Indian Health Service Counseling Technique Improves Medication Knowledge

by U.S. Medicine

March 5, 2016

By Annette M. Boyle

CORVALLIS, OR — An extra minute of patient interaction using the Indian Health Service (IHS) technique more than doubles the likelihood that patients will remember and understand what their new prescription treats, how to take the medication and its possible side effects.

In a study recently published in the Journal of the American Pharmacists Association, Oregon State University researchers compared the IHS technique to conventional, unidirectional instruction by pharmacists. According to the study, this “lecture format” provides no way to evaluate what a patient understands.1

“The most-distinctive characteristic of the Indian Health Service technique is the interactive process that verifies the patient’s understanding rather than just providing information, a modification of the teach-back technique of patient education,” said Robert W. “Bill” Boyce, director of pharmacy services in the Student Health Center Pharmacy at Oregon State University and corresponding author on the study.


Based on the patient’s answers to open-ended questions, “the pharmacist decides on what information to provide by determining what the patient already knows,” Boyce told U.S. Medicine. The interaction verifies that patients know what they are taking and why, how to store and use the medication, what side effects might occur and what to do if they experience adverse effects.

“This approach to prescription-drug counseling has now been shown to be a dramatic improvement over conventional methods,” Boyce said. “This is the first real analysis to prove that it works, and that the approach could be extremely important for healthcare in America.”

Boyce co-developed the technique during his 21-year career with the Public Health Service pharmacy program of the Indian Health Service, which serves American Indians and Alaska Natives. The IHS began using the technique in the 1970s. Boyce and his colleagues formalized it a decade later, when they started teaching the technique at the IHS Clinical Pharmacy Training Program at the Clinical Support Center in Phoenix.

The study measured the immediate recall of key counseling points and time spent on patient counseling for 500 patients at four community pharmacies in Oregon. The study compared two pharmacies that used traditional counseling methods and two that already used the IHS technique. The study only included counseling on new prescriptions.

Following the counseling with the pharmacist, patients met with the primary investigator, who assessed their knowledge of indications for therapy, medication use and expected adverse effects.

Of the 246 patients counseled using the IHS technique, 71% answered all three questions correctly compared to only 33% of the 254 counseled using traditional methods. Patients who received IHS counseling were four times more likely to know when take their medication and to be able to explain the potential adverse effects and what they should do if they occur. Patients had about the same recall for indications of therapy for both types of counseling.

The IHS technique averaged 128 seconds per patient, compared with 75 seconds for the traditional counseling method. Based on patient responses, failure to discuss adverse effects in more than one-third of the encounters contributed to the shorter time spent in traditional counseling. Just more than 11% of patients indicated that pharmacists using the IHS method did not mention the adverse effects of the medication.

A previous time-and-motion study in IHS pharmacies found it took an average of 75 seconds per outpatient visit to counsel patients on all prescriptions using the interactive method. In that study, patients had an average of 1.15 prescriptions per visit. Refill prescription counseling takes 15 to 20 seconds on average.

The back-and-forth of the presentation also informs pharmacists early in the process that they are speaking with a highly-knowledgeable patient. In those circumstances, the interaction time could be relatively short, even for a new prescription, Boyce noted.

The IHS technique provides significant benefits in addition to improved recall of key information. Inappropriate responses to the first questions about why the patient received the prescription can alert pharmacists to potential problems with patient cognition, language fluency and hearing, according to the study. The interactive nature of the method also allows pharmacists to identify prescription errors prior to dispensing.

The technique also could potentially lead to better treatment outcomes. While the study did not look at improvements in patient health, “you could reason that, if the patient is compliant because they have a better understanding, hopefully this would translate to [health] improvement,” Boyce said.

Because the interactive method has been used extensively in the IHS for decades and almost all schools and colleges of pharmacy teach the technique, new graduates are already familiar with it, according to Boyer. It’s his hope that “the study will convince more pharmacists that not using the technique wastes their and the patient’s time.”

1 Lam N, Muravez SN, Boyce RW. A comparison of the Indian Health Service counseling technique with traditional, lecture-style counseling. J Am Pharm Assoc (2003) 2015;55:503-510.

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