When you have a prescription filled regularly for a chronic condition like high blood pressure or diabetes, chances are your pharmacy will ask you to opt in for a service that allows them to automatically refill the prescription before your medication runs out. Once you agree, you will be notified by robocall or email when refills are ready for pick-up. The service will continue to contact you until you finally stop by the pharmacy.

The good news is the service eliminates the need for the patient to remember to request a refill, so it helps patients follow their doctor's instructions. It can also help improve safety in the pharmacy since staff can better prioritize their work flow and they won't feel so rushed. Most pharmacists appreciate it because there's less urgency to dispense on demand since patients don't need to stand by in the pharmacy until the prescription is ready.

But there's also a downside. The system may be fraught with errors and waste. At issue is that electronic prescribing systems currently used by doctors do not communicate discontinued medications to the pharmacy. It's a known flaw that has gone uncorrected by the industry and government since e-prescribing began. Unfortunately, rarely do patients or their doctors remember to communicate to the pharmacy that changes in medication therapy have taken place. But if the pharmacist doesn't know about changes the computer is not reset. The autorefill system just keeps rolling along, dispensing unneeded and possibly harmful medicines.

I wrote earlier about a patient who was taking Cardizem, a heart medication. His doctor increased the dose from 240 mg to 360 mg. The elderly gentleman purchased the new prescription for diltiazem 360 mg but also received the diltiazem 240 mg prescription that had been filled earlier through the automatic refill program. After receiving a call from the confused patient, the pharmacist contacted the patient's doctor to determine which strength the patient should be receiving. Had the patient accidentally taken both strengths of Cardizem, it could have caused serious heart or blood pressure complications.

Earlier this week I heard from a pharmacist who said she had 3 different strengths of a thyroid medication in the autorefill process for the same patient. She found that the patient had received 10 prescriptions in 3 months. The patient was on Medicaid so the medication didn't cost anything. The patient just kept accepting the older strength prescriptions. When the pharmacist called to ask which dose was her current one, she said she had been in the hospital for a while and wasn't sure, but was probably taking all of them. The pharmacist told me she's had elderly patients who were taking two blood pressure medicines that were incompatible with one another.

While pharmacists do appreciate that autorefill systems can help to increase patient adherence to the doctor's instructions, they do have to spend a lot of time trying to manage prescriptions that should be discontinued when another strength or different drug is prescribed. Many pharmacists are swamped with workload and do not take the time to carefully evaluate the patient's medication listings for duplicate therapy. One has to wonder how many adverse drug reactions have been caused by these autorefill programs. Not to mention that billing patients for medications they don't really need is unethical or possibly even fraudulent.

As I said, this major flaw with pharmacy automation is well-known to the industry. But there hasn't been much movement to fix the problem. I hope it isn't because leaving it as is happens to be good for pharmacies and drug companies since the reminders assure they'll sell more drugs. It's certainly an issue that government and payers should be looking into. At the very least, we need to assure that discontinued prescriptions are properly communicated to the pharmacy that lists them. And we need to develop a system to assure that no automatically refilled prescription is handed to a patient without certainty that the prescription is still valid. This shouldn't be difficult to accomplish. Automatically refilled prescriptions that are awaiting pick-up could very easily carry a special computer-generated note to confirm validity prior to dispensing.


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