In 2016, more than 4 billion prescriptions were filled at pharmacies in the United States, and the number of adults and children taking prescription medications is on the rise. As a result, renewing prescriptions has presented a major burden for primary care practices and may involve several staff members. The use of electronic prescribing by U.S. physicians also has increased, and although it has many benefits it has also presented new challenges in the medication renewal process. Many pharmacies still use a fax system to request medication renewals, and often this results in duplicate requests. To decrease the number of duplicated faxes, improve the efficiency of the medication renewal process, and improve staff satisfaction, a lean process was implemented by the Department of Family Medicine at Mayo Clinic Florida. As a result, duplicative faxes were reduced by 18%, turnaround time on renewal requests was reduced by five hours, and overall staff satisfaction improved by 20%.
In 2016, more than 4 billion prescriptions were filled at pharmacies in the United States.(1) In adults 62 to 85 years of age, prescription medication use is up, from roughly 84% in 2005–2006 to 88% in 2010–2011. In these adults, the use of five or more medications or supplements of any type increased from 53.4% to 67.1% during this five-year period.(2) Additionally, over a quarter of pediatric patients in the United States are taking at least one medication for a chronic condition.(3) As a result of the volume of prescription drugs being used, the process for renewing these medications has placed a major burden on primary care clinics. In most instances, several staff members are involved in the renewal process, including physicians, advanced practice providers (APPs), nurses, and office staff. Furthermore, electronic prescribing (E-prescribing) use by U.S. physicians has increased from 20% in 2008 to over 70% as of 2014.(4)
Although E-prescribing offers many benefits, it presents new challenges to primary care offices. One obstacle with E-prescribing is the limited ability for pharmacies and clinics to communicate bidirectionally within the electronic medical record (EMR). A cross-sectional study evaluating five independent pharmacies found that during one 14-day period, 155 communications were made to physician offices regarding prescription clarification. E-prescriptions required communication more often than any other prescription type, at 36%. Twenty-six percent of the communications were related to renewal prescriptions. The two most common methods of pharmacy communication were person-to-person phone calls (50%) and faxes (38%).(5)
In response to the increased demands of the medication renewal process, a lean process was used to standardize and reduce the volume of prescription renewals that were being managed by the Department of Family Medicine at Mayo Clinic Florida.
The Department of Family Medicine at Mayo Clinic Florida consists of a residency training location and three satellite community-based practices. This residency training program includes 10 staff physicians, 18 residents, and 3 APPs. The community-based practices consist of three separate clinics, which are located geographically within 45 minutes of one another, with a total of 15 physicians and 6 APPs. In sum, the department has a panel of 34,075 patients, ranging from newborn to 103 years of age. Of these patients, 57% are women, and 6% are less than 18 years old. The payer mix for the department is 18% government contracts and 82% commercial insurers. The support staff for the entire department includes 8 RNs, 25 LPNs, 2 medical assistants, 3 office managers, and 38 schedulers and front-desk staff (Table 1).
The residency training location maintains traditional clinic hours of 8 AM to 5 PM Monday through Friday. The community-based practices offer extended hours, from 7 AM to 7 PM Monday through Thursday and 7 AM to 5:30 PM on Fridays. Additionally, Saturday hours are available for all Family Medicine patients. This Saturday clinic is managed by one rotating physician from 8 AM to 1 PM and is designed only for acute illness needs. Medications are renewed only on an emergency basis during the Saturday clinic due to limited staffing.
A lean approach was instituted to identify activities that consumed resources but created no value (also known as waste) to the process of prescription renewal for non-controlled medications. The lean principles, derived from the Japanese automobile manufacturing industry, use a system of tools to reduce the time a process takes by eliminating non–value-added activities and waste without sacrificing productivity.(6)
In the initial phase of the project, three primary objectives were identified to improve the medication renewal process: (1) to reduce the overall number of faxes being received for medication renewal requests; (2) to reduce the time between renewal request and physician approval; and (3) to improve staff satisfaction. Secondary goals were to streamline and standardize the renewal process for all practice sites.
The first objective was to reduce the total number of faxes that were being received by pharmacies requesting medication renewals. In the practice, medication renewal requests are received either by faxes from pharmacies, patients calling the office for a renewal, patients requesting renewals through an online patient portal, or pharmacy phone requests. Nearly 75% of the requests come from faxes initiated by the pharmacy. In most instances, these faxes are automated and will be resent if a response has not been received in 6 to 12 hours, creating duplicative work. A Five S (5S) approach was used to eliminate unnecessary faxes being received and handled by the staff.
Five S is a five-step process:
Sort: the process of separating needed tools and instructions from unneeded materials, and removing the latter;
Set in order: neatly arrange and identify consumables and tools for ease of use;
Shine: the act of conducting a cleanup campaign;
Standardize: conduct Sort, Set, and Shine at frequent, daily, intervals to maintain a workplace in perfect condition; and
Sustain: form the habit of always following the first four Ss.
The second objective was to decrease the turnaround time for a renewal request. Time studies, spaghetti diagrams, and swim lane diagrams were used to evaluate the medication renewal process for each practice location. Rapid tests of change were performed to evaluate suggested methods and to assess the time required to renew a medication. The time was measured from the initial request for renewal to the time the medication was actually renewed by the office.
The final objective was to improve satisfaction among the members of the healthcare team who were involved in the medication renewal process—the physicians, nurses, and office staff. An electronic survey was sent to each individual with five questions specific to their involvement in the renewal process. The team received a survey prior to the initiation of the project and a survey at the completion of the project.
Between 200 and 350 faxes were received per day from multiple pharmacies requesting a medication be renewed. During the 5S process it was discovered that 32% of the faxes received were duplicate requests for a faxed request that had already been received. Three primary reasons were identified for duplicative requests.
The main reason a second request was received was lack of timeliness in responding to the initial request. As previously noted, pharmacies generally use an automated system that will refax a renewal request if the initial request is not responded to within a certain time period. Each pharmacy defines its own time period, but on average it is within 6 to 12 hours. Several methods were identified to improve efficiency in the response time to the initial request (see sidebar).
Another reason that pharmacies were sending duplicate requests was when physicians changed a medication, by either a change in the dosage, directions on how to take the medication, the quantity to be dispensed, or discontinuation of that medication. Although E-prescribing has improved the overall procedure of prescribing and renewing medications, it has created some new challenges. One study used a web-based, E-prescribing incident reporting tool designed to elicit information on pharmacists’ experiences with E-prescribing. Reports were collected voluntarily and anonymously during an 18-month period using convenience sampling. Out of 484 reports, 75% corresponded to electronic prescriptions received directly into pharmacies’ computers, and 23% were computer-generated prescriptions that were faxed to the pharmacy. Forty-nine percent of the incident reports were related to comments, complaints, or identified unsafe conditions regarding electronic prescriptions. Directions (24%) and quantity selection (12%) were the primary problems reported.(7)
One challenge is the inconsistent ability to communicate with pharmacies electronically regarding changes to medications. Even though the EMR has a “note to pharmacy” section within the prescription, this seldom works. It was discovered that if a medication was changed in any way, the pharmacy received and processed the prescription as a new prescription, and the initial medication remained on the automated renewal system within the pharmacy. As a result, renewal requests were still being sent for the initial medication, even if it had been discontinued. The only time this did not happen was when a patient informed the pharmacy of the change. The 5S process revealed that if a prescription request was faxed back with the requested changes, it eliminated a duplicate request 98% of the time. Calling the pharmacy directly consumed too much time and produced only a 38% reduction in duplication of faxes. If nothing was done in response to the duplicate fax request, another duplication was sent 79% of the time.
If a patient was not compliant with office visits or labs, that also created duplicative requests for the team. If a physician deemed that a patient needed an office visit or laboratory tests done before a medication could be renewed, he or she would “reject” the request for renewal with a reason for the rejection. This information would go back to the staff that proposed the request and would be saved to the EMR. Within 24 hours, however, the same request was being sent again from the pharmacy. To address this issue, the workflow was modified to allow the scheduling team to contact the patient for needed follow-up. If the patient did not respond or was no longer a patient in the practice, this information was faxed back to the requesting pharmacy, directing them not to request the medication again. This stopped additional requests from the pharmacy. To improve efficiency with faxing requests back to the pharmacy a rubber stamp was created (Figure 1).
Figure 1. Stamp used to send duplicate faxes back to the pharmacy.
The physicians and rooming nurses were encouraged to renew medications for 12 months, if appropriate, when a patient was being seen for a yearly evaluation. The goal of this method is to synchronize the patient’s yearly evaluation with his or her next medication renewal, thereby eliminating any medication requests for at least 12 months. This practice is endorsed and recommended by the American Medical Association and has been proven to significantly reduce the annual cost and time spent renewing medications.(3,8) Although Florida prohibits refilling a non-controlled substance after 12 months from the date of issue of the original prescription, other states allow for up to 18 months.(3) It is recommended that medications be renewed to the maximum allowed by one’s given state.
After approximately three months of implementing these changes, the number of duplicate faxes was reduced from 32% to 14% (Figure 2).
Figure 2. A comparison of faxes received on a Monday morning at one clinic prior to the lean process implementation and a Monday after the process was changed.
A time study was performed during the initial assessment of the medication renewal process. They found that it took about 13.5 hours from the time the request for a prescription was received to the time it was approved by the physician. This affected the number of duplicate requests that were received every day. The first step in evaluating the time from request to approval was creating a spaghetti diagram. Review of the spaghetti diagram revealed that the fax machine and the desks used by the individuals involved with preparing the renewals were spaced significantly apart. In response to this finding, the workspace was consolidated, with desks closer to the fax machine, to improve the speed of preparing prescriptions to be approved by the physicians.
A swim lane diagram was developed for each site to visualize what steps were involved at each practice location when renewing a medication. This method revealed several differences in the renewal process among the practice locations. To improve the efficiency of the teams, one standardized renewal process was established for all sites. This defined the role of each individual involved in the renewing of medications and eliminated uncertainty about one’s responsibility. The department shares ancillary staff, and standardizing this approach improved the cohesiveness between team members while maintaining efficiency in the renewal process.
Patient education also contributed to improving the timeliness of renewing medications and reduced some of the workload on the teams. A flier was created to educate patients on the best way to request a medication renewal and what to expect regarding the time required to process their request (Figure 3). The primary objective was to have patients contact their pharmacies first and then have the pharmacy contact the office if a renewal was needed. Providing this flier to patients helped reduce phone calls and online portal requests for medications. This reduction in patient requests resulted in a more streamlined approach for renewing medications and decreased unnecessary work, allowing the staff to maintain focus on faxed requests.
Figure 3. Medication renewal flier developed for patients.
Once these changes were initiated and fully functional, the time from request to renewal was reduced from 13.5 hours to 8.5 hours consistently.
At the beginning of the prescription renewal project, all of the individuals involved in the renewal of prescriptions were electronically surveyed. Only 53% were satisfied with the process. After implementing the changes we have discussed and clearly defining the role of each individual in a standardized workflow, overall satisfaction increased to 73.6%.
As the number of prescription medications continues to rise, so will the workload for those in primary care practices who are responsible for renewing these medications. Developing a standardized approach to managing renewal requests will reduce duplication of work, increase efficiency, and improve satisfaction among staff members. Using a lean process approach is an effective way of identifying and eliminating unnecessary steps in the medication renewal process, thereby improving turnaround time on requests without sacrificing the primary care practice’s productivity.
During the lean processes, it was found that having the non-licensed office staff collect the fax requests was the most productive way of managing the large volume of faxes. The office staff then reviews the patient’s chart, makes a notation when the last office general health evaluation was, identifies any outstanding office visits, and contacts the patient to schedule any needed appointments. Once these steps are completed, the office staff provides the request to an LPN, who then reviews the patient’s medication list to determine if the request is appropriate. If the request is incorrect for any reason, the LPN uses the dedicated stamp and faxes the request back to the pharmacy. If appropriate, the LPN then proposes the request to the primary care physician electronically in the EMR and the physician then signs the request.
Initially, there was an attempt to eliminate the LPN from the renewal process and have a nonlicensed staff member manage the requests, including proposing the medication to the physician, with the goal of allowing the LPN to engage in more clinically relevant activities. Unfortunately, this approach generated several clinical questions, which resulted in delays and inappropriate medication proposals to the physicians, so it was determined that LPN involvement was needed.
Additionally, the renewal process was temporarily centralized to one practice location, but it was too difficult to communicate with the other sites, and the variations (e.g., practice hours, number of patients, residents) among the locations resulted in a delay in the renewal process.
Another challenge was managing the renewal requests for physicians who were out of the office. An alternating “doctor of the day” was implemented for renewing medications when a physician was out of the office for a period longer than 24 hours. This improved efficiency by providing clarity to the LPN proposing medication renewals. Additionally, APPs began to assist in the process, which diffused the work among the teams.
With the changing technology, medication renewals should become less laborious. It is anticipated that more EMRs will be bidirectional, with pharmacies allowing renewal requests to be sent directly into the EMR. This will eliminate the need for faxed renewal requests. Likewise, primary care practices will be better equipped to communicate electronically with pharmacies about medication changes. These advances in technology should decrease some of the demand placed on primary care practices and increase efficiency.
Medication renewals will always present a major challenge to primary care clinics.
Despite these changes, medication renewals will always present a major challenge to primary care clinics. Developing a standardized renewal protocol that delineates the responsibility of each member involved in the process is recommended, therefore. Additionally, renewing medications for the maximum number of refills allowed by one’s state will reduce the annual cost and time spent renewing medications. Disseminating the work among the healthcare team (e.g., office staff, nurses, APPs) relieves some of the burden placed on primary care physicians and allows for more clinically focused work. Using a lean approach is an effective way to identify unnecessary steps in the process of renewing medications, thereby decreasing workload and improving efficiency and staff satisfaction.
The Henry J. Kaiser Family Foundation. Total number of retail prescription drugs filled at pharmacies. https://www.kff.org/health-costs/state-indicator/total-retail-rx-drugs/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D . Accessed April 29, 2017.
Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176:473-482.
Sinsky TA, Sinsky CA. A streamlined approach to prescription management. Fam Pract Manag. 2012;19(6):11-13.
The Office of the National Coordinator for Health Information Technology. E-prescribing trends in the United States. www.healthit.gov/sites/default/files/oncdatabriefe-prescribingincreases2014.pdf .
Smith M, Sprecher B. Pharmacist communications with physician offices on prescription clarifications. J Am Pharm Assoc. 2017;57:178-182.
Krafcik J. Triumph of the lean production system. Sloan Management Review. 1988;41-52.
Hincapie AL, Warholak T, Altyar A, Snead R, Modisett T. Electronic prescribing problems reported to the pharmacy and provider eprescribing experience reporting (PEER) portal. Res Social Adm Pharm. 2014;10:647-655.
Sinsky C. Synchronized prescription renewal. AMA. www.stepsforward.org/Static/images/modules/1/downloadable/Prescription_Renewal.pdf .
Medication Renewal Request
Utilized advanced practice providers (e.g., nurse practitioner, physician assistant) to assist with non-controlled medication renewals;
Developed a “Doc of the Day” to cover physicians out of the office greater than 24 hours;
Decreased the distance between the fax machine and the staff proposing renewal requests;
Instructed staff to contact patients with missed visits or orders on hold prior to proposing the renewal request to the provider;
Emphasized reconciliation of the medication list during office visits to eliminate inaccurate renewal requests;
Standardized the renewal process for all sites involved; and
Produced a flier to educate patients on how to request a medication renewal.
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