Guidance on conducting medication reviews in GP practices

1. Doing Medication Reviews
in GP Practices
Noshi Iqbal
Lead Pharmacist
Clinical Training & Development
September 2007

2. Medication Reviews – where did
it all start?
� There is considerable published
evidence on:
� issues associated with medicines
� benefits of medication reviews
� Paper in Am J Hosp Pharm (1992) –
effects of pharmaceutical care on
quality of patient care in an
ambulatory-care clinic
� Many other papers from 1999, 2001,
and so on about medication reviews
conducted by pharmacists in GP
practices (BMJ)
� NSF for Older People: all people over
75 yrs to have all meds reviewed
annually, and for those taking four or
more meds to have a six-monthly
medication review (2001)

3. Key Features of ‘Room for
Review’
� Greater patient and carer involvement in
medication review as a route to partnership in
treatment decisions and medicine taking:
� Concordance
� Guide focussed on the practice of medication
review in primary care with the needs of older
people, & people with long term conditions
particularly in mind
� There are practical issues for the NHS in relation
to capacity and staff time to undertake
medication review and meet NSF and other
targets:
� Usingskills of different healthcare professionals –
pharmacists

4. The need for medication review
Medication review is an important component of
medicines management:
� Medication review milestone in the Older People’s NSF
� Medication reviews are specifically mentioned in two
sections of the GMS contract:
� a medication review is recorded in the notes in the preceding 15
months for all patients being prescribed four or more repeat
medicines (standard 80%; medicines 5 indicator)
� a medication review is recorded in the notes in the preceding 15
months for all patients being prescribed repeat medicines
(standard 80%; medicines 9 indicator)
� The importance of medication reviews is further highlighted
in a number of areas of the GMS contract including,
epilepsy, asthma, CHD and hypertension. Over 300 points
are achievable by reviewing medication.

5. What is a Medication Review?
� ‘A structured, critical examination of a
patient’s medicines with the objective of
reaching an agreement with the patient
about treatment, optimising the impact of
medicines, minimising the number of
medicine-related problems and reducing
waste’
Room for Review, Nov 2002

6. Suggested principles of a
medication review
� All patients should have a chance to raise
questions and highlight problems about their
medicines
� Reviews should seek to improve or optimise
impact of treatment for an individual patient
� The review is undertaken in a systemic way,
by a competent person
� Any changes resulting from the review are
agreed with the patient
� The review is documented in the patient’s
notes
� The impact of any change is monitored

7. Why Medication Reviews are
important
� Providing patients general information
about their medical condition and
treatment
� How to take medicines properly
� Medication options (alternatives)
� Patients personal beliefs and preferences
(helps concordance)
� Concerns about medication discussed

8. Potential target patient groups
� At risk of medicines – related problems
� Taking 4 or more medicines every day
� Recently discharged from hospital with complex meds (e.g. TB
drugs)
� Receiving medicines from more than once source (hospital clinic
& GP e.g. dermatology)
� Significant changes to medication regimen in past 3 months
� Taking medicines requiring special monitoring (e.g. DMARDs,
warfarin), wide range of side effects (e.g. NSAIDs), or narrow
therapeutic range (e.g. digoxin)
� Where non-compliance is suspected or known to be a problem
� Special needs
� People with learning difficulties / communication difficulties
� Older people / residents in care homes
� Physical problems e.g. arthritis, inability to swallow
� Mental states e.g. confusion, depression, anxiety
� Literacy or language difficulties / ethnic groups

9. What patients want from
medication reviews
� General information about the medical condition &
treatment
� Confirmation of ‘what medication are on & why’
� How to take pills properly
� What to take & how much
� Medication options
� Alternative formulations to aid compliance
� Personal beliefs & preferences
� Concerns about medication
� Adverse drug effects

10. Levels of Medication Review
This is what we should read
code ‘medication review
done’ (‘seen by pharmacist’
code can also be added here)
This is what we should read
code as XaloW –
‘medication review done
by pharmacist’

11. Level 1 – Prescription Review
Community MURs
� Reviews done without access
to the patient’s clinical notes
and do not often include a
review of the full repeat
prescription (e.g. go by what
the patient or pharmacy PMR
says)
� Compliance issues, dose &
pack optimisation, resolving
quantity problems & generic
switches can be dealt with at
this level
� MURs are an integral part of
the Pharmacy Contract – each
MUR attracts a £25 fee (paid
by PCT to the Pharmacy)

12. Level 2 – Treatment Review
‘Medication review done by pharmacist’
� These reviews are done by pharmacists (or GPs) but
without the patient
� Medicines can be reviewed in the context of the patient’s
medical condition, history & treatment
� Review relies on formal record rather than patient’s own
account of the medicines they take
� Dose adjustments, removal of unwanted items, effect of
medicines on pathology (e.g. DMARDs & FBC, ACEIs &
renal function), adverse effects, reducing likelihood of
drug interactions
� Optimising medicines use (changing dosage forms for
residents with swallowing difficulties), checking
compliance, minimising waste by calculating quantity
actually required per prescription interval
� Identify patients who need a face to face review

13. Level 3 – Clinical Medication
Review
Face to face with patient
� At this level medicines will be examined in the context of the
patient’s condition & the way they live their lives – listening
to the patient’s views & beliefs about their medicines,
understanding their medicine taking behaviour, & taking full
account of their preferences in any decisions about
treatment
� Objective evidence e.g. BP; peak flow done
� A check to ensure the patient understands how to take
medications (inc. storage conditions)
� Requirements for any additional support (e.g. dosettes,
repeat dispensing, collection services by local pharmacy)
� The review should conclude with a summary of the
agreement with the patient about the treatment & an
explanation of what will happen next (e.g. date of next
review)

14. Recording Medication Reviews
� Pharmacists are well recognised as
being experts in pharmaceutical
knowledge and communication skills
� Conducting medication reviews (with
or without patients) is an important
opportunity for pharmacists to
establish the concept of partnership
between patients & health
professionals in relation to medicines
� It is imperative that this valuable
support that we provide to our
practices gets recorded & fed back to
the PCT
� We all have a responsibility to record
this information on our practice
timesheets & emailed to Hab before
the end of each week so that data can
be recorded

15. Using SystmOne to do
Medication Reviews

16. Medication Reviews in SystmOne
� Mostly done when ‘reauthorising’
medication for another 6 months
� The read code ‘XaloW’ should be used
� Clinical reports can be created for patients
on ‘x’ number of medicines which can be
used to do medication reviews on patients
records when have time after other daily
duties

17. Reauthorising medication as part
of a Medication Review
� Before reauthorising medication for
another six months, the following sections
must be viewed in the patients record:
� Quick Glance
� Summary & Family History
� New Journal
� Recent issues & repeat template
� Communications
� Pathology

18. Quick Glance Note the last time BP,
BMI & smoking status
was checked, check to
see if information is
present / absence here
Check if patient
is allergic to
any medication
Check the last
three
consultations
in the patients
record See if there are
any important
recalls e.g.
diabetes review

19. Summary & Family History
Check the summary of
the patients medical
conditions (listed in
date order here)
Check for any
relevant
family history

20. New Journal
By clicking on
the ‘custom’
yellow cup, the
new journal
window can be
maximised
The highlighted section above is
expanded providing more
information such as blood results,
letters & prescriptions issued

21. Recent issues Check if any important
medication has been issued
as an acute – some drugs
may be being titrated
By right clicking
on a drug and
selecting issue
history, a
By changing detailed record
the option to appears for that
summary, a list drug
of every drug
ever issued
appears

22. Repeat template
The date when
a medication
The date when
Issue review due
the medication
duration
was last issued
Frequency
Date when next of issues
supply of
Person
medication due
authorising
Clicking on medication
this bar will
arrange drugs
in alphabetical
order
The number of
repeat medication Date medication Number of
the patient is on started issues left

23. Communications Look through recent letters
to see if there has been
any change in medication,
or medical condition

24. Expanding this + sign
Pathology gives an option to view
trends in the pathology
This screen gives info on the
management of the results
i.e. whether the patient
needs to be informed

25. Results in pink are
abnormal; green are OK
Clicking the BP button
brings up a graph with
recent BP readings
Clicking the data tab will
list all the BP readings with
dates ever done

26. Reauthorising Medicines
Right click each drug turn
by turn and click on
‘reauthorise / restart’
Ensure that all details entered
on this page e.g. issue
duration, review date quantity
of drug all match with other
drugs – ‘synchronise medicines

27. BEFORE
AFTER

28. Read coding
� After all the medication have been reauthorised, ensure
that each medication has a correct read code assigned to
it. If a read code is missing, check the diagnosis box, new
journal and communications sections to find the
appropriate read code or the date for the diagnosis (which
can then be read coded)
Diagnosis box
� Sometimes may have to
look in paper records to
find the diagnosis to
read code

29. Read coding
Clicking here will
bring ‘link diagnosis
to repeat template’
box
Clicking here will
bring ‘record new
coded entry’ box

30. Consultation
� An entry needs to be made
in the consultation
� Some practices will have
templates where this entry
can be made
� After the consultation is
written, this needs to be
read coded ‘medication
review done by pharmacist’
or XaloW
If a read code is not known by
value, free typing the word will
bring a browser up

31. The finished record The finished entry
in the new journal

32. Putting Medication Review into
practice
� Select patients via Clinical Reporting (ask
Hab to show you)
� Discuss with GP which patients need to be
seen (complex drug treatments, chronic
disease patients, etc)
� Develop good working relationships with the
local community pharmacists who can check
compliance via MURs if time is limited to
see patients (e.g. if do surgery half day)

33. Where to obtain further
information
� National Prescribing Centre website
www.npc.co.uk
� CPPE training packs on Medication
Review
� Room for Review (pdf version available –
ask Noshi)