Medication Therapy Problem (MTP) Documentation Tool: Guidance Document

Purpose of the Tool:

To provide pharmacists a tool for documenting and tracking the identification and resolution of medication therapy problem
interventions, printing medication lists for patients, and generating reports on clinic activities.

What are Medication Therapy Problems?

A medication therapy problem (MTP) exists when the use (or non-use) of a specific medication results in a less-than-optimal
clinical outcome for the patient. The identification of MTPs provides pharmacists an opportunity to address and resolve the
MTPs, thereby improving health outcomes for patients.

Each MTP identified can be broadly categorized as a problem related to medication indication, effectiveness, safety, or
adherence. From there, MTPs can be further categorized and subcategorized in order to describe the specific nature of the
problem. The MTP Categories Framework used in this tool was created by the Pharmacy Quality Alliance (PQA) and is listed in
full in Appendix A. For further description of this framework and how it was developed, see:
https://www.pqaalliance.org/medication-therapy-management

Detailed definitions of the MTP categories and subcategories used in this tool, along with relevant examples of each, can be
found in Appendix B.

Appendix A: PQA Medication Therapy Problem (MTP) Categories Framework

Appendix B: Definitions of Medication Therapy Problem (MTP) Categories and Subcategories

Why Document Medication Therapy Problems?

With the evolution of healthcare towards the provision of value-based care and away from traditional fee-for-service models,
there has been a growing emphasis on the measurement and reporting of outcomes. In attempt to measure the specific
impact on the improvement of patient outcomes and the reduction of overall healthcare costs through pharmacist-led
interventions, some pharmacists regularly track and document MTPs identified and resolved in practice. Reports generated
from these documentation efforts are then used to help demonstrate the pharmacist’s clinical and financial value to the
organizations and patient populations served. Additionally, identifying and documenting MTPs helps pharmacists clearly
articulate to their interdisciplinary team (e.g., physicians, nurses) medication-specific issues that need to be addressed.

The identification and resolution of MTPs is best accomplished through the practice of comprehensive medication
management (CMM), wherein a patient’s full medication list is regularly reviewed and evaluated.

What is Comprehensive Medication Management (CMM)?

Comprehensive medication management (CMM) is a patient-centered approach to optimizing medication use and improving
patient health outcomes that is delivered by a clinical pharmacist working in collaboration with the patient and other health
care providers.1 A comprehensive review of all the medications a patient is taking is completed, specific interventions are
identified, and routine follow-ups to assess the resolution of MTPs are provided.

For more information on the essential functions and operational definitions of CMM, see:
https://www.accp.com/docs/positions/misc/CMM_Care_Process.pdf

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
FAQs

How do I log in if I am a pharmacist in multiple clinics/clinical settings? If you are using this tool in more than one clinical
setting, you will be prompted to select the clinic for which you wish to enter information at each login.

How do I add a new patient? You can add a new patient by simply clicking the ‘Add New Patient’ button on your clinic’s
homepage. Once you click ‘Add New Patient’, you will be directed to enter basic demographic information for the patient.

How do I start a new encounter for an existing patient? You can start a new encounter one of three ways: 1) Click the ‘New
Encounter’ action icon next to the patient’s name on the Clinic Homepage; 2) Click ‘Save and New Visit’ on the Patient
Information page, and then select the appropriate visit type; OR 3) Click on the desired visit type on the Patient Homepage
(CMM Baseline Visit, CMM Follow-up Visit, or Quick Check In).

Do I have to enter my patient’s medication list into this system? No, entering information on the Patient Medication List
page is optional. You may skip this page altogether if desired. This option was created for users who would like to keep a
record of their patients’ medications, allergies, vaccine history, and pharmacies within the system &/or would like to provide
their patients a copy of their medication list and/or patient-specific notes at the end of an encounter.

Should I document each of the MTPs I identify individually? You should document each MTP individually, selecting only one
medication, condition/indication, MTP category, MTP rationale, and Intervention for each. If you have identified more than
one MTP during the visit, clicking ‘Save’ will allow you to remain on the page to enter your next MTP. The MTP just entered
will be saved in the chart at the top of the page.

What if the medication or condition/indication for which I wish to record an MTP is not in the tool’s dropdown list? If you
need to record a medication or condition/indication that is not listed in the tool’s menus, simply select ‘Other’ and you will be
prompted to type in the medication or condition/indication you would like to enter.

If the patient needs a medication therapy they are currently not receiving, what should I select in the ‘Medication’ field
when I document the MTP? If the patient has an untreated condition for which you would like to start a new medication,
select ‘None (no medication therapy at present)’ in the ‘Medication’ field.

Where can I record a note of the encounter for future reference? You can enter clinic notes in the ‘Notes’ section found on
the Encounter Summary page. This field is for notes (e.g., SOAP notes) you would like to leave for your clinic’s future
reference. You may also enter MTP-specific notes on the Enter MTPs page in the field labeled ‘MTP Note’. Any note you would
like to provide the patient should be included in the ‘Patient Visit Summary’ section (which can be found on both the Patient
Medication List page and the Encounter Summary page).

How do I print a summary of an encounter for a patient? You can print a patient visit summary (with any other information
entered into the Patient Medication List page) from either the Patient Medication List page or the Encounter Summary page.

How do I view and print auto-generated reports from the tool? You can access the Reports and Analytics page from the
Clinic Homepage or the My Action List page, wherein auto-generated reports of your clinic’s data can be found. You can
select the date range for which you would like the displayed data to be filtered. Clicking ‘Print’ will allow you to print a copy of
this page.

How do I find which patients in my clinic have unresolved MTPs? You can see a list of all unresolved MTPs for your clinic on
the My Action List page. The data found on this page can be filtered and organized according to the filters displayed and then
downloaded for personal use. You can access the My Action List page from the Clinic Homepage or the Reports and Analytics
page.

How do I download raw data from the tool? You can download raw data from the tool by clicking ‘Export’ on the My Action
List page. You can filter the data as needed prior downloading.

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
Sections of the Tool (+ what you can do on each page)

I. Homepage
a. Log in
i. Enter username & password
ii. Select clinic (if prompted)

II. Clinic Homepage

a. Add a new patient:
b. Search for an existing patient by number, name, date of birth, or medical record number (MRN)
c. Edit/View Patient Information for an existing patient
d. Go to the Patient Homepage for an existing patient
e. Start a new Patient Encounter
f. View My Action List (default: pending MTPs):
g. Access Reporting page

Clinic
Homepage

Patient Patient
My Action List Reporting
Information Homepage

Encounter Patient Encounter

Enter MTPs
Information Medication List Summary

III. Patient Information: Enter or edit general demographic information

a. Information collected:
i. First and Last Name
ii. Medical Record Number (optional)
iii. Gender
iv. DOB
v. Age (calculated from DOB)
vi. Phone Number and Email (optional)
vii. Longitudinal Pharmacist
viii. Status: Enrolled, Not Enrolled (+ reason), No Longer Enrolled (+ reason)
ix. Total # Medications (manual entry)
x. Total # Chronic Conditions (manual entry)
xi. Clinic-specific population tag(s) (to facilitate population health management) [optional]

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
 b. Can start a new encounter from this page: select ‘Save and New Visit’ instead of ‘Save’. (‘Save’ will
send you to the patient’s homepage)

IV. Patient Homepage

a. Return to Patient Information page to edit patient information: click on ‘Edit Record’ at the top of the
page
b. Start a new encounter (select one):
i. CMM Baseline Visit: first comprehensive medication management visit
ii. CMM Follow-Up Visit: all subsequent comprehensive medication management visits
iii. Quick Check In: targeted visits (i.e., Medication Titration; Review of New Medication;
Adherence Follow-Up; Patient Education; MTP Follow-Up; Other)
c. Visit Log:
i. View and/or edit past and current encounters
1. Medication List
2. Documented MTPs
3. Encounter Summary
ii. Filter MTPs for one specific encounter
d. MTP Log: can view and/or edit past and current MTPs for this patient
i. Edit MTPs
ii. Delete MTP
iii. View MTP-specific notes

V. Encounter Information:
a. Enter the following information about the visit/encounter
i. Visit Pharmacist: automatically filled with logged-in user’s name
ii. Visit Date: defaults to current day’s date
iii. Secondary User (e.g., student, intern): free text entry; optional
iv. Visit Setting: select from a drop-down menu
v. Visit Length: select from a drop-down menu (can also record ‘No Shows’ here)
vi. For Quick Check-ins, select encounter type(s): Medication Titration; Review of New
Medication; Adherence Follow-Up; Patient Education; MTP Follow-Up; Other
vii. Social Determinants of Health identified: optional

VI. Patient Medication List: optional

a. Enter the following patient-specific information
i. Total # of Medications: manual entry; same field as is on Patient Information page
ii. Total # of Conditions: manual entry; same field as is on Patient Information page
iii. Medication List [can Add, Edit, Delete]
1. Medication name*: select from a drop-down menu (brand or generic)
2. Dose: free text
3. Sig: free text
4. Condition/Indication*: select from a drop-down menu
iv. Allergies and Adverse Reactions [can Add, Edit, Delete]
1. Allergen/Medication*: select from a drop-down menu

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
 2. Reaction*: select from a drop-down menu
v. Vaccine History [can Add, Edit, Delete]
1. Vaccine*: select from a drop-down menu
2. Date Administered
vi. Pharmacy Utilization: free text entries [can Add, Delete]
vii. Medication Adherence Tools Utilized: select all that apply
viii. Patient Visit Summary: free text notes to patient
b. Download & print Calendars and Templates: select printable pdfs from a drop-down menu
c. Keep track of patient’s Medication History: for reference only, will not print
d. Print page for patient: includes everything on page

VII. Enter MTPs:

a. Enter one MTP at a time. For each MTP, select:
i. Medication name*: select from a drop-down menu (brand or generic)
ii. Condition/Indication*: select from a drop-down menu
iii. MTP Type: select from a drop-down menu (new or carry-over)
iv. MTP Category and Subcategory: select one of each (see Appendix A for PQA MTP Categories
Framework)
v. Intervention: select from a drop-down menu
vi. To Be Implemented By: select from a drop-down menu
vii. Medical Provider Name/NPI: free text entry, optional
viii. MTP Note: free text entry
ix. MTP Status: select from a drop-down menu; can edit/update later
x. (Resolved By): select from a drop-down menu
xi. (Reason Not Implemented): select from a drop-down menu
b. If no MTPs are identified during the encounter, select: ‘No Medication Therapy Problems at present’
c. Track MTPs as they are entered. All MTPs entered for the current encounter will display at the top of
the page if ‘Save’ is selected after each entry

VIII. Encounter Summary: optional

**This page provides a summary of the patient’s medication list, all MTPs documented during the encounter,
your notes of the encounter, and a patient visit summary.**
a. Document your encounter in the Notes section: free text notes for clinic/user purposes
b. Enter your Patient Visit Summary: free text notes to patient (also saves on Patient Medication List
page)
c. Download & print Calendars and Templates: select from a drop-down menu
d. Print encounter summary and/or patient medication list with patient visit summary

IX. My Action List

a. View all pending MTPs
b. Download all raw MTP data into a CSV file: can apply selected filters beforehand
c. Go to Reports and Analytics page: click on ‘Reports’

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
 X. Reports and Analytics
a. Filter reports by the date range you desire
b. View the following auto-generated reports for the date range selected
i. Number of unique patients
ii. Number of unique encounters
iii. Average number of medications per patient
iv. Average number of chronic conditions per patient
v. Total number of MTPs identified
vi. Average number of MTPs identified per patient
vii. Average number of MTPs identified per encounter
viii. Total number of MTPs resolved
ix. Average number of MTPs resolved per patient
x. Average number of MTPs resolved per encounter
xi. No Show Rate
xii. Total number of visits completed, broken down by visit type (baseline, follow-up, quick check-
in) and visit setting
xiii. MTP Totals, by month, broken down by MTP status (pending, resolved, not implemented)
xiv. MTPs by Category
xv. MTPs by Subcategory
c. Go to My Action List to download raw data: click on ‘All MTP Data’

*Selection of OTHER will allow user to enter additional option via free text
1The Patient Care Process for Delivering Comprehensive Medication Management (CMM): Optimizing Medication Use in Patient-Centered, Team-Based Care
Settings. CMM in Primary Care Research Team. July 2018. Available at http://www.accp.com/cmm_care_process

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
Appendix A: PQA Medication Therapy Problem (MTP) Categories Framework1

1 Pharmacy Quality Alliance (PQA) Medication Therapy Problem Categories Framework for PQA Measures document for a framework of MRPs and detailed description of
categories and rationale. Available from: https://www.pqaalliance.org/assets/Measures/PQA%20MTP%20Categories%Framework.pdf. Accessed October 2018

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
Appendix B: Definitions of Medication Therapy Problem (MTP) Categories and Subcategories

Duplicate Therapy
The individual is receiving a drug that is duplicative of another medication they are
taking and the duplication poses unnecessary risk/safety issues. (e.g., concomitant
ACE-Inhbitor and ARB therapy)

No medical indication at this time

The individual is receiving a medication that has no indication. (e.g., omeprazole in
the absence of GERD or heartburn)
Non-medication therapy more appropriate
Unnecessary medication The individual is receiving a medication when non-medication therapy would be more
therapy appropriate. (e.g., use of a benzodiazepine as a sleep aid)

Addiction/recreational medication use

The individual is taking a medication for recreational use or to satisfy an addiction.
(e.g., taking opioids obtained illicitly or using a BZD beyond intended dose or
frequency)
Indication

Treating avoidable adverse medication reaction

The individual is taking a medication to treat an adverse medication reaction from
another medication that can be avoided. (e.g., taking an antihistamine for a rash
caused by an antibiotic when another antibiotic is equally effective)
Preventative Therapy
The individual has a medical condition, lab abnormality, or risk factors for a disease
that would benefit from therapy for primary prevention, but they are not receiving
indicated therapy. (e.g., aspirin for someone with CAD or calcium/vitamin D for
someone at risk for osteoporosis)
Untreated condition
Needs additional
The individual has an untreated chart-diagnosed medical condition warranting drug
medication therapy
therapy, but is not receiving indicated therapy. (e.g., diagnosis of HTN, but no
antihypertensive therapy has been prescribed)

Synergistic therapy
The individual has a chart-diagnosed medical condition that requires additional drug
therapy to achieve the desired response or outcome. (e.g., Type 2 diabetes mellitus
treated with maximum dose of one drug and addition of another antidiabetic
medication is needed to achieve therapeutic goals)

More effective medication available

The individual is receiving a drug that is not effective and there is a potentially more
effective medication available. (e.g., use of a specific antidepressant to treat
depression has been ineffective; trial of another antidepressant is warranted)

Condition refractory to medication

Effectiveness

Ineffective medication
The individual is receiving a drug that is no longer effective. (e.g., the use of
methotrexate for treatment of rheumatoid arthritis and is no longer effective)
Dosage form inappropriate
The individual is receiving a drug in a dosage form that is not appropriate. (e.g.,
patient is unable to swallow pills; use of an ODT or liquid formulation is warranted)

Dosage too low Dose too low

The individual is taking an appropriate medication, but the dose is not optimal to
achieve desired therapeutic response. (e.g., patient has uncontrolled peripheral

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
 neuropathy, is on a low dose of gabapentin, and experiencing no adverse effects. A
dose increase is warranted for improved control of symptoms)

Frequency inappropriate
The individual is taking an appropriate medication, but the frequency is not optimal to
achieve desired response. (e.g., patient is taking carvedilol once daily for congestive
heart failure, but twice daily would be more appropriate)
Incorrect administration
The individual is taking an appropriate medication, but the mode or method of
administration is not optimal to achieve desired response. (e.g., patient incorrectly
uses their Symbicort® inhaler, resulting in administration of a lower-than-effective
dose)
Medication interaction
The individual is receiving a medication that has a significant drug interaction with
another medication, causing decreased efficacy of the medication. (e.g., concomitant
use of lamotrigine and an estrogen-containing contraceptive; contraceptive failure is
possible due to a significant Drug-Drug Interaction)
Incorrect storage
The individual is taking an appropriate medication, but they are storing it in a manner
that reduces the desired response. (e.g., incorrect storage of insulin resulting in
reduced efficacy of the insulin)

Duration inappropriate
The individual is taking an appropriate medication, but the duration is not optimal to
achieve desired response. (e.g., patient stopped taking an antibiotic several days short
of the appropriate 14-day course of therapy)

Medication requires monitoring

Needs additional The individual is receiving a drug and monitoring is required to assess response to
monitoring therapy, but monitoring has not been done. (e.g.,: use of an anti-diabetic agent
without appropriate follow-up A1c monitoring)

Undesirable effect
The individual is experiencing an actual adverse effect attributed to a drug or the
inappropriate use of a drug. (e.g., ACE-inhibitor-induced cough with lisinopril)
Unsafe medication for the patient
The individual is receiving a drug that is potentially not safe (i.e., risk of using drug
outweighs benefit). (e.g., use of promethazine for nausea in an elderly patient)

Medication interaction
The individual is receiving a drug that has a significant drug interaction with another
Safety

medication, causing increased risk of adverse effects of the medication. (e.g.,

Adverse medication event
concomitant use of an SSRI and tramadol: increased risk of serotonin syndrome)
Incorrect administration
The individual is taking an appropriate medication, but the mode or method of
administration has the potential for harm. (e.g., patient inappropriately leaves
lidocaine patches on for a full 24 hours, but should only leave them in place for a
maximum of 12 hours in any 24-hour period)
Allergic reaction
The individual has experienced an allergic reaction attributed to a drug. (e.g., hives
with a sulfa-containing drug)

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
 Dosage increase/decrease too fast
The individual is experiencing an adverse effect attributed to a drug due to a dosage
increase/decrease that was too fast. (e.g., excessive somnolence due to a rapid
increase in the dose of an antipsychotic medication)
Dose too high
The individual is taking an appropriate medication, but the dose has the potential for
harm. (e.g., patient’s INR is 3.8 on their current warfarin dose)
Frequency inappropriate
The individual is taking an appropriate medication, but the frequency has the
potential for harm. (e.g., patient has been taking metoprolol XL twice daily when they
should be taking it once daily)
Duration inappropriate
Dosage too high
The individual is taking an appropriate medication, but the duration has the potential
for harm. (e.g., patient continues to take high dose prednisone longer than the
prescribed duration)
Medication interaction
The individual is receiving a drug that has a significant drug interaction with another
medication, causing the plasma concentration of the drug to have the potential for
harm. (e.g., metronidazole is given to a patient who is currently stable on their current
dose of warfarin. Warfarin serum concentration may be increased)
Medication requires monitoring
Needs additional The individual is receiving a drug and monitoring is required to prevent harm, but
monitoring monitoring has not been completed. (e.g.,: thiazide diuretic is initiated without
appropriate follow-up monitoring of potassium and serum creatinine)
Patient does not understand instructions
The individual has not filled a prescription, is not taking a drug, or is not using a drug
as prescribed because they don’t understand the instructions.
Patient prefers not to take
The individual has not filled a prescription, is not taking a drug, or is not using a drug
as prescribed because they prefer not to take the drug.
Patient forgets to take
Adherence The individual has not filled a prescription, is not taking a drug, or is not using a drug
as prescribed because they cannot remember to take the drug.
Medication product not available
The individual has not filled a prescription, is not taking a drug, or is not using a drug
as prescribed because the medication was not/is not available.
Adherence

Patient cannot swallow/administer medication

The individual has not filled a prescription, is not taking a drug, or is not using a drug
as prescribed because they are unable to swallow/administer the medication.
More cost-effective medication available
The individual is prescribed a medication for which a less costly, equally effective and
safe drug is available and which is preferred by the patient, but the patient is
receiving the more expensive product. (e.g., taking Lipitor when atorvastatin is
available at a lower cost)
Cost [NOTE: Although the medication therapy problem rationale, more cost-effective medication available, is
placed under the medication-related need of adherence, it may not necessarily relate to adherence directly
or represent a patient-focused medication therapy problem]

Patient cannot afford medication product

The individual is prescribed a medication they cannot afford and for which a less
costly, equally effective and safe drug is not available.

Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019
Center for Medication Optimization, UNC Eshelman School of Pharmacy - June 2019