 13.
e
14.
8. 9.
Vol. NS 16, No. 2, February 1976
e e A, e and D B Band e Bande
e
1. Berry C., and Latiolais, C., "Misuse of Medications by Outpatients," Drug Intell. , 3, 270-277 (Oct. 1969) 2. Clinite, J., and Kabat, H., " Errors During Self Administration of Prescribed Drugs," JAPhA , NS9, 450- 452 (Sept
1969) 3. Stewart, R.B. , " A Study of Outpatients ' Use of Medications," Hosp. Pharm., 7, 108-117 (April 1972) 4. Sharpe, T., and Mikeal, R., "Patient Compliance With Antibiotic Regimens," Am. J. Hosp. Pharm. , 31, 479-484 (May 1974) 5. Rosenberg, S., " A Case for Patient Education," Hosp. Form. Mgt., 6 , 14- 17 (June 1971)
toring will uncover. It is hopetl that work such as this is assisting in the training of health professionals who will communicate and work together toward solving the difficult problems of delivering quality health care in the community. • References 1, Curry, H. B., Family Practice Residence Brochure, Medical University of South Carolina, Charleston, S.C. (1975) 2. Karig, A. W. , James, J. D., Braunstein, M. L., and Henderson, W. M., Am. J. Pharm. Ed., 38,161 (1974) 3. Golod, W. H., Karig, A . W., 'James, J. D., and Braunstein, M. L., Am. J. Pharm. Ed. , 38, 511 (1974) 4. Hulka, B. S., and Cassel, J. C., "The AAPF-UNC Study of the Organization, Utilization, and Assessment of Primary Medical Care," Am. J. Publ. Health, 63, 494-501 (June
1973) 5. Hussar, D. A., "Drug Interactions-A Review of the Mechanisms by Which They Develop," Hosp. Form. Mgt., 5, 16 (Oct. 1970) 6. Martin, E. W., Hazards of Medication, J. B. Lippincott Company, Philadelphia, Pa. 430-439 (1971) 7. Garb, S., Clinical Guide to Undesirable Drug Interactions and Interferences, Springer Publishing Company, Inc., New York (1970)
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