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Introduction

Collecting patient-specific information for MTM involves a combination of 1) obtaining information from the patient's medical or pharmacy records, and 2) obtaining information directly from the patient, and 3) communicating relevant information to other providers. An overarching goal of MTM is to connect these sources, so the patient understands what has been prescribed, and the prescriber recognizes how the patient is using medical therapies. Based on the information collected, collaborating providers can determine which components of the overall regimen are in the person's best interest.

Obtaining patient-specific information is not necessarily a straightforward process. Medical history information is not always readily available to the pharmacist.  Conversely, the physician may not have medication fill or refill history from the pharmacy available in the patient's electronic medical record (EMR). By optimizing data collection in both "data poor" and "data rich" environments, the pharmacist who is conducting an MTM session is likely to identify some conflicting information between the physician's records and what the patient says he or she is taking. Therefore, obtaining information from patients in a way that elicits open communication and promotes a positive approach to self-care is a skill that pharmacists must develop during the process of conducting MTM sessions.

Gathering Information In Advance

Ideally, the pharmacist should begin the MTM process with access to information about the patient's medical history and medication use. How much data can be gathered in advance often depends upon the practice setting: in hospitals, long-term care settings, or primary care/outpatient clinics, a paper or electronic medical record can often be examined to begin the process of creating a personal medication list and MTM action plan. Such settings may be considered "data-rich" environments.¹

Pharmacists or staff members can initiate contact with the patient's healthcare provider in advance of an MTM session to seek medical records or any specific missing details. Realistically, pharmacists should not rely on timely and complete medical records from other providers.  When patients consent to participate in MTM, they should be provided with Health Insurance Portability and Accountability Act (HIPAA) forms that allow sharing of information between physicians and the pharmacy or MTM provider. When the patient signs the form prior to MTM, the pharmacy must keep a copy of the form. The physician's office may request a copy of the signed HIPAA form in order to release information to the pharmacy. If information is being transferred electronically, it's important for the pharmacist to be familiar with firewalls within the organization (e.g., a pharmacy chain) that can help to safeguard patient privacy.²

Physicians' offices are not required to provide patient information to pharmacists without a HIPAA release form; however, the Centers for Medicare & Medicaid Services (CMS) advises physicians who accept Medicare Part D patients that MTM providers may be contacting them for information about their patients.³ These requests for patient medical records or other data from doctors' offices may be delayed. Requests may be met with resistance due to a heavy administrative burden in the medical practice or other factors.  Sometimes, engaging the patient or caregiver to help in obtaining medical records can facilitate the process.  However, some medical offices will charge a fee for this service. Some electronic medical record systems will allow pharmacists and other caregivers to access patient records in a "read-only" format.

Sometimes, little or no background information is obtainable from outside sources. If so, the MTM session must rely mainly on details supplied by the patient and/or caregiver. Many pharmacists operate in environments where only limited patient information is available in advance of MTM. Community pharmacies may be examples of "data-poor" environments.¹

Table 1 contains a checklist of sources for patient information for use in MTM, to be obtained before the MTM meeting and during the interview portion.

Table 1. Source Document Checklist Before MTM session, if applicable Electronic medical record, from primary care physician or outpatient clinic In-house pharmacy records Medication utilization documents from Part D sponsor or payer (insurance company) Hospital discharge instructions Recent laboratory results Pharmacy claims history (fill history, cost information) During MTM interview (to be brought by patient/caregiver) Medical records or lab results Prescription containers (preferable) or lists of medications taken Supplements (in original containers when possible) Over-the-counter medications, in original packaging if possible Symptom diaries, adherence diaries/records kept by patient Syringes, inhalers, other devices used by the patient

Preparing the Patient for an MTM Session

When communicating with the patient prior to an MTM interview, it's a good idea to encourage the person (or the caregiver) to bring along as many items as possible (in a gym bag or other container) that may be related to medication therapy.  Some patients are meticulously organized with their medications; others may bring in a shoebox with a jumbled mix of prescription and over-the-counter medication containers. Having the actual items in hand provides a more accurate picture of the medication names, doses, and number of doses remaining in the container than would a written list or the patient's own recollection. For example, the patient may choose to bring some older prescriptions that are not documented on the physician's record. He or she may not be aware of why they are being taken, or whether they should still be taken. So, while it may seem time-consuming to pick through all the containers, this process can be done as part of an active dialogue with the patient that is likely to yield much information. Many people are "visual thinkers" and/or have low health literacy levels. Thus the person may be more likely to be able to answer the question, "How do you take this medicine?" as you are holding the bottle or an individual tablet, than if they are asked by medication name alone.

Health literacy is often different from other types of literacy. It's important to keep in mind that anyone—even someone who is highly educated—may be unaware of the generic name of a branded medication, mix up the names of one or more of the drugs being taken, or fail to understand the intended purpose of a medication or how to interpret the patient instructions.

When the pharmacist or pharmacy technician confirms the patient's MTM appointment over the phone, this is a very good time to remind the person to bring along everything related to medication use (see Table 2). This includes old medications (to evaluate for refill or disposal), non-oral formulations (such as patches, topical preparations, and injectable medications, and recent lab reports.

Table 2. Key Steps to Prepare in Advance for an MTM Session Background research Obtain available information from pharmacy, medical, or health plan records Identify the patients' apparent diagnoses and chief complaints MTM appointment planning Note if the person will be coming to the appointment alone or with a caregiver/relative Prepare relevant HIPAA forms (these may be needed prior to obtaining information from providers for MTM) Clearly advise the patient/caregiver on what to bring to the appointment, including all prescription and over-the-counter medications, laboratory work, etc. Setting the stage Determine if there are any special needs regarding communication (e.g., need for a translator) or accessibility (e.g., wheelchair access) Reserve a private space where the MTM provider and patient can sit comfortably and privately Assemble forms and background information Obtain pharmacy records ahead of time to avoid searching during the session Ensure that any permissions or forms requiring the patient's signature are on hand Gather templates or forms needed to compile the patient's medication list and action plan

Tips and Techniques for Interviewing the Patient

Making the most out of the time in a face-to-face (or telephone) patient interview is a key goal for an MTM session. Appropriate interviewing techniques can help to make patients feel comfortable and more open to sharing detailed, often-personal information. For many people, talking about medications, health problems, and daily habits is deeply personal—and may often be embarrassing or awkward. The principals of motivational interviewing—expressing a non-judgmental attitude using open-ended questions, affirmative statements, reflective listening, and summarizing statements—will further the goals of MTM. More details about the techniques involved in motivational interviewing are covered in Module 5, Communication Essentials and Module 14, Adherence.

Setting the stage
MTM should be conducted in a private setting, whenever possible, where other staff (and certainly members of the public) cannot overhear the discussion. The session should begin with an introduction. ("Good morning, Mrs. Jones. I'm ________. I'll be talking to you about your medications.") If the patient brings along a family member or friend, be sure to ask the patient's permission (and give them options) prior to including the other person in the interview session. ("Are you comfortable having your son present, or would you rather call him when we're finished?").  Sometimes a formal meeting with a pharmacist in this setting to speak about medications may be new to patients.  It is important to discuss general goals for the visit and/or provide background on the pharmacist. The patient should understand that the pharmacist and their physician are a team and all decisions will be handled collaboratively.  It is also helpful to elicit the patient's goals for the visit.  The pharmacist can ask: "If there is one thing I can do for you related to your medications, what would it be? Or, "What are you hoping to get out of our visit today?" Because the session may last up to one hour, the patient should be comfortably seated. The pharmacist conducting the MTM interview can help to increase the person's comfort by:

• appearing relaxed—not rushed or distracted
• maintaining eye contact
• avoiding distractions and interruptions
• silence your smart phone (if you use it during the visit to obtain drug information, make sure you explain what you are doing to the patient)

Steps in the interview process
A chief goal in the MTM interview process is to establish a rapport with the patient and a sense of trust that will enable the pharmacist to obtain truthful information. A top priority is to establish whether the patient recognizes the need for the medication/s.

The list in Table 3 covers the basic recommended steps of the patient interview.

Table 3. Steps in the MTM Patient Interview Introduce the benefits of MTM: how it's different from usual pharmacy services; why MTM can help the patient to better manage and understand medication use Also introduce the pharmacist's background and provide an overview for goals of the visit Determine the patient's chief complaint: "What are your main concerns about your medications or healthcare?" Gather social history: marital status, living situation, occupation, cooking/eating habits Use of alcohol, tobacco, caffeine, illicit drugs Past medical history, family medical history Allergies and adverse reactions to medications, if any Medications tried and failed in the past (and reason why) Lab results, blood pressure, weight, pulmonary function testing results, etc.  Medications Perceived indication: Why are you taking this medicine? Dosage: How are you taking it? How often? (Note if medication is PRN) Perceived effectiveness: Is this medication doing what you expect it to? Perceived safety/tolerability: side effects, interactions Convenience/adherence: How many doses would you say you miss per week? Is there something about this medication that makes it hard to use it regularly? Usual medication-taking behaviors (does the patient use an adherence aid, is a caregiver involved, etc.) Affordability: Are there cost or co-pay issues that affect how often you take or refill these medicines?

Using Subjective and Objective Information to Develop a Problem-Oriented Medical Record

When organizing the data from various sources, some MTM providers follow the problem-oriented or "SOAP" system, beginning with Subjective information (based on the patient's opinions and personal understanding of their experience on a medication), followed by Objective information (dosage, administration, etc.). The last two aspects of SOAP, Assessment and Plan, are discussed in more detail in Module 4. Subjective information refers to anything that cannot be validated with objective evidence.  Even laboratory values reported by the patient must be considered subjective unless they can be verified with a lab report or other evidence.

Recording Medication-Specific Information: SOAP

Document for each medication (including OTC and supplement)

SUBJECTIVE:

Does the patient understand/acknowledge the need for the drug?
What is the patient's perception of this drug's efficacy?
What adverse effects/tolerability issues has the patient experienced?
Has the patient taken the agent as directed? If not, what barriers to adherence are present?
Have the medication directions changed since the prescription was written?

OBJECTIVE:

Name of medication/brand or formulation used
Prescriber
Dosage/route of administration
Indication: Why is the medication being taken?
Index date (date of original prescription)
Special instructions or precautions (e.g. allergies, interactions)
Physical assessment and lab values obtained at the visit (blood pressure, HbA1c, etc.)

ASSESSMENT:

A brief but complete description of the problem and description of therapeutic options.  These usually include the benefits and limitations of each viable option. List in priority order of most important to least.
A conclusion or diagnosis supported by the subjective and objective data
(Should not include a problem that is not supported by the subjective or objective data)

"Patient has not taken preventive medications and is at high risk for rehospitalization."
"Patient needs education about the risks of a secondary thromboembolic event such as stroke or heart attack."

PLAN: (Should be short, to the point, and without opinion. A simple statement of what was done or is to be done for the patient and who will complete the task.)

Recommended further workup
Treatment
Patient education
Monitoring
Follow-up

Table 4. Summary of Patient and Medication Information General patient demographic and medical information: Patient contact and emergency contact information Provider contact information (all providers/prescribers) All pharmacies being used for prescriptions Allergies, including medication allergies For each medication: Why are you taking this medication? What purpose does the medication have? How is this medication helping you?  Do you believe it is helping you? What dose did the doctor prescribe? What are the instructions for its use? What dose are you taking now? How often do you miss these doses? What trouble does this medication cause? How are you taking it? What time of day? What does "twice daily" or "take 2 tablets daily" mean to you? How do you feel when you take it? Is there anything about taking this medication that bothers you? What warnings or risks about the medicine worry you? How does this affect the way you take it? What about affordability? Do you ever skip doses or avoid refilling the medicine because of the cost?

The Personal Medical Record: What It Is, What It's Not

The essential take-home document for the patient following an MTM session is the Personal Medication List (PML). This document goes by many names, including personalized medical record (PMR). According to CMS, the Personal Medication List:

"...Is intended to help your patient understand their medications and how they relate to their treatment plans. Your patient can make notes on their Personal Medication List such as when and why they stopped taking a medication."^3,4

What It Is:

• A record for use by the patient in managing current medication therapies
• Concise, usable, portable
• Combines medication information with actionable items for the patient
• Able to be shared with other healthcare professionals
• Updated regularly and dated
• Integrated into the patient's electronic medical record, if possible

What It's NOT:

• A complete history of all the medications a patient has ever taken
• A heavy discharge summary with legalese and a small portion 
• A document that contains jargon, acronyms, or assumptions that could be misunderstood by the patient
• A substitute for the Comprehensive Medication Review kept by the pharmacist

The next module (Module 4) contains the steps for taking all the information that has been gathered throughout the MTM process and developing a strategy that will benefit the patient and/or caregiver, the physician or other healthcare provider, and the payer/health plan. There are many approaches to doing this, depending on the practice setting.

Conclusion

Information gathering is an essential part of the MTM process. It may seem sometimes that there exists too much information about a given patient—especially those with long medical histories and multiple chronic diseases. It is the role of the MTM pharmacist to find out whether that information is up-to-date, accurate, and relevant to the patient's current health status and needs, in order to begin the process of fine-tuning the healthcare regimen.

References

1. Stebbins MR, Cutler TW, Parker PL. Assessment of Therapy and Medication Therapy Management. In: Alldredge BK, Corelli RL, Ernst ME, et al. Koda-Kimble and Youngs Applied Therapeutics : The Clinical Use of Drugs. 10th ed. Baltimore: Wolters Kluwer/Lippincott Williams & Wilkins; 2013.
2. HIPAA and Privacy 2013: A survival guide to the law. Pharmacist's Letter. Volume 2013, Course 301. Available at: http://pharmacistsletter.therapeuticresearch.com/ce/cecourse.aspx?pc=13-303.
3. Centers for Medicare & Medicaid Services (CMS). A Physician's Guide to Medicare Part D Medication Therapy Management (MTM) Programs. MLN Matters Number SE1229.
4. Centers for Medicare & Medicaid Services (CMS). CY 2014 Medication Therapy Management Program Guidance and Submission Instructions. April 5, 2013.

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