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Wednesday, November 11, 2009

Chronic disease tracking using a refill protocol

A few years before we joined the TransforMed National Demonstration Project, my office was having a lot of problems dealing with prescription refills. The volume of requests was tremendous. We were fielding 50 to100 requests per physician per day. We had the feeling that we were not doing a very good job with turnaround time on these requests. We had negative feedback from nursing, pharmacists and, worst of all, patients.

We decided to study the problem. For a solid week, we tracked the process each refill request went through from the time it was received in the office via fax, phone or in-person patient request to the time the authorization or denial was sent back to the pharmacy or the patient. What we found was surprising: the turnaround time was an average of 48 hours, but with a range of 30 minutes to 5 days. This variance arose from absences of staff and physicians, as well as day-to-day variations in how busy we were. But it did not seem to be caused by variations in fax traffic or whether prior authorizations or patient instructions were needed.

From our study, we were able to craft a plan to reduce this time. Our goal was to reduce the turnaround time to 2 hours per prescription on average. In mapping each process (made very easy by our EMR system, Centricity), we tried to identify every time the request would sit in a "parking lot" or queue where it was waiting for the next person to act upon it. Our goal was to reduce the number of parking lots. We realized that for certain classes of medications, mainly maintenance medications, the physicians used pretty much the same criteria to refill them every time: When was the patient's last appointment? When and what were their last labs? We decided to collect these criteria into a protocol that the nurses could follow immediately when the request arrives and the physicians could review and sign later.

Within 2 months of implementing this policy, we had reduced our turnaround time to less than 2 hours. This in turn greatly reduced our rate of call-backs from patients and pharmacies and consequently reduced our total phone call volume.

The protocol also served as an excellent way to track and schedule patients appropriately for their chronic disease follow-ups. The physicians make a point to prescribe medications in refill amounts to coincide with the allowed amounts on the protocol. At first, patients complained about having to come in "so often" for appointments, which let us know that they had not been coming in as often as they should have before we had the protocol in place.

The entire process is streamlined now and we all are happier: patients, pharmacies, nurses and physicians. It is also educational for the nursing staff; they have a much better understanding of medications, what they are for and how they are used now.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

Note: This blog is no longer updated; this is archived content.

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