❝ A Toronto family practice first saw a patient's blood pressure renewal five days after the pharmacy's fax and three days after he ran out, with his bloods four months overdue, because nothing in the clinic looked at run-out dates until a fax arrived. The setting is a five-doctor practice with about 7,500 patients and, in the model, about 95 renewal requests a week, most of them by fax. Modelled over 12 weeks, 404 of 1,140 requests arrived with three days or less of supply left, 96 arrived after the patient had run out, and 137 were held because a required test or check was overdue. The design below works out every run-out date nightly from the clinic's own records, checks the doctors' monitoring protocol 21 days ahead, puts overdue tests on the nurse's list to request under the doctors' signed directive, and gives each doctor a twice-weekly list of draft renewals to sign. A prescriber signs every renewal. The only call that can leave Canada carries drug names alone. It costs about CA$40 a month to run.
The pharmacy faxed the renewal request on a Thursday afternoon, when Desmond had two tablets left. The fax reached the clinic. Nobody read it until the following Tuesday.
Desmond Clarke is 68 and takes four tablets a day for his blood pressure, his cholesterol and his type 2 diabetes. He collects them from the same pharmacy on Danforth Avenue, and he had handed in the last repeat on his ramipril prescription in October. When he went back on Thursday, the pharmacist told him there were no repeats left and faxed his family doctor's clinic for a renewal. It arrived at 15:42, in an inbox that had taken 31 faxes that day.
Dr Priya Raman, his doctor, does not work Fridays. Desmond ran out on Saturday. On Monday his pharmacist, who is allowed to renew many prescriptions in Ontario, gave him a short supply to cover the gap and faxed the clinic to say so. On Tuesday morning Dr Raman opened both faxes, one after the other, and then opened his chart. His last kidney function and potassium bloods were sixteen months old. The clinic's own rule for ramipril is twelve.
Nothing about this was an appointment problem. Desmond had no visit due and no reminder to miss. The clinic's records knew, from the day the prescription was written, the date his tablets would run out. Nothing in the clinic was looking at that date.
The clinic, Desmond, Dr Raman and Lorna are a composite, built from the patterns we see in family practices of this size, and the figures attached to them are design projections. The regulations, the professional rules and the published figures are real, and linked to their sources.
The business
A five-doctor family practice in Toronto's east end with about 7,500 rostered patients. Three people work the front desk, led by Lorna, who has been there eleven years; one registered nurse handles injections, dressings and the phone calls nobody else can answer. The clinic runs on Accuro, a common Ontario EMR, and receives faxes into it through an online fax service.
About 2,600 of its patients take at least one medication long term. Renewals reach the clinic two ways. Pharmacies fax a request when a patient asks for a refill with no repeats left. Patients phone, usually when they notice the bottle is light. Either way the request goes to the front desk, who pull the chart, check when the patient was last seen, put the request in the doctor's inbox, chase it if it sits, fax the signed renewal back and, sometimes, ring the patient. The doctor reads it between appointments or at the end of the day.
The clinic also runs appointment reminders, and they work. They have nothing to say about Desmond, because Desmond has no appointment.
What is actually going wrong
Every request arrives with the deadline already close, and the clinic has no list of who is about to run out.
The run-out date is known on the day the prescription is written. A prescription for 30 tablets, one a day, with five repeats, covers 180 days. The EMR holds the date, the quantity, the repeats and the dose. Nothing in the clinic adds them up until a pharmacy fax arrives, which by definition happens at the end.
The pharmacy usually asks late because the patient asks late: the request starts when the patient comes in for a refill and finds no repeats left. The request is triggered by the patient standing at the counter with a few days to go, which is the worst possible moment to discover that the prescriber is on holiday, or that the bloods are overdue.
The fax is still the channel. Canada Health Infoway announced in February 2026 that it was shutting down PrescribeIT, the federally funded service built to carry prescriptions and renewal requests electronically; it closed at the end of May 2026. For most Ontario clinics we see, renewal requests come in by fax and go back by fax, one page at a time, into an inbox that also holds lab results, specialist letters and insurance forms.
The pharmacist's renewal keeps the patient supplied, and leaves the clinic unaware of the gap. Ontario pharmacists may renew many prescriptions themselves for continuity of care, within limits set by regulation, and must tell the prescriber. That got Desmond his tablets on Monday. It did not get him his bloods, because the pharmacist had no sight of the clinic's twelve-month rule and the clinic was not looking.
Monitoring is found at the counter. The clinic's own protocol says which medications need a recent blood test or blood pressure reading before renewal. That check happens when the request lands, so an overdue test turns a renewal into a hold, a requisition, a phone call and, often, a short supply to cover the wait.
The doctors have no spare time. In its 2023 survey of members, the Ontario College of Family Physicians reported that family doctors spend about 19 hours a week on administrative work. Renewals arriving one fax at a time, each needing a chart opened, are part of that.
What it costs
Model twelve weeks of the clinic's fax and phone log and this design gives 1,140 renewal requests, about 95 a week: 702 by pharmacy fax and 438 by phone. In the model:
404 requests arrived with three days or less of supply left.
96 requests arrived after the patient had already run out.
137 renewals were held because a blood test or blood pressure check required by the clinic's protocol was overdue, found only when the request arrived.
2 working days was the modelled median time from a request arriving to a signed renewal going back to the pharmacy.
And one pattern that only shows up when the requests are lined up by patient: in the model, about one in four patients with three or more long-term medications had them running out on three or more different dates, so the same chart was opened three or more times a year for renewals that could have been one.
The cost the clinic pays every week is time. In this model each request takes the front desk about seven minutes (finding the chart, checking the last visit, routing, chasing, faxing back, the occasional call) and a doctor about two. At 412 requests a month, that is about 48 hours of front desk time and about 14 hours of doctor time. At CA$28 an hour for the front desk including on-costs (our assumption), the front desk share alone is about CA$1,345 a month, spent mostly on requests that could have been seen coming three weeks earlier.
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