The article “A Streamlined Approach to Prescription Management” [November/December 2012] was well done! As with most process ideas, one size may not fit all. However, if I can become more mindful of this notion of synchronizing prescriptions throughout my day, I'll see opportunities to get more of my eligible chronic patients into this model and I will certainly save time overall.

One issue with the authors' system of bundling a patient's prescriptions and handling them all at the annual visit is that prescription refills often assist with appointment compliance. If a patient with diabetes must come into the office quarterly for refills, he is more likely to keep his appointments than if he were given a year's worth of refills.

Authors' response: In our practice, we do not use prescriptions as a hook, enforcer, or reminder for appointments. Rather, we promote adherence by scheduling each patient's next appointment at the conclusion of the current visit and then subsequently obtaining preappointment lab work. We aim to make the visit more meaningful than just a means to obtain a prescription renewal. Our approach includes an automatic pre-appointment reminder call, and for the 4 percent of our patients who no-show, we make a follow-up phone call to reschedule their appointment.

Consider the example of a patient with type 2 diabetes, hypertension, hyperlipidemia, chronic sinusitis, and depression. He is taking metformin, hydrochlorothiazide, lisinopril, atorvastatin, fluticasone, and citalopram at the time of the annual comprehensive care visit. Vitals and labs for this patient are as follows: A1C is 6.2, LDL is 90, and blood pressure is 160/80. Sinus and depression symptoms are well controlled. At the annual visit, we will increase the lisinopril dose and then resynchronize and renew all medications for 15 months. If the patient's blood pressure is not well controlled at the three-week follow-up visit, then the lisinopril will be further adjusted. When medications are changed, our nurses send a note to the pharmacist to discontinue the previous prescription.

If the rest of the patient's conditions remain stable, then the other five prescriptions need only be processed once per year. However, if a practice were to renew each of these medications quarterly, it would mean 15 more prescription renewals to address by phone/fax/email or at interval visits throughout the year. Multiply this work by, say, 1,000 patients who have multiple chronic disease medications, and you have just added 15,000 prescription renewals to your workload for the year.

Holding your entire patient population hostage with the threat of expired prescriptions adds unnecessary work to your practice and contributes to medication nonadherence. If there are specific patients for whom expired prescriptions are the only way to ensure continued compliance with follow-up visits, then limit refills for that small population only. It is not necessary to place the burden of this work on the practice for all patients. Remember to design your workflow to be efficient for 90 percent of patients and deal with the outliers separately rather than abandoning an efficient process because it is not applicable to a small minority of patients.