Transforming Medicines Optimisation Through Asynchronous Digital Care

Cardinal Medical Practice

Project summary

Following the 2023 merger of three GP practices serving a highly deprived urban population, the practice faced overwhelming demand, poor access, increasing complaints, workforce shortages press and regulatory scrutiny . Rather than relying on expensive external systems, the clinical leadership team developed a locally designed asynchronous digital medicines optimisation model tailored specifically to the needs of patients, clinicians, and operational workflows.

The project began with mental health medication monitoring pathways because the team recognised that there can be no physical wellbeing without mental wellbeing. Structured antidepressant and anti-anxiety medication review questionnaires were integrated directly into repeat prescribing workflows, enabling patients to report symptoms, adherence, side effects, and wellbeing remotely and asynchronously at a convenient time without requiring traditional appointments.

This initiative was entirely developed in-house without external funding, procurement programmes, consultancy support, recurring licensing costs, or additional infrastructure investment. Clinical leadership teams invested their own time to create sustainable workflows that would release future clinical and administrative capacity.

With the significant success the innovation has since expanded into multiple preventative and medicines optimisation pathways including - High QRISK and statin shared decision-making, asthma review stratification, gastroprotection reviews -identify and prescribe for some and deprescribe for others of PPI, benzodiazepine and Z-drug monitoring, stroke prevention in atrial fibrillation , valproate MHRA safety pathways for women and men, SGLT2 inhibitor education, electronic repeat dispensing optimisation, care home medication review support, and community pharmacy contraception referrals.

This is not just generic online triage. It is a scalable model of asynchronous longitudinal medicines optimisation, proactive digital prevention, integrated medication safety, and population-health-driven care redesign.

The project transformed care from reactive and overwhelmed to proactive, risk-stratified, patient-centred, and sustainable. Patients are no longer passive recipients of care, but active participants in informed decision-making. The model has improved access, medication safety, operational sustainability, team integration, and workforce resilience while remaining low (no)cost, easily interoperable, highly scalable, and entirely self-sustaining without recurring funding requirements.