CCPP Module 12, Section 1: Conducting Complete Medication Reviews (CMRs)
MODULE 12: COMPREHENSIVE CLINICAL ASSESSMENT

Section 12.1: Conducting Complete Medication Reviews (CMRs)

A deep dive into the systematic process of a true CMR, moving beyond basic medication reconciliation to a thorough evaluation of every medication for appropriateness, effectiveness, safety, and adherence.

SECTION 12.1

Conducting Complete Medication Reviews (CMRs)

From Clinical Detective to Therapeutic Architect: Mastering the Pharmacist’s Most Powerful Tool.

12.1.1 The “Why”: The Philosophical Shift from Reconciliation to Review

In every facet of your pharmacy education and practice, you have encountered the term “medication reconciliation.” You have performed this task countless times—at the community counter, during an MTM session, at hospital admission and discharge. It is the foundational act of creating an accurate list of what a patient is taking. It is an essential, life-saving process that prevents countless errors. But it is only the beginning of the story. Medication reconciliation is an act of accounting; a Complete Medication Review (CMR) is an act of clinical judgment.

To transition into a truly collaborative practice role, you must make a profound philosophical shift. The goal is no longer simply to create the most accurate list possible. The goal is to take that list and subject it to a rigorous, systematic, and evidence-based clinical investigation. A perfectly reconciled list that contains dangerous, ineffective, or inappropriate medications is a perfectly documented failure. The CMR is the process by which you transform that list from a static inventory into a dynamic, optimized therapeutic plan.

This shift is about moving from “What is the patient taking?” to a series of much deeper questions: “Why are they taking it? Is it working? Is it harming them? Can we do better?” A CMR is not a passive review; it is an active clinical encounter. It requires the same diagnostic rigor a physician applies to a set of symptoms. You are not merely a consultant on drugs; you are a diagnostician of medication-related problems. You are the specialist who looks at the entire picture—the patient, their diseases, their labs, their lifestyle, and their medications—and identifies the points of friction and opportunities for optimization that others have missed. Mastering the CMR is the single most impactful skill you can develop. It is the core of what it means to be a clinical pharmacist.

Pharmacist Analogy: The Home Inspector vs. The Mover’s Inventory List

Imagine you are buying a new house. You hire two different professionals. The first is a moving company, and they provide you with a detailed, room-by-room inventory list. It meticulously documents every piece of furniture, every box, and every item the previous owner has. This list is accurate, comprehensive, and perfectly organized. This is Medication Reconciliation. It tells you exactly what is there.

The second professional you hire is a licensed home inspector. They don’t just list what’s there; they investigate its function, safety, and appropriateness. They go into the basement and check the foundation for cracks (evaluating for untreated conditions). They test the plumbing for leaks and pressure (assessing for safety and adverse effects). They examine the furnace to see if it’s heating the house efficiently or if it’s dangerously old (judging effectiveness and appropriateness). They climb on the roof to see if it’s about to fail (predicting future risks). They might discover that the beautiful new stove is wired improperly and poses a fire hazard, or that there’s a slow leak behind a wall that will eventually cause catastrophic damage.

The home inspector’s report is the Complete Medication Review. It uses the inventory list as a starting point but goes far deeper to provide a clinical judgment on the safety and function of the entire system. As a collaborative practice pharmacist, you are the home inspector. The patient’s health is the house, and their medications are the plumbing, wiring, and appliances. Anyone can make a list of what’s there. Only a clinical expert can determine if it’s safe, effective, and built to last.

12.1.2 The Systematic Framework: The Four Pillars of a World-Class CMR

A powerful investigation requires a reliable framework. To avoid missing critical issues and to ensure your review is comprehensive every single time, you must build your CMR around four central pillars. For every single medication on the patient’s list, from their lisinopril to their daily multivitamin, you must ask the core questions associated with these four domains. This systematic approach transforms the review from a random series of checks into a disciplined clinical process.

Masterclass Table: The Four Pillars of Medication Review
Pillar Core Question Pharmacist’s Deep-Dive Investigation (Key Questions to Ask)
Appropriateness Does this patient need this medication?
  • Indication vs. Medication: Is there a valid, documented, and current indication for this drug? Match every drug to a problem on the problem list. If you can’t, it’s a major red flag.
  • Untreated Indications: Conversely, look at the problem list. Are there any conditions that should be treated with medication according to clinical guidelines, but are not? (e.g., A patient with diabetes, hypertension, and albuminuria who is not on an ACE inhibitor or ARB).
  • Therapeutic Duplication: Is the patient taking two or more drugs from the same class for the same indication without a clear, specialist-driven rationale? (e.g., two NSAIDs, an ACE inhibitor and an ARB).
  • Prescribing Cascade: Is this medication being used to treat a side effect of another medication? (e.g., prescribing a laxative for opioid-induced constipation; prescribing a memory medication for confusion caused by anticholinergics). This is a critical area for pharmacist intervention.
  • Contraindications: Is the medication contraindicated due to a patient’s concurrent disease state, allergy, or other medications? (e.g., an NSAID in a patient with advanced CKD and heart failure).
  • Non-Drug Therapy: Is there a non-drug therapy that might be more appropriate or could reduce the need for this medication?
Effectiveness Is this medication working?
  • Therapeutic Goals: What are the specific, measurable goals for this therapy? (e.g., “A1c < 7%", "BP < 130/80 mmHg", "LDL < 70 mg/dL", "no seizures in the last 12 months"). Are these goals documented and appropriate for this specific patient?
  • Achieving Goals: Is the patient actually achieving these goals? Review lab data, clinical notes, and patient-reported outcomes. If not, why?
  • Dose Optimization: Is the dose appropriate to achieve the goal? Is it too low (sub-therapeutic)? Has it been titrated to effect? Or is it at the max dose with no further benefit?
  • More Effective Alternative: Is there a different medication that is proven to be more effective for this indication, either through guidelines or patient-specific factors?
  • Duration of Therapy: Is the duration of therapy appropriate? (e.g., Is a patient still on a PPI for stress ulcer prophylaxis six months after their ICU stay?).
Safety Is this medication causing or risking harm?
  • Adverse Drug Reactions (ADRs): Is the patient experiencing any side effects? This requires meticulous interviewing, as patients often don’t connect a symptom (like a dry cough or muscle aches) to a medication.
  • Dose Too High / Toxic: Is the dose too high based on the patient’s age, weight, or organ function (especially renal or hepatic)? Calculate CrCl for every patient.
  • Drug Interactions: Systematically screen for clinically significant drug-drug, drug-disease, drug-lab, and drug-food interactions. Don’t just rely on software; use your clinical judgment.
  • Monitoring: Is appropriate laboratory or clinical monitoring being performed to ensure safety? (e.g., INRs for warfarin, LFTs for statins, potassium and SCr for ACE inhibitors). Is the monitoring happening at the correct frequency?
  • High-Risk Medications: Pay special attention to drugs on the Beers list for elderly patients, drugs with a narrow therapeutic index, and drugs that require REMS programs.
Adherence Is the patient able and willing to take this medication as intended?
  • Understanding: Does the patient know what each medication is for and how to take it correctly? Assess health literacy.
  • Practical Barriers: Are there physical barriers to adherence? (e.g., difficulty swallowing pills, can’t open vials, complex insulin regimen).
  • Financial Barriers: Can the patient afford the medication? Is cost leading to rationing or non-adherence? This is a primary question, not an afterthought.
  • Cognitive/Psychosocial Barriers: Are memory issues, depression, or lack of social support impacting their ability to manage their regimen?
  • Side Effects / Perceptions: Is the patient intentionally not taking the medication due to experienced or feared side effects? Do they believe the medication is not working or unnecessary?
  • Regimen Complexity: How complex is the overall regimen? A high pill burden or multiple daily dosing times are major predictors of non-adherence.

12.1.3 The CMR Process: A Step-by-Step Clinical Workflow

A successful CMR is not a single action but a multi-stage process. Each stage builds on the last, moving from broad data collection to specific, actionable recommendations. Adhering to this workflow ensures that your review is thorough, efficient, and clinically sound. We will now walk through this process in granular detail, providing the tools and scripts you need to execute at a high level.

Step 1: The Pre-Encounter Data Gauntlet

The most effective CMRs begin long before you ever speak to the patient. A master clinician does their homework. Your ability to walk into a patient encounter already armed with a deep understanding of their clinical history is what separates a basic MTM from a true clinical consultation. You must become a forensic investigator of the electronic health record (EHR) and other available data sources. Your goal in this stage is to build a preliminary “case file” for the patient, identifying potential areas of concern and formulating initial questions.

The Pharmacist’s Pre-CMR Dossier: A Checklist for Data Investigation

Before each CMR, dedicate protected time to systematically gather and review the following sources. This is non-negotiable.

  1. Electronic Health Record (EHR) Deep Dive:
    • Problem List: This is your anchor. Is it accurate and up-to-date? Use it to check for appropriateness.
    • Most Recent Progress Notes: Review notes from the PCP and any key specialists (Cardiology, Endocrinology, etc.). What are their stated goals and concerns?
    • Hospital Discharge Summaries: Review the last 1-2 discharge summaries in detail. This is a goldmine for identifying medication changes and post-discharge discrepancies.
    • Laboratory Trends: Don’t just look at the most recent lab value. Trend key safety and efficacy labs over time (e.g., SCr/eGFR, K+, LFTs, A1c, INR). A rising creatinine is a story that a single value doesn’t tell.
    • Vital Signs: Trend blood pressure and heart rate. Is the patient’s hypertension or heart failure actually well-controlled?
    • Allergies: Review the documented allergies. Are they true allergies or intolerances? What was the nature of the reaction?
  2. Prescription Drug Monitoring Program (PDMP/PMP) Review:
    • Controlled Substances: Check for any undisclosed prescribers (“doctor shopping”), early refills, or overlapping prescriptions (especially opioids and benzodiazepines).
    • Adherence Clues: The PDMP can also provide clues about adherence to chronic controlled substance therapies. Are they filling on time?
  3. Pharmacy Dispensing / Claims Data:
    • Fill History Analysis: Calculate the Proportion of Days Covered (PDC) for key chronic medications. Gaps in refills are objective evidence of non-adherence.
    • Uncover Hidden Meds: Claims data can reveal prescriptions from outside providers that are not documented in the primary EHR.

Step 2: The Patient Interview – The Art of Clinical Inquiry

The data you’ve gathered provides the skeleton of the patient’s story; the interview provides the flesh and blood. This is your single best opportunity to uncover adverse drug reactions, assess true adherence, understand the patient’s health beliefs, and identify barriers to care. Your retail experience is invaluable here—you are already an expert at talking to patients. The key is to elevate this skill from a transactional conversation to a structured clinical interview. This requires a shift in questioning techniques, moving from closed-ended questions that elicit “yes/no” answers to open-ended, empathetic inquiries that encourage the patient to tell their story.

Masterclass Table: CMR Interviewing Techniques
Assessment Area Common (Less Effective) Question Expert-Level (More Effective) Question Clinical Rationale
Opening the Encounter “I’m here to do your medication review.” “Thank you for meeting with me today. My role is to partner with you and your doctor to make sure your medications are the safest, easiest, and most effective for you. To start, could you tell me in your own words what you hope to get out of our conversation today?” Sets a collaborative tone, empowers the patient, and immediately helps you understand their primary concerns and goals.
Assessing Adherence “You take all your medications every day, right?” “It can be really tough to remember to take medications every single day. In a typical week, how many days would you say you miss a dose of your blood pressure pill?” (Uses a normalizing and non-judgmental approach). A “yes/no” question encourages a socially desirable answer. Normalizing the difficulty of adherence and asking for a specific number provides a more honest and clinically useful answer.
Probing for Side Effects “Are you having any side effects?” “Sometimes, medications can cause issues that don’t seem related. Since starting the new statin, have you noticed any new muscle aches, tiredness, or fogginess that you didn’t have before?” (Asks about specific, known side effects). A general question is often met with “no.” Asking about specific, common side effects of their actual medications prompts the patient’s memory and helps them connect symptoms to drugs.
Evaluating Effectiveness “Is your lisinopril working?” “I see your doctor started you on lisinopril to protect your kidneys because of your diabetes. Have you had a chance to talk with them about what your recent lab numbers mean for your kidney health?” or “How have your home blood pressure readings been since the dose was increased?” Links the drug to its specific clinical purpose and prompts a conversation about measurable outcomes (labs, home readings) rather than a vague feeling of “working.”
Uncovering Financial Barriers “Can you afford your meds?” “Many people find that the cost of medications can be a real burden. Have you ever had to choose between filling a prescription and paying for something else, or have you ever stretched out your pills to make them last longer?” Directly asking about cost can feel intrusive. Framing it as a common problem and asking about specific cost-coping behaviors (like pill-splitting or stretching) is more empathetic and effective.
The “Brown Bag” Review “Let me see what you brought.” “This is great, thank you for bringing everything in. Let’s go through them one by one. Can you pick up the first bottle and tell me what you take it for and how you take it?” (The “show and tell” method). This technique assesses not only what they have, but also their understanding of each medication’s purpose and instructions. It’s a powerful tool for assessing health literacy and adherence.

Step 3: Synthesis – Identifying and Prioritizing Medication-Related Problems (MRPs)

This is the cognitive heart of the CMR. You have gathered a mountain of objective data and subjective patient information. Now, you must synthesize it all to identify discrete, solvable problems. A Medication-Related Problem (MRP) is “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes.” Your job is to systematically pinpoint these MRPs using the four pillars (Appropriateness, Effectiveness, Safety, Adherence) as your guide. It is crucial to document these problems clearly and concisely, as they will form the basis of your action plan.

The Prescribing Cascade: A Classic MRP to Hunt For

The prescribing cascade is a common but often-missed MRP. It occurs when a side effect of one drug is misdiagnosed as a new medical condition, leading to the prescription of a second, unnecessary drug to treat it. As the medication expert, you are uniquely positioned to identify and dismantle these cascades.

Drug A (e.g., Amlodipine)

Causes an Adverse Drug Effect (e.g., Peripheral Edema)

Which is misinterpreted as a New Medical Condition (e.g., “Fluid Overload”)

A new Drug B is prescribed (e.g., Furosemide)

The Pharmacist’s Solution: Identify the cascade and recommend discontinuing Drug B and either reducing the dose of or switching Drug A to an alternative (e.g., an ACE inhibitor).

After identifying all potential MRPs, you must prioritize them. Not all problems carry the same weight. An untreated indication for an ACE inhibitor in a diabetic patient is important, but an active bleed in a patient on a DOAC and an NSAID is a five-alarm fire. A simple prioritization matrix can be helpful:

  • Urgent/High-Risk: Problems that pose an immediate risk of significant harm (e.g., major drug interactions, critical dose errors, active bleeds, supratherapeutic INRs). These must be addressed the same day.
  • Important/Non-Urgent: Problems that could lead to long-term harm or represent significant opportunities for optimization, but are not immediately life-threatening (e.g., adding a guideline-directed medication, addressing adherence issues, deprescribing a low-value medication).
  • Lower Priority: Issues that are valid but have less clinical impact (e.g., switching to a once-daily formulation for convenience, minor cost-saving opportunities).

Step 4: The Action Plan – Crafting Evidence-Based Recommendations

For every MRP you identify, you must develop a clear, concise, and actionable recommendation. This is where you transition from diagnostician to therapeutic architect. A weak recommendation is vague (“Consider adjusting BP meds”); a strong recommendation is specific, evidence-based, and provides a clear plan for implementation and monitoring.

Masterclass Table: From Problem to Plan
Identified MRP (Example) Vague / Ineffective Recommendation Specific & Actionable Recommendation
Safety & Appropriateness: 82 y/o female with dementia, falls, and stress incontinence is taking oxybutynin 5mg TID (high anticholinergic burden). “Patient is on oxybutynin, consider changing.”

Recommendation: Discontinue oxybutynin and initiate mirabegron.

  • Rationale: Oxybutynin has a high anticholinergic burden (ACB score of 3), which is strongly associated with confusion, falls, and cognitive decline in the elderly, and is on the Beers list. Given the patient’s existing dementia and falls, this is a high-risk agent.
  • Proposed Action: Taper and discontinue oxybutynin over 1 week. Initiate mirabegron 25mg daily as a safer alternative with a different mechanism of action.
  • Monitoring Plan: Monitor for improvement in incontinence symptoms and assess for any changes in mental status or fall frequency over the next 4 weeks. Check blood pressure one week after initiation of mirabegron.
Effectiveness: 65 y/o male with T2DM and HFrEF (EF 35%). Current meds include metformin and glipizide. A1c is 8.5%. Not on an SGLT2 inhibitor. “A1c is high. Needs better diabetes control.”

Recommendation: Add empagliflozin for glycemic control and cardiovascular benefit.

  • Rationale: Current guidelines strongly recommend SGLT2 inhibitors (like empagliflozin) in patients with T2DM and HFrEF due to proven mortality benefit, reduction in heart failure hospitalizations, and moderate A1c-lowering effects. Glipizide carries a risk of hypoglycemia and is not a preferred agent.
  • Proposed Action: Initiate empagliflozin 10mg daily. Consider reducing or discontinuing glipizide to minimize hypoglycemia risk as A1c improves.
  • Monitoring Plan: Monitor renal function (eGFR) and blood pressure at baseline and within 2-4 weeks. Counsel patient on sick day protocol and risk of euglycemic DKA.

Step 5: Communication & Follow-Up – Closing the Loop

Your brilliant clinical work is useless if it is not effectively communicated to both the patient and the provider. You must create two key documents: a Medication Action Plan (MAP) for the patient and a formal consult note or recommendation for the prescriber. Following up is equally critical to ensure your recommendations were implemented and to assess their impact.

For the Patient: The Medication Action Plan (MAP)

This document must be written in plain, patient-friendly language (aim for a 5th-grade reading level). It is not just a list; it is their personal guide.

  • Updated Medication List: A clean, easy-to-read list of all their current medications, including the name, dose, purpose (in simple terms), and instructions.
  • Action Steps for the Patient: What is the patient supposed to do? (e.g., “Start taking this new water pill once every morning,” “Call Dr. Smith’s office to make a follow-up appointment.”).
  • What to Watch For: Simple instructions on key side effects or monitoring tasks (e.g., “Check your blood sugar if you feel shaky,” “Call us if you notice any new muscle aches.”).
  • “My Questions for the Doctor”: A space to empower them to be active participants in their next appointment.
For the Provider: The Formal Recommendation

Your communication with the prescriber must be professional, concise, and clear. The SBAR (Situation, Background, Assessment, Recommendation) format is an excellent model.

  • Situation: “I am calling/writing about [Patient Name] following a comprehensive medication review today.”
  • Background: “Key findings include an A1c of 8.5% despite metformin and glipizide, and a concurrent diagnosis of HFrEF with an EF of 35%.”
  • Assessment: “The patient has an untreated indication for a guideline-directed SGLT2 inhibitor, which would provide both glycemic and cardiovascular benefits.”
  • Recommendation: Provide the specific, actionable recommendation as crafted in the previous step, including drug, dose, rationale, and monitoring plan.

Finally, the CMR cycle is not complete without follow-up. Schedule a follow-up call or visit to assess the outcome of your interventions. Was the new medication started? Was the problematic drug stopped? How is the patient feeling? What do the follow-up labs show? This demonstrates your commitment to the patient’s care, allows you to address any new issues that arise, and is essential for demonstrating your value to the healthcare team.