A preceding posting, How To Create and Use A Personal Medication Record, noted that (1) everybody, regardless of age and health, needs an individual Personal Medication Record that includes at least basic information about current medications and is always available to that person and those treating him or her and (2) several choices of Personal Medication Records (PMR) are available. Today, the focus is on the means by which you can audition the formats to determine how well a given PMR fits your needs.

In my research for these posts on the PMR, I discovered far too many offerings to provide viewers with even a representative sampling, let alone an exhaustive review. I also discovered, however, that there are a few telltale signals that provide valuable insight into the design of the PMR and its potential fit with the user.

To maintain accessibility to this essay, it occupies its own page within the AlignMap web site, where it can now be read at

• Test-Driving The Personal Medication Record
• Choosing The Right Personal Medication Record
• Compiling The Personal Medication Record
• Once More, Everyone - Not Just The Elderly - Needs A Personal Medication Record
• Another Reason The Personal Medication Record Is Essential

The Personal Medication Record - Part IV

Although this is the fourth and final AlignMap post focusing on the Personal Medication Record¹ (PMR) as an important method of decreasing unintentional medication noncompliance (i.e., errors in taking medication),² it summarizes the previous entries and can be read as a stand-alone manual on the practical steps to create and use a PMR.

Because there is an extensive amount of information and portions of the reading are quite dense, I have provided a condensed version of the lengthier discussion in the section entitled The No-Nonsense Summary just after the introduction.

Finally, the continuation of this post³ will be a description of some of the practical issues I found in creating my own PMR and will illustrate many of the points raised in this discussion.

To maintain accessibility to this essay, it occupies its own page within the AlignMap web site, where it can now be read at

Footnotes

1. ”Personal Medication Record” is the quasi-official name for a document with the important information about the medicines you take. Instead of “How To Create and Use A Personal Medication Record,” the title could have been “How To Create and Use A List Of Your Drugs,” “How To Make A Medication List,” “How To Make A List Of Medicines,” etc. [back]
2. The previous posts in this series were
   1. Everyone Needs A Personal Medication Record
   2. Choosing The Right Personal Medication Record
   3. Compiling The Personal Medication Record

   [back]

3. The continuation should be published in the next 2-3 days [back]

• How To Create and Use A Personal Medication Record
• Everyone Needs A Personal Medication Record
• Choosing The Right Personal Medication Record
• Compiling The Personal Medication Record
• Test-Driving The Personal Medication Record

The Personal Medication Record - Part III

[This is the third in a series of AlignMap posts offering pragmatic tips for decreasing unintentional medication noncompliance (i.e., errors in taking medication) with methods now available. It is also the follow-up to The Personal Medication Record - Part I:Everyone Needs A Personal Medication Record and The Personal Medication Record - Part II:Choosing The Right Personal Medication Record.]

1. Decide which data to enter into your Personal Medication Record based on its utility to you and your healthcare providers, not on the slots and prompts of a form.

2. Enter information. especially personal identifying data, only if it yields a distinct advantage that outweighs the risk of privacy invasion and fraud.

3. Revise your Personal Medication Record immediately if there is any change in the medications you take, regardless of why the change took place. An outdated PMR may not only be inaccurate but also dangerous.

Not Too Much Data, Not Too Little Data, Just The Right Data

Despite the simplicity of the fundamental concept of a Personal Medication Record, which is, after all, at its heart only a gussied up list of the medications you take, the choice of which information is entered into a PMR can is neither obvious or insignificant.

A Personal Medication Record can be significantly diminished in value if certain information is not included, yet if every imaginably useful data point is required, it can become so complex that errors are generated and so burdensome that one avoids using it. Entering still other specific information (as prompted in some formats) puts the PMR’s owner at risk for fraud and other abuse.

The precise content of your PMR may be influenced by multiple factors, such as your heath status, support system, economic situation, relationship with those treating you, etc. Your degree of concern about the privacy of your data and the potential for fraud also play a role in this decision. The important issue is that it is indeed a decision for you to make. That a given PMR form has a space indicated for your Social Security Number, for example, does not mean that you entering that information is a good idea.

Consequently, rather than list a one size fits all protocol, my goal is instead to assist you in deciding which information to include in your PMR. Toward that end, have listed all the data categories from the PMRs I’ve researched in one of four classifications: Essential Personal Medication Record Information, Non-essential Information With High Potential Utility, Non-essential Information With Possible Utility, and Optional Information of Limited Utility That Incurs Privacy Risks.

Group A: The Essential Personal Medication Record Information

• Date of PMR creation and of most recent update
• Patient’s name
• Primary physician’s name and contact information
• Emergency contact information
• Medication* name, strength, and directions for use
• The reason for taking the medication (e.g., “for high blood pressure” “precaution against infection secondary to dental work”)
• Allergies and other medicine-related problems

*Include all medications, including those taken only occasionally, (e.g., medication for pain) or seasonally (e.g., allergy medication), over the counter drugs, vitamins and dietary supplements, herbal medicines, and samples)

Group B: Non-essential Information With High Potential Utility

• Medication issues and precautions (e.g., “Take with food” “Avoid sunlight”)
• Start date of currently used medications
• Stop date of discontinued medications
• Non-medication healthcare supplies (e.g., blood glucose test strips for diabetics, CPAP settings)
• Pharmacist’s name and contact information
• Prescriber name(s) and contact information
• Age (Not birth date)
• List of current medical problems

Group C: Non-essential Information With Possible Utility

• Illustration or description of medication’s appearance
• Specific notation whether generic or brand name of the medicine is taken
• Date of last vaccinations

Group D: Optional Information That Incurs Privacy Risks

• Social security number
• Insurance Information (e.g., Company, Group Number, Policy Number)
• Birth date (Listing age is not a significant privacy risk; birth date is)
• Location where medications can be found in home
• Address
• Home phone number
• Cell number
• Date of birth

Instructions For Use Of Personal Medication Record

1. Create and maintain a separate Personal Medication Record for each individual.
2. Carry a current copy of your Personal Medication Record with you at all times
3. Bring extra copies to any healthcare appointment, including pharmacy visits
4. If there is any change in the medications you take, regardless of why the change took place, immediately revise your Personal Medication Record and change the “Last Revised” date. It is also essential to send an updated copy of your PMR to your primary physician and your pharmacist. Finally, destroy all copies of the now outdated PMR.
5. Take care to spell medication names exactly as they are listed on their labels (many different medications have similar names) and and list their dosages and the frequency with which they taken accurately. If you cannot do so or if you are unsure, bring all your medications, including over the counter drugs, herbs, and vitamins with you to the doctor or pharmacist to receive help in completing the list.
6. If your understanding of your medication regimen is not identical to the information in your PMR, ask your physician or pharmacist for clarification; prompting questions and facilitating enlightenment is an excellent use of PMRs
7. Keep one copy of your PMR with you at all times, another copy in a safe, easy to find place (e.g., in an envelope taped under the dash or seat of your car), and another with your emergency contact. Replace all copies if the medications you take change. These paper copies of your PMR are necessary even if it is available online (in that case, print out copies).

Additional Instructions For Use Of On-line Personal Medication Record

1. Arrange for your physician to receive instructions to access your on-line PMR. Check that your physician’s office received them and has actually completed the procedure to assure they can access your PMR
2. Change your password no less often than every three months

Next

The next and final Personal Medication Record post is the account of how I chose a PMR for my own use, completed it, and have put it to use, drawing on the information in the first 3 Personal Medication Record posts.

• How To Create and Use A Personal Medication Record
• Choosing The Right Personal Medication Record
• Everyone Needs A Personal Medication Record
• How To Create and Use A Personal Medication Record
• Test-Driving The Personal Medication Record

The Personal Medication Record - Part II

[This is the second in a series of AlignMap posts offering pragmatic tips for decreasing medication noncompliance by error with methods now available. It is also the follow-up to The Personal Medication Record - Part I: Everyone Needs A Personal Medication Record.]

1. Any Personal Medication Record, including a list scribbled on the back of an envelope crammed into a wallet, is better than no Personal Medication Record.

2. The perfect Personal Medication Record form that isn’t used and kept up to date is not as good as the 23rd best Personal Medication Record form that is used and kept up to date.

3. The importance of selecting a Personal Medication Record that is satisfactory to your clinicians is secondary only to the importance of that PMR being satisfactory to you.

4. The information in a Personal Medication Record or Personal Health Record that is stored, whether in written or electronic form, or is maintained on-line by an employer, pharmacy, medical provider, insurer, etc. is at risk for being stolen or provided, intentionally or inadvertently, with others. That risk can be minimized but not eliminated. The issue is whether the benefits outweigh the risk.

5. The major factors to consider in choosing a Personal Medication Record are (1) who provides the PMR and thereby controls access to it and (2) is the PMR is accessible on-line.

Many institutions and organizations, either alone or in collaboration, offer one or more versions of a Personal Medication Record (PMR) or a more comprehensive Personal Health Record (PHR) that includes a Personal Medication Record.²

The source of the PMR typically has a significant impact on its utility, cost, portability, accessibility, protection from theft and fraud, and especially the extent to which the privacy of its contents is guarded.

There may be no single Personal Medication Record from any source that combines all the best features with none of the negatives, but consumers should be aware of the tradeoffs before choosing one or another offering.

Personal Medication Records And The Healthcare Provider

One of the most important benefits of the PMR is providing your primary healthcare providers with information about the medications you are currently taking, even if someone else prescribed them or they are non-prescription drugs. Consequently, your Personal Medication Record should not only be easy for you to access and use but it should also be easy for your clinicians to access and use.

This principle is so fundamental that if your doctor or your healthcare organization offers³ or promotes a particular Personal Medication Record⁴ or expresses a preference in response to your query, I suggest you make that PMR your presumptive choice, opting for another format only if you find a distinct disadvantage with the clinician-preferred program (e.g., a significant fee is charged without compensatory benefits or the privacy policy is unacceptably lax) or another offering is clearly superior.⁵ My belief is that a clinician’s willingness to offer, promote, or state a preference for a PMR increases the chances that the clinician will be comfortable and skillful with that methodology and decreases the risk of using an unfamiliar PMR that the clinician finds frustrating or impossible to use.

In any case, I recommend that anyone choosing a Personal Medication Record check with the doctor’s office before making a final commitment to a format. I suspect most doctors will adhere to the same principle I do (i.e., that any medication list is better than no medication list) but the office may have experience with a given form and can advise that, for example, healthcare providers are not allowed on-line access to the Personal Medication Record affiliated with the XYZ Insurance Company. Additionally, asking for the doctor’s feedback can strengthen your working alliance with the clinician.

Advantages:

1. The clinicians who offer, promote, or prefer a specific PMR are more likely to use it, thus benefiting the patient
2. In a well constructed system, data collected by the provider will be automatically entered in the record rather than requiring the patient to do so
3. These programs are most often offered without charge

Disadvantages:

1. Patients who leave a practice that administers its own PMR will usually have to terminate their use of that system.
2. Provider-administered online PMRs may be less likely to allow other practices to access this data, regardless of the wishes of the patient.

Pharmacy-Affiliated Personal Medication Records

Many pharmacies, especially those in large chains make a PMR available. Also, in some regions, such as the states of Tennessee and Minnesota, pharmacy associations are involved in efforts to move to a standardized medication list format.⁶

Many of the drugstore chains have integrated a Personal Medication Record format into their refill ordering system and can alert you when refills should be due. At the least, nearly every pharmacy can provide a printout of your medication purchases, which may be helpful in completing your Personal Medication Record. Also, many pharmacists are willing to assist customers completing the forms, which may be helpful for anyone with a large number of medications, is unsure of the need for the medications prescribed, or needs extra help in organizing the record.

If you select your pharmacy’s PMR, be sure to list all your medications, not just those you purchase from that specific store. Include over the counter drugs, samples received from your clinicians, and prescriptions you fill elsewhere.⁷

Advantages:

1. Many pharmacies systematically monitor medication lists to alert customers to potentially dangerous doses or combinations of drugs
2. Some drugstore chains have integrated the Personal Medication Record format into their refill ordering system and can alert patients when refills are due
3. Much of the necessary data (i.e., the information re those medications obtained at that pharmacy) can be automatically entered, decreasing the patient’s workload and decreasing the risk of error
4. These programs are most often offered without charge

Disadvantages:

1. Fewer pharmacy-supported PMRs are available online

Personal Medication Records Provided By Health Insurers

Your health insurer may offer a Personal Medication Record, either free-standing or as part of a more extensive Personal Health Record, for their clients’ use. Many have designed their formats independently or in collaboration with hospital groups, pharmacists’ associations, other insurers, etc., and offer assistance in completing and storing them. This may be especially beneficial if you are involved in special programs offered by your insurer, such as a disease management program (e.g., for control of diabetes).

There are, however, two specific caveats:

1. Check the insurer’s policy re sharing information from the Personal Medication Record. Some insurance companies have maintained policies forbidding on-line access to this data to healthcare providers, regardless of the patient’s wishes.
2. Also check the company’s policy and procedures about the possibility of continuing the same insurer-administered Personal Medication Record should you change or drop your insurance with that company.

That these two issues are potential concerns does not mean that they are problems at all insurer-sponsored Personal Health Records. The following excerpt from Blue Cross and Blue Shield of Louisiana Introduces Portable Personal Health Record was selected for use in this post because it was the first documentation that turned up in my search that specifically addresses these points:

A third, even more serious concern is the potential that healthcare information held by the insurer could be used by companies to deny coverage or could be given, intentionally or accidentally, to others, such as employers, with deleterious results for the patient. This issue is especially worrisome because responses from insurers when this concern has been raised have characteristically been reassuring in tone but lacking in specific procedures that would safeguard the patient. The case is set forth in this excerpt from Insurers Push Patients Toward E-Health Records

More ominously, as noted in this report from the American Health Information Management Association “the Blue Cross Blue Shield of Illinois Web site informs members in the privacy disclaimer that information supplied may be used to better understand healthcare needs,” a clause so elastic as to justify almost any use of any information.

Advantages:

1. These programs are most often offered without charge
2. Much of the necessary data (i.e., the information re those medications covered through that insurance) can be automatically entered, decreasing the patient’s workload and decreasing the risk of error

Disadvantages:

1. Privacy issues are a potential problem
2. Patients who drop or change their insurance coverage may have to terminate their use of that system.
3. Some insurer-administered online PMRs do not allow on-line access to this data, regardless of the wishes of the patient.

Employer-Sponsored Personal Medication Records

Many employers supply Personal Health Records for employees to promote wellness programs and the concept of personal responsibility for ones own healthcare. The employer sponsored PMR may be administered by the employer-funded health insurance carrier and thus may resemble the insurer-sponsored PMRs and share its advantages and disadvantages.

Advantages:

1. Employer sponsored PMRs are usually offered without charge or at low cost
2. Employer sponsored PMRs may be linked to employer sponsored health coverage such that covered medications may be entered automatically

Disadvantages:

1. If the individual leaves the employer for another job, the PMR may be terminated.
2. There is the potential for the information to be used by the employer or other organizations to the patient’s detriment.

Independent Vendors Of Personal Health and Medication Records

Several companies, perhaps the most well known of which are Google⁸ and Microsoft,⁹ design and provide a Personal Medication Record, often as an element of a Personal Health Record, to sell to individuals who then control the content of and access to the record.¹⁰

Advantages:

1. The individual is in control¹¹
2. Many options, such as linkage to 911 systems, are available (at a price) or under development

Disadvantages:

1. Most charge a fee
2. The patient must enter all the data himself or herself

Pros and Cons of On-Line Personal Medication Records

Other than the issues arising as a result of which entity offers the PMR, the major factor in determining which Personal Medication Record best suits an individual is the distinction between those Personal Medication Records maintained on-line and those that are not.

On-line records almost always require a routine connection to the Internet (although some function so sluggishly with dial-up access that frustration could well discourage their use) and are password protected. They have the advantage of being available any time and (almost) anywhere, an especially important point in an emergency.

On-line records, however, do raise concerns about privacy and the trustworthiness and long-term viability of the organization providing service.

Concerns about losing data precipitously if the on-line provider folds are handled easily enough by maintaining ones own hard copy and electronic backups.

More problematic are the issues of privacy and theft. The consequences of one entire healthcare database falling into the wrong hands can be catastrophic. Consider this assessment from Loss of Protected Patient Information Real Danger for Health Care Plans

In fact, the increase in cybercrime has led to some advocating alternative technologies, such as portable media smart cards or encrypted USB keys to store health data, that are discussed later in this post. Of course, taking the data off the Internet sacrifices the advantage of 24 hour a day accessibility and facilitated sharing of information with, for example, emergency personnel.

Identity theft or fraud, data wrongly used by insurers, employers, or marketers, and data mining for litigation purposes are legitimate concerns about on-line health records that have, today at least, only incomplete answers.

As noted in the discussion of insurer-sponsored health records, one may wish to restrict data entry exclusively to medication information. If these on-line records do not include insurance ID and social security numbers, diagnoses, fiscal data, and similarly sensitive information, the risk of larceny is significantly diminished albeit not eliminated altogether.

For those of us who have surrendered the illusion of privacy for the convenience of Amazon holding the details of our credit cards for our next purchase there, limiting data we make available on-line and dealing only organizations with good reputations and track records may sufficiently assuage lingering anxieties.

And, there are alternatives available for those mistrustful of computers and the Internet, including a wide variety of paper and pencil medication records, electronic versions that can be used with a computer or handheld device (such as a Palm) without being accessible on-line, and hybrids which provide paper copies of electronically configured and stored files. Paper files have the advantage of requiring only basic literacy to complete and decipher but anyone who has kept a phone directory of friends for more than a year or two knows how difficult it can be to keep such files organized and decipherable. PMRs kept only on computers may be easier to construct but few of us carry our desktop computers with us at all times and emergency personnel may not be able to find a medication list within the documents stored in a Palm or to access password protected encrypted data.

Sample Personal Medication Records

The AARP offers a paper and pencil Personal Medication Record that can be downloaded at My Personal Medication Record as a Microsoft Word document or a PDF in English or Spanish or a printed copy can be ordered at 1-888-687-2277. Instructions on completing the form, how to manage updates, and more is also available.

The paper medication record developed by the American Society of Health-System Pharmacists is available at My Medicine List, and the MVP Heath Care full page and wallet sized formats can be downloaded in PDF format at Personal Medication List.

Information about free and for-fee on-line Personal Medication Records, courtesy of the American Health Information Management Association, can be found at My Personal Health Record.

Examples of companies selling encrypted USB keys for storing medical data include CapMed’s HealthKey and MedInfoChip.

WebMD Health Manager is an online service that organizes ones health information for a monthly fee.

Followme.com offers, for a yearly fee, both online and paper-based ways to manage medical records.

On-line PMR’s offered by providers (e.g., Kaiser-Permanente), insurers, and employers are available only to individuals affiliated with those organizations.

Next

The next post will address the information components that are essential to a Personal Medication Record, those that are optional but may prove helpful, and the information that is sometimes requested but may best be omitted. Then, to summarize this information, the final PMR post will be an account of my determination of the PMR best for me, the data entry for it, and how I use my PMR.

Footnotes

1. There is currently no formal definition of “Personal Medication Record” that is widely accepted, let alone a standardized Personal Medication Record format. A later post will discuss at length the essential and optional elements of a Personal Medication Record, but for now the Personal Medication Record can described, as it was in the previous post, as “a list that (1) includes at least the names of all the medications currently taken by the individual, the dosage of each medication, and the problem each medication is treating and (2) is readily accessible to that individual and to those treating that individual.” [back]
2. In the context of this post, the definition of the term, “Personal Health Record,” is that set forth by the American Health Information Management Association: The personal health record (PHR) is an electronic, universally available, lifelong resource of health information needed by individuals to make health decisions. Individuals own and manage the information in the PHR, which comes from healthcare providers and the individual. The PHR is maintained in a secure and private environment, with the individual determining rights of access. The PHR is separate from and does not replace the legal record of any provider. AHIMA e-HIM Personal Health Record Work Group. “The Role of the Personal Health Record in the EHR.” Journal of AHIMA 76, no. 7 (July–August 2005): 64A–D. [back]
3. The Department of Veterans Affairs is an example of a provider that supplies patients and employees Personal Health Records, including Personal Medication Records, developed in-house [back]
4. Some providers may provide access to data concerning their care but not allow the patient to enter additional data. If the patient cannot enter data, the offering is insufficient as a Personal Medication Record [back]
5. If the provider’s recommendation is rejected, it is essential that the person who made the suggestion is alerted to the decision and its rationale. [back]
6. See Personal Medication Record Campaigns Get Underway [back]
7. Whether or not you use the pharmacy’s Personal Medication Record, it is wise to routinely use only one pharmacy to consolidate all of your prescriptions and make it possible for the pharmacist to check for possible interactions and alert you to potential problems. This is especially helpful if more than one physician write prescriptions for you. [back]
8. See Google, then Gargle [back]
9. See Microsoft To Launch “Search-Engine Supported” Site For Health Records [back]
10. Other independent vendors may develop PMRs and PHRs which are sold to insurers, employers, pharmacies, and other entities who, in turn, offer them to individuals. In those cases, the characteristics, advantages, and disadvantages of the PMR are those of the sponsoring body. [back]
11. While the concept of the individual controlling his or her health information is fundamental to independent PMRs and PHRs, the sanctity of that principle is ultimately protected only by the integrity of that vendor [back]

• How To Create and Use A Personal Medication Record
• Compiling The Personal Medication Record
• Everyone Needs A Personal Medication Record
• How To Create and Use A Personal Medication Record
• Test-Driving The Personal Medication Record

The Personal Medication Record - Part I

[As I had indicated before technical problems intervened, the next AlignMap posts will deal with pragmatic tips for decreasing medication noncompliance by error with methods now available. Today's post is the first in that series.]

1. To achieve optimal healthcare in general and decrease unintentional medication noncompliance in particular, every individual needs a Personal Medication Record¹ - a list that (1) includes at least the names of all the medications currently taken by the individual, the dosage of each medication, and the problem each medication is treating and (2) is readily accessible to that individual and to those treating that individual.

2. Every individual needs a Personal Medication Record, regardless of the individual’s age, health status, and amount or type of medications taken, including those taking no medications.

A Medication List Is Essential For Optimal Healthcare and Patient Compliance

This is hardly a controversial recommendation. The most restrictive Google search for the term, “personal medication record,” shows over 13,000 hits, and my cursory scan of at least the first 100 indicates they are sites offering to provide such records or to instruct clients in their use.

Everyone Means Everyone

Yet, the large majority of these recommendations are directed at the elderly. And, while one might argue that older patients have the greatest need for such lists because they tend to take more different medications and to have more problems with memory than younger individuals, that hardly negates the value of a personal medication record for everyone else.

Spinning scenarios in which the brightest young adult on a single medication might nonetheless need a personal medication record is easy and amusing.

Less dramatically, it’s far too easy for anyone, even with an intact memory, to forget to include a medication, especially if it is an over-the-counter preparation or is taken only as needed, or to fail to notify one doctor’s office of a dosage change made by another doctor. Most of us have had the experience of shopping at the grocery store, only to return home without the item that was the primary reason for the trip. And, consequently, most of us acknowledge the wisdom of a grocery list. Well, “The Personal Medication Record” is, in its fundamentals, the gussied up version of that grocery list that we usually scrawl on the back of an envelope.

Even more mundanely, it saves time and reduces anxiety if one can respond to the triage nurse’s standard and important query, “Do you take any medications?” by handing over a written list rather than attempting to re-create that list from memory at a time when ones psychological and physical condition may be impaired.

And, “everyone” includes those who take no medication. The most empathic and clinically astute physician cannot ascertain from the absence of a medications list if the patient is taking no medication, one medication, two medications, 24 medications, … . A medication listing that reads “22 April 2007 - Currently taking no over the counter or prescribed medications” is potentially as useful as a list containing a dozen prescribed drugs.

Now that it’s clear Who should have a personal medication record (everyone, regardless of age and regardless of if he or she takes medication), the next post will focus on how to go about choosing Which of the many personal medication records available is best for a specific patient.

Footnotes

1. There is currently no formal definition of “Personal Medication Record” that is widely accepted, let alone a standardized Personal Medication Record format. A later post will discuss at length the essential and optional elements of a Personal Medication Record, but for now the Personal Medication Record can described, as it is above, as “a list that (1) includes at least the names of all the medications currently taken by the individual, the dosage of each medication, and the problem each medication is treating and (2) is readily accessible to that individual and to those treating that individual.” [back]

• How To Create and Use A Personal Medication Record
• How To Create and Use A Personal Medication Record
• Choosing The Right Personal Medication Record
• Compiling The Personal Medication Record
• Test-Driving The Personal Medication Record

Source: Drug diaries help patients keep their scripts straight
By John Stobo. National Review of Medicine. Vol 4 No 13. July 30, 2007

This article consists of practical advice from Dr Alan Forster for helping patients organize their medication to improve the odds that they will follow the prescribed regimen. While directed at elderly patients, the same tips could apply to any age group.

The key to his recommendations is the use of a medication diary,¹ which includes not only the schedule prescribed for the medication but also the side-effects, date the medication was started and stopped, and so forth.

Other recommendations, such as emphasizing hazards, promoting the use of memory aids, and staying in touch with patients, appear potentially useful although one should be aware that these appear to be distillations of clinical experience rather than evidence-based tactics. Research derived compliance enhancement methodologies being few and far between, however, tips such as these should be considered by practicing clinicians concerned about noncompliance.

Footnotes

1. A sample medication diary page is shown below.
   

   
   [back]

• Helping Patients Help Their Doctors
• Fixed-Dose Combinations Improve Medication Compliance: A Meta-Analysis
• Pillbox Organizers May Improve Adherence To HIV Treatment
• Medication Adherence Of ADHD Patients And Frequency Of Office Visits
• Patients’ Tool Improves Treatment Decisions, Adherence

The Midlife Midwife Returns

Readers may recall Looking At Patient Compliance From Both Sides Now, the 11 April 2007 AlignMap post that introduced The Midlife Midwife, who in Patient Compliance had compared her own resistance to following her dentist’s prescription for ongoing care of her teeth (e.g., flossing, regular exams) with the recalcitrance of her own patients to adopt her recommendations for preventive health care (such as pap smears, mammograms, and exercise).

At that time, she had also decided to undergo the necessary dental work she had deferred for seven years.

The Sequel

It turns out that, as is often the case in healthcare, the decision to undergo treatment was not the end of the story. In Patient Compliance ACT 2, we learn that efforts to prepare her tooth for a crown led to an exacerbation of problems and the necessity of a root canal. Having previously endured more than my share of ministrations by dentists of widely varying degrees of skill,¹ I am sympathetic to Midwife’s anxiety about dental work and the pain she is currently undergoing.

The good news, however, is that Midlife Midwife stubbornly persists in her determination to examine her own healthcare experiences for clues into how to better manage the patients in her practice:

Even more impressive, she has translated these considerations into behavioral changes:

Midlife Midwife’s new, more positively focused response to the belatedly compliant patient is along the lines of

And, since I couldn’t improve on her own conclusion, I’ll close my post with her final words:

Credit Due Department: Atop this post is a photo of an Iowa dentist, circa 1895, from the State Historic Society, Iowa City.

Footnotes

1. ”Dentists of widely varying degrees of skill” is, of course, code for “Some of the dentists I’ve seen were incompetent clods with more than a tad of the stereotyped sadistic streak; thank goodness the dentist I see now knows what he’s doing and is a nice guy to boot.” [back]

• My deal is that I have almost perfectly med compliant for 17 years–98.6 percent of the time
• The Impact of Parents’ Medication Beliefs on Asthma Management
• The Effect Of The Spouse Of An Autonomous Patient On Adherence
• Statin Choice Tool Clinical Trial
• Patient Compliance Subverted By The Temptation Of Now

A method that dramatically improves patient adherence to depression treatment: use of a flow sheet, coupled with patient education and diligent follow-up, improves medication adherence
by Gary Ruoff
J Fam Pract. 2005 Oct;54(10):846-52.

Premise

This pragmatically oriented article addresses adherence to medication by depressed patients although one suspects the same enhancements could well prove applicable to other diagnoses as well. Its premise, most of which is contained in the title, follows:

Study Parameters

While 103 patients were enrolled in the study, only 61 met criteria for the adherence measurement segment. No control group was used; comparisons were instead made to results from the clinical literature.

All patients completed a PHQ9,. were educated by their physicians, and were given explanations of the disease and the necessity of adhering to a prescribed 9 month regimen. A flow sheet, containing office calls, follow-up PHQ-9s, and other summaries of medication, comorbidities, and treatment regimens was completed for each patient. Patients were encouraged to schedule visits at 4 weeks, within 4 to 9 months, and at one year. At these appointments, physicians focused on the importance of continuing medication for at least 9 months. Nurses contacted patients who missed appointment to reschedule and to ascertain whether or not they were still following the regimen.

Results

According to the article,

Caveats

The author acknowledges certain limitations:

• The small number of subjects
• The lack of a control group (The author notes, “However, comparisons were made between this study and the adherence rates documented in other studies.”)
• Other than the PHQ-9, data collection was by patient self-report
• “Even though the project stressed patient adherence, the use of the flow sheet may very well have contributed to increased physician awareness and physician education, which therefore, in itself, may have resulted in improved patient compliance.”
• The results may be setting-specific

Author’s Recommendations

In keeping with the pragmatic tone of the article and the journal, the following recommendations are made (direct quotes):

1. Discuss with patients the need to continue medication for the prescribed period, to help ensure treatment success.
2. Be open about possible side effects of the drug you prescribe, and assure the patient that a change in medication can be made if the initial choice proves intolerable.
3. Consider using a treatment flow sheet as a means of tracking the patient’s course and as a prompt for regular communication with the patient.

Commentary

This is an article with built-in appeal; it’s straightforward, clinically oriented, and admirably audacious in its titular claim of a “method that dramatically improves patient adherence to depression treatment.”

From my perspective, however, the study’s limitations outweigh its utility. While its recommendations are at worst innocuous and, indeed, appear to compose a rational approach to compliance enhancement, there is little scientific evidence presented in their support.

Most egregious is the comparison of self-reported patient adherence, a data collection methodology repeatedly shown to produce overestimated rates of compliance, to a 33% adherence rate drawn from the literature. Indeed, the medication adherence issue in this study revolves around the finding that “40 of these 61 patients (66%) adhered to prescribed daily drug therapy for depression for at least 9 months — double the 33% adherence rate described in clinical literature.”

The reference given for the 33% compliance rate¹ lists, in turn, 6 other references as evidence for its declaration (as part of its general introduction) that “… rates of treatment discontinuation within 3 months after the start of treatment can reach 68%, depending on the type of antidepressant prescribed and the population studied.” My reading of that statement is that the worst case scenario is a noncompliance rate of 68%. If a researcher eschews a control group in favor of comparison to previous studies, it would seem that the comparison should be to a mean rate derived from several studies, to the rate from a study that is, for one reason or another, specifically congruent to the research being reported, or to the best results previously obtained. A quick search turns up a number of articles reporting higher compliance rates. Lin and associates, for example, found that “Approximately 28% of patients stopped taking antidepressants during the first month of therapy, and 44% had stopped taking them by the third month of therapy.”²

There may be valid reasons for using the Bull article’s 33% compliance rate; if so, it is incumbent on the author to make those reasons clear.

Footnotes

1. Discontinuation of Use and Switching of Antidepressants: Influence of Patient-Physician Communication.Bull et al. JAMA.2002; 288: 1403-1409. [back]
2. Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67–74. [back]

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Spotting Noncompliance By Joyce A. Cramer, B.S. Ophthamology Management April 2005

While the article’s focus is ostensibly on adherence to ophthalmologic medications, the principles can be widely applied across many diagnoses and treatments. The prevalence of noncompliance and the problems in recognizing it are discussed with a emphasis on the special difficulty in discovering noncompliance of the sort that occurs when a patient takes her medication erratically or only occasionally.

Common errors in diagnosing noncompliance, such as assuming that well educated patients are less vulnerable to noncompliance and that patients who have a good relationship with the clinician are more likely to be adherent to treatment, are also noted.

Eschewing the equivocation often noted in the clinical literature when considering the topic of compliance measurement, the author declares straightforwardly

The article ends with Ms Cramer planting yet another flag in what has become, justifiably, known as her designated territory – the correlation between simplified medication regimens and higher rates of compliance.

This is an excellent, if not comprehensive, introduction to the challenge the clinician meets on a day in/day out basis in trying to detect and deal with treatment noncompliance.

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Five Tips for Generating Patient Satisfaction and Compliance
Manoj Pawar, MD, Fam Pract Manag. 2005;12(6):44-46.
Posted at Medscape 07/13/2005

The parallels between yesterday’s post on Motivational Interviewing and this piece extolling the use of salesmanship in clinical practice are overt and obvious. The author of today’s article covers five points, making specific suggestions pertinent to healthcare.

1. Establish a Sense of Trust
Like good salesmen, clinicians must be perceptive listeners and careful observers of small details that provide clues about their needs, values, and goals.

2. Uncover Patients’ Actual Needs
This requires asking questions with a sense of curiosity to understand how patients perceive the world. Open-ended question are the beginning of the path, not the end.

3. Think Dialogue, Not Monologue
Just as customers dislike salespeople who dominate the interaction, patients dislike doctors who do the same.

4. Don’t Force “The Close”
Obtaining a commitment from the customer to buy a product or service is a salesman’s goal, but pushing customers to make this commitment too early can be catastrophic.

5. Always Follow Up
Just as effective salespeople check in with their customers after the sale to determine satisfaction and avoid problems, physicians should follow up to determine if the treatment plan is being followed and if it is working.

Commentary

While some physicians may be uncomfortable characterizing their interactions with patients as a sales pitch, man of the tactics of ethical salesmanship are directly applicable to patient interventions, making this brief paper well worth reading.

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These tips were found in Learning From Patient Noncompliance by Lili Church, MD (Fam Med 2000;32(1):11-2.)

The author suggests several issues to review whenever a patient is noncompliant. While the original focus seems to have been on training residents, there is much that could be useful in any physician’s practice. I’m especially taken with these three points:

1. Remember that they are the patient[s], not you
Although it’s a shibboleth and one that applies to many areas of healthcare as well as noncompliance, it’s nonetheless important to keep in mind the dangers of the clinician viewing the patient’s noncompliance as a personal affront.

2. Work with the patient to focus and identify what they do want to do. Encourage them to make a choice and try that. (Even no choice can be viewed as a choice.)
The author’s point is that egosyntonic recommendations are more likely to produce positive results than are confrontations about what the patient is doing wrong or not doing.

3. Regularly ask patients, “So, What Worked? What Do You Think Made the Difference?”
There are two benefits to this tip:

1. It’s a reminder that it’s obvious that clinicians should routinely ask their patients “What worked?” or “What have you tried that hasn’t worked?” Just as obviously, most of us don’t ask unless spurred on by a specific reason (e.g., a dramatic improvement or deterioration in the patient’s condition).

2. The phrasing is respectful to the patient, is an inquiry instead of an accusation, and aligns the patient and the clinician in a mutual task.

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