Using Data to Identify High-Risk Patients for Targeted Care

Pharmacists see the consequences of medication risk every day: a missed dose, an untreated adverse effect, an interaction that was overlooked, or a patient who quietly stops therapy because the regimen has become unmanageable. The community pharmacy is often the most accessible healthcare setting, which gives pharmacists a valuable opportunity to identify risk before it develops into a hospital presentation.

Using data to identify high-risk patients for targeted pharmacist interventions makes that opportunity more systematic. Instead of relying solely on memory, intuition or a patient’s ability to volunteer concerns, pharmacy teams can combine dispensing records, clinical information and conversations at the counter to find people who need timely support.

Data does not replace professional judgement. A patient may appear stable in a software report while struggling with transport, cost, health literacy or loneliness. Conversely, a person with several risk markers may be managing well because a family member provides daily assistance. The purpose of risk stratification is to guide a better conversation, not to label people permanently.

For Australian pharmacies, this work must fit real operating conditions. Teams may be serving a busy suburban chemist in Melbourne, a small rural pharmacy near Dubbo, or a remote service with limited access to prescribers. Good systems need to be clinically meaningful, privacy-conscious and practical during a demanding trading day.

Build A Useful Patient Risk Profile

A high-risk patient profile should combine several signals rather than depend on a single threshold. Relevant indicators can include multiple medicines, recent additions or dose changes, high-risk medicines, frequent early or late refills, repeated missed collections, and a history of adverse drug reactions. A sudden increase in pharmacy visits can also indicate worsening symptoms, poor control or confusion about therapy.

Clinical complexity matters as well. People living with diabetes, cardiovascular disease, kidney impairment, respiratory illness, cancer or mental health conditions may face greater medication-related risk, particularly when treatment is changing. Older adults taking many medicines are an important group, yet age alone should never determine whether someone receives an intervention.

Pharmacy dispensing data can reveal adherence patterns that are difficult to observe in a short consultation. Repeated gaps in supply may suggest forgetfulness, side effects, financial pressure, a hospital admission or a change in treatment. Early refills could indicate stockpiling, dose escalation, loss of medicines or the practical difficulty of attending the pharmacy at the expected time. Each pattern requires clarification before action.

The best profile also includes social and behavioural factors. Limited English, low confidence with health information, unstable housing, cognitive impairment, carer stress and difficulty travelling can all affect safe medicine use. With consent and appropriate governance, information from medication reviews, care plans and previous counselling can help the team respond to the whole situation rather than treating the dispensing record as the patient’s complete story.

Choose Data Sources With Care

A pharmacy’s own records are usually the most accessible starting point. Dispensing history, medication possession patterns, dose administration aid enrolment, owing prescriptions, vaccination encounters and documented counselling can be reviewed at regular intervals. A simple dashboard might flag patients with multiple prescribers, several pharmacies, frequent therapy changes or a combination of medicines associated with falls, bleeding, sedation or hypoglycaemia.

Australian pharmacists may also work with information from My Health Record, hospital discharge summaries, pathology results when available, and communication from general practices or residential aged-care services. The value of these sources depends on completeness, timeliness and patient consent. A missing record should not be treated as evidence that an event did not occur.

Risk algorithms should be transparent enough for staff to understand why a patient has been flagged. A score generated by a system can prioritise a queue, but it should show the contributing factors: for example, a recent anticoagulant change combined with a missed collection and a documented history of falls. This allows the pharmacist to check whether the alert is current and clinically relevant.

Privacy must remain central. Collect only information that supports a defined care purpose, restrict access according to staff roles, and document consent and clinical decisions appropriately. Patients should be able to understand how their information is being used. A risk program that feels like surveillance can damage trust, particularly for people who have experienced stigma in relation to mental illness, opioid dependence or financial hardship.

Turn Alerts Into Human Conversations

An alert is useful only when it leads to a proportionate intervention. A patient flagged for a missed repeat may need a brief phone call, reminder or discussion about opening hours. Someone starting insulin, an opioid analgesic, an anticoagulant or a medicine with a narrow therapeutic index may warrant a structured counselling session, follow-up contact and communication with the prescriber.

Medication reconciliation is a practical response when records suggest duplication or unexplained change. The pharmacist can ask the patient to bring all medicines, including over-the-counter products, supplements and medicines from other pharmacies. In mental health care, careful questioning about effectiveness, adverse effects, adherence and safety can be especially important. Resources such as this guide to antidepressant interactions can support preparation, while clinical decisions should remain grounded in the individual patient’s circumstances.

Communication should be specific and non-judgemental. “I noticed there was a longer gap between supplies; what was happening for you?” is more likely to uncover barriers than “You are non-compliant.” The patient may explain that the medicine caused dizziness, the prescription was too expensive, the GP appointment was delayed, or the dosage instructions were confusing.

Interventions can include synchronising repeats, arranging staged supply, providing an updated medicines list, recommending a MedsCheck where appropriate, teaching inhaler technique, connecting the person with a GP or nurse, or escalating an urgent concern. If the data indicates possible overdose, severe adverse effects, self-harm risk or unsafe medicine use, the pharmacist should follow relevant clinical protocols and local emergency pathways rather than relying on an automated score.

Design A Workflow The Team Can Use

A workable process usually has four stages: identify, review, intervene and follow up. Identification may occur through a weekly report or dispensing-system alert. Review requires a pharmacist to confirm the signal. Intervention should be documented with an owner and timeframe. Follow-up then checks whether the problem was resolved or needs escalation.

The workflow should distinguish urgent risks from routine opportunities. A possible insulin error or serious interaction needs rapid review. A patient who is overdue for a preventive conversation can be placed in a planned outreach queue. Colour coding or a small number of priority categories can help, but excessive alerts create fatigue and cause important warnings to disappear among low-value reminders.

Pharmacy assistants and technicians can support the process within their training and role boundaries. They may identify a flagged patient, confirm contact details, prepare a medicine list or arrange a suitable appointment. The pharmacist remains responsible for assessment, clinical advice, documentation and referral. Clear escalation rules protect patients and staff when a concern falls outside the pharmacy team’s authority.

The presentation of data matters. A dashboard should use plain language, show recent activity and make the next action obvious. Visual storytelling principles, including the kind illustrated by this data storytelling example, can remind pharmacy teams that a clean display is easier to interpret than a crowded spreadsheet. The aim is not to produce impressive charts; it is to help a pharmacist make a sound decision during a busy shift.

Measure Impact And Improve Equity

Evaluation should examine whether the program changes care, not simply how many alerts it generates. Useful measures include completed medication reviews, resolved discrepancies, successful referrals, improved collection patterns, documented follow-up and patient-reported confidence. Where appropriate, teams might monitor hospital readmissions, falls, hypoglycaemic events or medicine-related incidents, while recognising that many factors influence these outcomes.

The pharmacy should also assess false positives and missed cases. If most alerts are irrelevant, the thresholds or data sources need review. If people who do not speak English, live remotely or lack reliable digital access are rarely identified, the process may be reproducing existing inequities. Data should be examined across age, location, cultural background, disability and socioeconomic circumstances where collection and use are lawful and appropriate.

Australian settings require local flexibility. In regional and remote communities, a pharmacist may need to coordinate with a visiting GP, Aboriginal Community Controlled Health Organisation, hospital service or community nurse. In an urban pharmacy, the main challenge may be high prescription volume and fragmented care across multiple clinics. The same risk model will not work equally well in every setting.

Professional reflection helps keep the program grounded. Pharmacists can review a small sample of flagged patients in team meetings, examine whether the intervention was acceptable, and identify where the system encouraged useful care or created unnecessary work. Independent perspectives from pharmacy practice writing can add context to discussions about professional judgement, communication and the changing role of pharmacists.

A successful approach treats data as a prompt for curiosity. It asks what may be happening in a patient’s life, checks the evidence with the person and connects them with appropriate care. It also recognises that the most meaningful outcome may be modest: a patient understands a new medicine, a prescriber receives timely information, or a preventable problem is addressed before it becomes an emergency.

Start with a clearly defined risk group, such as patients newly prescribed anticoagulants or people with repeated refill gaps. Agree on the data signals, the pharmacist’s review process and the follow-up standard. Test the workflow with the team, listen to patient feedback and refine it before expanding across the whole pharmacy. Used thoughtfully, patient data can help pharmacists focus their time where a timely, personal intervention is most likely to improve safety.