Medication reconciliation efforts meeting needs and showing promise

Since the inclusion of medication self-management and dynamic patient-centered records by Dr Eric Coleman in his Care Transitions Intervention process, recognition of the importance of accurate medication information transfer and its potential impact on patient outcomes has been increasing.¹

Medication Reconciliation, “med rec” as it has come to be known, is recognized as an important part of the growing practice of medication management and a critical step in improving the care of patients in all settings. Despite the many challenges associated with implementation of a successful med rec program, the potential for significant value drives the ongoing effort to find scalable, cost-effective solutions.

Background

Medication errors and the resulting adverse drug events (ADEs) have a major impact on patient outcomes and pose a significant financial burden, both to the patient and the health care system. According to the Agency for Healthcare Research and Quality, approximately 838,000 emergency department visits and 1.8 million hospitalizations annually are due to ADEs, with an estimated $2.6 billion in total mean hospital costs.² Medication reconciliation is now recognized as an important component of patient safety, as well as an important part of the strategy for reducing healthcare costs.

In 2005, medication reconciliation was included as a National Patient Safety Goal by the Joint Commission. From 2005 through 2008, the Joint Commission expected hospitals to reconcile a patient’s medication from admission through discharge, documenting a complete list of the patient’s current medications on admission and communicating a complete list of the patient’s medications at discharge to the next provider.³

As hospitals began serious efforts to address the process of medication reconciliation, through paper-based methods and with technology, the difficulties of implementing an acceptable med rec process became evident. From 2009 through 2011, the Joint Commission suspended scoring of medication reconciliation during on-site accreditation surveys, in recognition of the lack of proven strategies for accomplishing the task.³

As of July 2011, medication reconciliation was reintroduced as part of the National Patient Safety Goal #3, “Improving the safety of using medications.”³ With this inclusion, the expectation for reconciliation of medication information was streamlined to place emphasis on critical risk points in medication reconciliation as part of the care transition process. The revised National Patient Safety Goal requires hospitals to record and pass along correct information about a patient’s medication, find out what medicines the patient is taking, compare those medicines to any new ones intended to be or newly given to the patient, make sure the patient knows which medicines to take when he or she is at home, and to tell the patient it is important to bring his or her up-to-date list every time he or she visits a doctor.⁴ The last 2 points highlight the importance of the patient or caregivers in closing the loop and ensuring provider efforts result in measurable improvements in care.

Provider Challenges to Effective Med Rec

The Joint Commission listed the breakdown of provider-to-provider communication as the most frequently found cause in listed sentinel events.⁵ In a study conducted at the Mayo Health System, poor communication of medical information at transition points was responsible for as many as 50% of all medication errors in the hospital and up to 20% of ADEs.⁶ Pharmacist-provided medication therapy review and consultation in various settings resulted in reductions in physician visits, emergency department visits, hospital days, and overall healthcare costs.⁷ While pharmacists have taken a key leadership role in successfully implementing the medication reconciliation process, pharmacists and their fellow healthcare team members continue to struggle with the challenges of scaling up a predominantly manual task. Pharmacists across various care settings have been evolving this capability and support systems to provide leadership in successful med rec implementation.

Medication reconciliation is only as accurate as the initial list of medications obtained. This may be a function of a lack of proper staff training on how to obtain an accurate, detailed medication history. Data collection forms are often poorly designed and confusing, and sometimes more than one list may exist. Further, in a busy practice setting, staff members frequently fail to obtain an accurate history due to lack of time. There may be an emphasis on completing the requirement to acquire a list (any list) rather than ensuring the accuracy of such a list. The end result is an inaccurate medication list, despite being prepared by licensed medical professionals.⁸

Physicians may also fail to thoroughly review the medication list obtained on admission for accuracy and order medications as listed. There may be a lack of communication from a primary physician to the admitting physician on duty when a patient is admitted through the ED. In addition, the physician caring for the patient transitioning through the hospital frequently isn’t the patient’s primary physician, but may be a surgeon, hospitalist, and/or specialty physician.⁸

Hospital-based clinicians also may not be able to easily access patients’ complete medication lists or may be unaware of recent medication changes made just prior to admission. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrect dosages.

Patient’s Role in Med Rec

To streamline healthcare delivery and control costs, both market forces and government regulations are driving the formation of new outcomes-focused practice models, such as accountable care organizations (ACOs) and medical home model group practices. These new care delivery models are forcing the recognition of the critical role played by the patient in the healthcare equation. Patients are an important part of the medication reconciliation process.⁶ However, they are not clinicians and do not consider themselves “patients” in their everyday lives, thus presenting a unique set of challenges for the medication reconciliation process.

Patients admitted to a hospital are often unsure what medications they are taking and often fail to keep an accurate, updated record of their medications. Many lists provided by patients have wrong dosages and discontinued medications and are missing new prescriptions. They often do not mention medications like those not in pill form or non-prescription medications, both of which can have significant clinical consequences. The proverbial “brown bag” solution is also problematic, with patients mixing discontinued medications, their spouse’s medications, and their current medications in the same bag.⁸

Ideally, a patient medication list would be created digitally, from a nationally standardized pharmacy database. The Meaningful Use guidelines call for the capability to perform medication reconciliation to be included in the certification standards for certified electronic health record (EHR) technology.⁹ However, obtaining an accurate list of medications electronically faces its own challenges, such as patients obtaining medications from multiple pharmacies, hospitals, and physicians. In addition, the current state of electronic medical records (EMRs) and health information exchanges does not permit the exchange of data across systems, even within the same state.¹⁰

Until further progress toward regional, state, and/or a national electronic database linked to software that provides a timely and accurate record of a patient’s medication, the process of med rec will continue to rely significantly on direct communication between healthcare providers and patients.

A growing area of concern is now known as “white bag.” This situation arises when medications are shipped by mail directly to patients for use in an ambulatory, clinic, or in-hospital setting due to benefit coverage rules under both medical or pharmacy benefits. Health plans and other self-funded entities are tightening drug cost management at the same time physician practices are being consolidated under a hospital or health system umbrella. These coincidental events create an ever-growing number of patients with white bags entering a previously closed healthcare system.

Effective Med Rec

Effective medication reconciliation requires accurate and complete information collection, a standardized process for information hand-offs, and a multidisciplinary approach. When done right, medication reconciliation can be a cost-effective tool to reduce costs and improve patient care. For example, in a 2012 study of 563 patients admitted to Johns Hopkins Hospital, a collaborative nurse-pharmacist medication reconciliation effort, which included pharmacist review and identification of medication discrepancies, dramatically and cost-effectively decreased the risk of ADEs. The researchers found that, at a cost of $113.64 per potentially harmful discrepancy, the program would need to prevent one ADE per 290 patients to offset costs. In fact, the program prevented 81 potentially harmful ADEs per 290 patients.⁶

Recognizing communication patterns and addressing breakdowns at critical points in the information transfer process is the first step in implementing an effective medication reconciliation process.¹¹ This requires a cross-functional approach with organizational support including leadership, physicians, nurses, pharmacists, and other stakeholders that play a role in the medication management process. Once mapped out and in place, the process requires qualified professionals trained in medication reconciliation, focused on obtaining a detailed medication history, and generating an accurate medication list.

After the medication list has been obtained and reviewed by the pharmacist and/or his or her designated support person, the list needs to be effectively communicated to the physician responsible for the patient’s care across each point of transition. The increasing use of hospitalists creates both challenges and opportunities in the med rec handoff process. Hospitalists have less involvement in the long-term care of a patient, but their focus on hospital care processes and patient outcomes affords them a key role in optimizing the med rec process.¹²

Development of multidisciplinary educational programs and ongoing program assessment are also key to a successful medication reconciliation process. Along with training on enhanced medication history-taking skills, education needs to recognize the important role patients and caregivers play in the success of the process. Training on how to educate patients and families about how to maintain accurate medication lists as part of an updated personal health record is critical to achieving measurable results. Following an in-depth education program, the medication reconciliation process should be audited, and healthcare providers should be given feedback on their performance.

The Future of Med Rec

The benefits of reduced healthcare costs and improved return on the healthcare dollars spent are driving the development of new processes and technologies designed to facilitate a scalable medication reconciliation process. In the absence of a centralized database, hospital software vendors, such as EPIC and Cerner, offer software applications designed to be integrated into the hospital’s CPOE system to maintain a digital medication reconciliation record. In some of these systems, a physician can be locked out of placing orders using CPOE unless the medication reconciliation record is updated to ensure that medication reconciliation is completed for all their patients.¹³

On the outpatient side, the movement to ACOs and medical home models is fostering the evolution of anticoagulation clinics and other medication-focused clinics into “medication management” clinics.¹⁴ These clinics provide a resource for patients with conditions that place them at risk for hospitalization, such as congestive heart failure or chronic obstructive pulmonary disease, to proactively prepare accurate medication lists in a more relaxed setting. In some cases, the use of these pharmacist-run clinics is covered by insurance.

Along with the government regulation and financial incentives driving these market-based solutions, professional associations and healthcare quality organizations are also actively supporting efforts to improve medication reconciliation. For example, the American Society of Health System Pharmacists (ASHP) offers a medication reconciliation toolkit to provide ASHP members with tools, references, and recommendations as well as ideas and examples of success stories and lessons learned.¹⁵ Alternatively, the Institute for Health Improvement (IHI) offers guidance for the development of a toolkit based on the MATCH medication reconciliation initiative at Northwestern Memorial Hospital.¹⁶

Summary/Conclusion

The process of medication reconciliation while complex is very important in today’s healthcare marketplace and continues to evolve. The reality of healthcare today presents a number of challenges, which hinder efficient as well as effective medication reconciliation, including the following:

‐Patients who are unaware of current medications.

‐The “brown bag” effect, where prescription medications of spouses and family members are mixed.

‐The “white bag” effect, where medications are shipped by mail directly to patients for use in an ambulatory or hospital setting due to benefit coverage rules.

‐Poor communication among providers on the care team.

‐Poorly designed data collection forms.

‐Inconsistent implementation of EMR and EHR in general.

All of these situations inhibit efforts aimed toward better medication reconciliation across the continuum of care settings. Pharmacists are stepping up to take a greater leadership role in the process of medication reconciliation, not only those who are hospital‐based, but in the community, too.¹⁷ Pharmacist‐led medication reconciliation clinics are showing promise, especially for complex diseases such as chronic obstructive pulmonary disease. In addition, equally promising are new hospital-based technologies that connect to multiple provider systems and a wider range of care-related toolkits and electronic capabilities focused on providing solutions.

As healthcare becomes more complex as an industry-with more patients entering the system, more providers on the increasingly integrated care team, greater use of technology, and increasingly greater oversight-new strategies for medication reconciliation will continue to be needed. Current experiences are showing that when pharmacists take a leadership position in the process and reach out to deliver better coordinated education and inform patients and caregivers, the result will be enhanced collaborations to provide better outcomes and lower costs.⁷

References

1.     Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817-1825.

2.     HCUP Statistical Brief #109. April 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb109.pdf.

3.     AHRQ Patient Safety Primer - Medication Reconciliation. October 2012. http://www.psnet.ahrq.gov/primer.aspx?primerID=1.

4.     National Patient Safety Goals Effective January 1, 2013, Pages 5-6. http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf.

5.     Dingley C, Daugherty K, Derieg MK, Persing R. Improving Patient Safety Through Provider Communication Strategy Enhancements. http://www.ahrq.gov/downloads/pub/advances2/vol3/advances-dingley_14.pdf.

6.     Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: A consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5(8):477-485.

7.     Improving care transitions: Optimizing medication reconciliation. March 2012. http://www.pharmacist.com/improving-patient-care-through-better-medication-reconciliation-white-paper.

8.     Brown S. Overcoming the pitfalls of medication reconciliation. Nurs Manage. 2012;43(1):15-17.

9.     The Federal Register (July 28, 2010). The daily journal of the United States government: Rule health information technology: Initial set of standards, implementation specifications, and certification criteria for electronic health record technology. http://www.federalregister.gov/articles/2010/07/28/2010-17210/health-information-technologyinitial-set-of-standards-implementation-specifications-and.

10.   West DM, Friedman A. Health information exchanges and mega-change governance studies at Brookings. February 8, 2012.

11.   Feldman LS, Costa LL, Feroli ER, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7:396-401.

12.  Clay BJ, Halasyamani L, Stucky ER, Greenwald JL, Williams MV. Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med. 2008;3: 465-472.

13.  Anderson HJ. Medication reconciliation: Is there a better way? Health Data Manag. 2010;18(1):14-18.

14.  http://www.bannerhealth.com/Locations/Arizona/Banner+Baywood+Medical+Center/Programs+and+Services/Outpatient+Services/Medication+Management+Clinic.htm.

15.  http://www.ashp.org/menu/PracticePolicy/ResourceCenters/PatientSafety/ASHPMedicationReconciliationToolkit_1.aspx#.

16.  Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer Review Organization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. Revised August 2012.

17.   Bailey AL, Moe G, Moe J, Oland R. Implementation and evaluation of a community-based medication reconciliation (CMR) system at the hospital-community interface of care. Health Q. 2009;13 Spec No:91-97.