The Pharmaceutical Journal
Vol 270 No 7252 p787-788
7 June 2003

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Community pharmacist given direct access to GP records for reviews

Pharmacists can play a vital role in medication reviews. In a pilot that began in May, one pharmacist in Thaxted, Essex, has direct access to patients’ medical records from his pharmacy. Clare Bellingham (on the staff of The Journal) reports

Conducting medication reviews is an obvious role for pharmacists. But it is one that community pharmacists have largely been prevented from doing because they cannot access patients' medical records.

Some community pharmacists choose to undertake sessional work at general practitioners' surgeries in order to carry out medication reviews. Many more are unable to leave their premises so cannot become involved in such roles.

But can community pharmacists access patients' medical records from a community pharmacy? Some people say that this is not possible: they say that the technology is not there or they raise concerns over patient confidentiality. However, it is possible, it is secure, patient confidentiality is maintained and the technology exists today.

In what is believed to be the first scheme of its kind in the United Kingdom, Thaxted pharmacist Mike Barbour is able to dial into the local surgery's computer system and access patient records.

The project was initially the idea of one of the GPs at Thaxted surgery. Dr Rob Howlett explains: "I had read an article in the BMJ about pharmacists looking at repeat prescribing at a general practice. It showed benefits in lots of ways including reducing prescribing costs, improving the quality of care and linking the primary health care team. I thought it was a good idea so approached the primary care trust about it." He adds: "Doctors don't have enough time to check the quality of repeat prescribing. This provides an opportunity for the pharmacist to help with this and with costs. It is a win-win scenario."

Support from Uttlesford PCT and Mr Barbour quickly followed. The local pharmaceutical committee has also given the scheme its full backing. The scheme is being co-ordinated by Carol Roberts, the prescribing adviser for Uttlesford PCT.

What does the scheme involve?

First of all, patients are invited by letter to make an appointment for a medication review. The surgery identifies people who need reviews, largely based on the target in the National Service Framework for Older People, which states that all people aged over 75 years should have an annual medication review and all those taking four or more medicines should be reviewed every six months.

The letter stresses that the pharmacist is part of the surgery team: "The clinic is being run by an expert pharmacist. He is based in the pharmacy and works with your doctor." In addition, it points out that no medicines will be altered without the agreement of the patient and doctor. Patients are asked to bring all the medicines they take, including over-the-counter medicines and herbal remedies, and any medicines they have stopped taking.

After the first 10 invitation letters were sent out, five patients telephoned the pharmacy. Four made appointments for review and one said that she did not want to participate. One person required the review to be undertaken at home, something Mr Barbour is happy to do. The surgery has also asked him to conduct a mini-review by telephone for people who do not make appointments.

Patients are asked to give verbal consent for Mr Barbour to access their records and, providing it is given, this is recorded in the patients' notes. Mrs Roberts comments: "The practice was against us asking for written permission because they consider the pharmacist to be part of the team in the same way that district nurses are, and the district nurses don't have to ask for written consent."

Once the patient has given consent, Mr Barbour uses a laptop computer in the pharmacy to access the records. The laptop is password protected and also has a security system for access to the GP system. It involves a random pin number. First, Mr Barbour puts his personal pin number into a small calculator. Next he obtains a random number from the computer. He feeds this into the calculator and it "decodes" the number giving him a new response number. This is the pin number required to log onto the computer at that particular time — the random numbers change continually. Mr Barbour is having a dedicated phone line installed so that he can access the surgery's computer system at any time of day.

The review itself

In terms of conducting the review, Mr Barbour uses a standard set of questions adapted from published papers about medication reviews. It includes questions about how patients take their medicines, their knowledge about what the medicine is for, side effects and how patients store medicines.

Mr Barbour also uses information from the patient's record about previous drugs, other medical conditions and test results to recommend any changes needed to the patients' medicines. Mrs Roberts provides clinical support if it is needed.

The surgery is completely paperless. Any test results or letters from consultants are scanned into the computer and added to the records. So Mr Barbour is also able to check that monitoring has taken place and, if it has not, then recommends tests as part of a care plan, for example liver function tests for patients taking a statin.

Mr Barbour has access to all levels of the computer system: he can read everything and also add information. So he records the outcome of the review directly on to the patient's medical record. If a change to a medicine is required then he indicates this on the record entry to ask the doctor whether the change can be initiated. At the same time, he sends an internal e-mail to the doctor to alert him to the fact that a medication review has been carried out. The doctor then replies to Mr Barbour by adding a note in the patient's record.

If Mr Barbour discovers an urgent problem he telephones the surgery to discuss it with the doctor. However, since most of the medicines are prescribed for chronic conditions, problems are less urgent and communication via the records is fast enough.

Once the GP has given the go-ahead, Mr Barbour is allowed to make changes to the patient's repeat prescription. Changes might include deleting an inappropriate item or adding an item.

The reviews are conducted in a new consultation "quiet area" of the pharmacy. It is at the end of the counter with a door to the shop floor and a sliding panel into the dispensary allowing Mr Barbour to keep an eye on the counter when he is in the quiet area. "The pharmacy staff have been trained to interrupt me for queries or prescriptions during consultations," he says. "I also leave an hour between appointments to allow me to sort any issues out."

In addition to the medication reviews, Mr Barbour reviews patients' prescriptions without seeing the patient. Some of these reviews will look at cost savings. Mr Barbour is able to carry out the following changes to patients' medicines without contacting the surgery:

• Optimising strengths

• Synchronising quantities

• Making generic substitutions

• Discontinuing any old or unused repeat medicines

For other cost-saving changes, such as correcting for duplications of therapy or stepping down proton pump inhibitors, he has to advise the doctor and obtain authorisation before he can make a change.

Since Mr Barbour uses a laptop to dial into the surgery, he only needs a phone line to be able to access the records. This means he can take the computer with him on home visits. The scheme is also planned to be extended to residential homes, and having the computer to take with him on these visits will be essential.

Time and money

The review process takes an hour per patient. This is broken down into 15 minutes' preparation work before a consultation to look at the patient's notes, half an hour for the consultation itself and then 15 minutes afterwards to prepare recommendations for the GP. Mr Barbour is paid £20 per hour by the PCT and it is expected that, during the pilot, he will see 30 patients a month.

In addition, he is paid for two hours a week to look at cost-saving interventions through prescription review only (not seeing the patient face to face). The PCT also funded some training time and the secure link to the practice computer. Before starting the scheme, Mr Barbour completed the prescribing support series of packages produced by the College of Pharmacy Postgraduate Education. The quiet room and laptop computer were funded by Mr Barbour as part of a planned refit.

"Thaxted is a one-surgery, one-pharmacy town so I collect the prescriptions from the surgery in the morning and get most of them dispensed in the morning. This means that the afternoons are quieter so I can book patients in for review then," he explains. "The biggest challenge for me is time," concedes Mr Barbour. "Before the scheme started I was always busy so I have had to free some time." In order to make better use of skill mix, he has employed a new member of staff to take on some of his roles so he has the time to conduct the reviews.

One of the advantages from the PCT point of view is that the scheme is cost-effective and sustainable. Mr Barbour comments: "It is important from my point
of view to have a scheme that works in community pharmacy. It is not a long-term viable option for pharmacists to be off the premises." Apart from anything, PCTs cannot afford to fund locums to cover pharmacists being away from the pharmacy. He also speculates that this is the reason that many projects do not go past the pilot stage.

GP viewpoint

Thaxted surgery is a dispensing practice. About half the patients have their medicines dispensed by the practice and about half are given prescriptions. However, they are all offered medication reviews at the pharmacy.

Dr Howlett comments that the medicines are prescribed in the same way so patients should be given the same medicine review because the review is not about dispensing. So far patients who get their medicines dispensed by the surgery have been happy with the idea of going to the pharmacy for a review.

"Some patients do not ever see a pharmacist so this scheme gives them some appreciation of pharmacists' skills and encourages them to come to the pharmacy in the future," says Mrs Roberts.

Dr Howlett says that one of the reasons the scheme works in Thaxted is because the pharmacist is considered to be part of the primary health care team. "Mr Barbour is effectively part of our team so having him as a named individual dialling into the practice system is fine." Security is a real issue and this is the reason that locum pharmacists do not have access. "One person dialling in is fine but it could not be a carte blanche."

Mr Barbour attends practice meetings at the surgery and is in regular contact with the PCT prescribing team. Mrs Roberts explains: "We want him to be aware of the prescribing issues for the PCT. If he is making recommendations to the practice then we have to make sure that they are not different to the PCT prescribing team's."

The pilot stage of the scheme will run for six months. It will be evaluated in two ways: by examining cost savings from more appropriate prescribing and by looking at whether the quality of care has improved by rating the consultations and interventions.

The future?

It is clear that this scheme works because the three parties involved — the pharmacy, the surgery and Uttlesford PCT — have close working relationships. None is competing; they are working together for the best joint outcome.

Could this project be rolled out? Mrs Roberts says "yes in principle" but there are conditions. First there is the need for the GP surgery to be paperless. More and more surgeries are switching to becoming entirely computerised but it is a slow process. A good history of co-operation is needed between the GPs and pharmacist. The computer and telephone line, and the quiet area in the pharmacy, need to be funded.

The scheme works well here because there is one pharmacy and one surgery. How it would work in a town with several pharmacies is more complicated. But the scheme shows what is possible.

These same conditions apply to how successful this project could be nationally. Pharmacists have to work closely with GPs before this type of scheme can begin and convince them of what they can offer. If they do so then there is no reason to stand in the way of community pharmacists all over the UK accessing medical records and conducting medication reviews in this way.

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