The American Society of Consultant Pharmacists Foundation (ASCPF) successfully implemented a medication monitoring software program, Monitor-Rx, to optimize the medication regimens of older adults by pharmacists. Monitor-Rx is a web-based clinical tool that assists in identifying, resolving and preventing medication-related problems among older adults. The initiative was conducted in six practice sites that provide pharmacist services: OASIS Older Adult Full Service Partnership (OASIS), University of California Irvine Senior Health Center (UCI-SHC), Alzheimer's Family Services Center (AFSC), HbL PharmaConsulting, and UC Irvine Health Assessment Program for Seniors (UCI-HAPS). The goals of this initiative were to:
Monitor-Rx identiﬁes medications that may cause, aggravate, or contribute to common geriatric problems, including identiﬁcation of potentially inappropriate medications and drugs with anticholinergic properties; and provides medication-monitoring recommendations to foster early recognition of medication problems that can be avoided, managed, or reversed. Monitor-Rx can be securely operated as a stand-alone website or can be integrated into clinical, practice or electronic medical record systems.
ASCPF trained staff at each of the practice sites, providing information and tools to better understand the potential for medications to cause or aggravate physical, functional or cognitive decline in older adults and to utilize Monitor-Rx to improve medication monitoring practices.
The project evaluated:
Positive Effect on Pharmacist Referrals. Through the use of Monitor-Rx the total number of patients and number of referrals to pharmacists increased steadily over one year. Nearly every site had a 50% increase in the number of referrals to the pharmacist between the 3rd and 4th quarters of the project.
Medication Regimen Effects Not Significant. No reductions were seen in the percentage of patients receiving anticholinergic medications or taking potentially inappropriate medications. Because of the length of the project and the frequency of interactions with patients, the number of medication changes was not as high as expected and there was insufficient time to determine and record the results of the pharmacist recommendations.
Increased Staff Understanding of the Association between Medications and Geriatric Problems. Over 90% of project staff (providers, support staff, life coach, and social worker) had a better understanding of the association between medications and geriatric problems as a result of utilizing Monitor-Rx. Staff knowledge increased regarding medication effects that may contribute to the risk of falls, medications known to cause or contribute to memory problems/cognitive impairment and depression, and the association between anticholinergic medications and the increased risk for adverse drug effects. Nurses, social workers and care managers at the project sites all reported increased benefits from using the information generated by Monitor-Rx.
Program Useful as a Pharmaceutical Educational System for Families. Project staff (case workers, social workers) found Monitor-Rx provided an accurate and reliable information resource for pharmaceutical information for families as well as patients. Project staff had improved communication and compliance when referencing the system to provide information on specific medications for patients.
Sustainability and Replicability:
Monitor-Rx was made available at no charge during the 2010 grant period. Currently, Monitor-Rx is available to other sites for a license fee. Use of Monitor-Rx use has expanded dramatically—from approximately 300 patients served during the 2010 grant period to more than 14,000 patients served in the year after the grant period.
Need to Overcome Data Entry Hurdles. Monitor-Rx analyzes medications and clinical symptoms. This information was not available in electronic form at some of the sites participating in this project. Hence, converting data from paper to electronic records was a significant hurdle in program implementation. Another data entry hurdle was the need to allocate time and appropriate personnel for completing data entry tasks. Programs that relied on pharmacists as the primary data entry resource experienced significant delays. Though the pharmacist is most familiar with medication data, this is an expensive resource. A pharmacy technician or a medical records technician that is familiar with medication names, dosage forms, and directions for use, may be better suited for the initial data entry. This would free up time for pharmacists to interpret data/reports, develop and manage interventions, and educate other clinicians, patients and caregivers.
Accurate Medication List and Maintenance Needed. Sites using Electronic Medical Records (EMRs) or were in transition to digitized records found their medication lists were too often inaccurate and not up to date. Use of Monitor-Rx helped surface this problem, leading to some sites increasing the frequency of medication reconciliations as well as rechecking and reconciling data before entry into Monitor-Rx.
Importance of Individual Department Training with Regular Follow-up. It was determined that individual department training at each site was more effective than group training. Multiple, shorter trainings with “teach back” on what was learned, coupled with follow-up training throughout the implementation of the program, were associated with improved program usage and provider satisfaction. Providing one training session to a large audience across multiple departments without follow-up was associated with limited Monitor-Rx use.
Appropriately Targeting Practice and Practitioner. This intervention was utilized in a variety of settings and with a variety of practitioner types. Providers within this project that benefited most from Monitor-Rx use were those that did not have a geriatrics specialty focus, specifically social workers, case managers, and primary care physicians.
Actionable, Targeted Reports Compatible with Organization’s Record Keeping. Monitor-Rx patient medication reports were initially identified by sites as lacking clear action steps and being too long. Sites recommended that: reports be concise and include actionable steps targeted to specific program staff, inclusion of a checklist of what to do to with the report(s) once generated, and customizing reports to make them compatible with an organization’s record keeping process.
Coordination of Roles and Responsibilities are Key. At two project sites, Monitor-Rx enabled non-medical staff to identify medication problems, but staff felt that resolving such problems were not within their scope of work. Determining personnel roles and time requirements for data entry, medication reconciliation, workflow, and report follow-up are needed for project success by preventing confusion and redundant activities, and maximizing effective use of resources.