MEDICATION RECONCILIATION

Mary Pat Friedlander, MDUPMC St Margaret’s Residency Program

October 23, 2013

Disclosure

Neither I nor any immediate family member (parent, sibling, spouse or child) has a financial relationship with or interest in any commercial entity that may have a direct interest in the subject matter of this session.

Objectives

Define the components of an accurate medication reconciliation

Recognize gaps and inconsistencies in the medication reconciliation process

Identify next steps in your practice to improve medication reconciliation

Background

Poor communication at transition points led to 50% of the medication errors and 20% of adverse drug reactions

Variability in medications patients take prior to admission and admit orders up to 70%

Background

Discharge drug summaries 66% one inconsistency 32% potentially harmful drug omissions 17% unjustified medications

16% were potentially harmful

JACHO

2005-National Patient Safety Goal #8 8A-process must exist for comparing current

meds with those ordered while in the organization

8B-complete list of medications must be communicated to the next provider on service or outside the organization and a complete list given to patient at discharge.

2009-Announcement of need for change Many organizations came together

2013—NPSG #3.06.01

NPSG #3

Improve the safety of using medication 1. Label all medications, medication

containers, and other solutions on and off the sterile field in perioperative and other procedural settings

2. Reduce the likelihood of patient harm associated with the use of anticoagulant therapy

3. Maintain and communicate accurate patient medication information.

NPSG #03.06.01

Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit the doctor.

IHI

100,000 lives campaign—2005 (18 month project)Prevent ADE’s-implementing med reconciliation

NCQA and MU

PCMH 3: Plan and Manage Care

• Identify patients with specific conditions including high-riskor complex, behavioral health• Care management– Pre-visit planning– Progress toward goals– Barriers to treatment goals• Reconcile medications• E-prescribing

Meaningful Use Criteria• Clinical decision support• Medication reconciliation with transitions of care• E-prescribing• Drug-drug, drug-allergychecks• Transmit prescriptions using EHR• Drug-formulary checks

HEDIS Measure

Medication reconciliation post-discharge: percentage of discharges from January 1 to December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.

Medication Reconciliation

Process of identifying the most accurate list of all medications a patient is taking Name, dosage, frequency and route

Use this list to provide correct medications for patients anywhere within the health care system

Compare the patient’s current list against the admission, transfer or discharge orders

Three Steps

Verification—collection of medication history

Clarification—ensuring medications and the dosages are appropriate

Reconciliation-Documenting the changes in the orders

Med Reconciliation cont.

Drug is started Drug is discontinued Dose of drug changed Frequency of administration is changed

Accurate Medication History

Engage the patient Engage the caregivers Ask open ended questions Have patient bring in “bag of meds” Provide a list of meds Date the list

Accurate Medication History

Use systematic approach Ask about allergies

Medication allergies Reactions Other allergies

Prescriptions Do you take anything prescribed every day

How many times a day Do you take anything on as needed basis Do you take anything prescribed by other

provider

Accurate Medication History cont.

Prescriptions Do you use any patches or creams Do you receive any injections at the doctor’s

office Do you take any sample medications

OTCs Do you take any medications that don’t need

a prescription What do you take when you get sick?

Heartburn? Menstrual cramps? Headaches?, etc.

Accurate Medication History Cont.

Herbals/Natural/Vitamins What vitamins do you take What herbal medications do you take What natural supplements do you take What dietary supplements do you take

Review Medical Problems list Do you take anything for your high blood

pressure? diabetes? your heart? thyroid?, etc.

Accurate Medication History Cont.

Medication Concerns Tell me about missed doses in the last week What problems do you have with your meds? What concerns do you have about side effects Tell me about any difficulty paying for your

meds? Tell me about any medications that you don’t

think are helping you? Medications with incomplete information

Who, what, where, when and why?

Hospital Med Rec

Admission *Accurate* Medication History

Transfer Compare home meds, current meds and transfer

Discharge Same as transfer Share list with provider and patient Teach patient/family

Discontinued Resumed meds (i.e. metformin) New Meds

Hospital Ambulatory Setting

ER, tests, same day surgery, procedure Current Meds Let know of any changes or need to

discontinue medication

Office Setting

Collect Medication list/Verify a previous list

Two Questions Did any current medication change? Have any new prescriptions been added?

Give clear instructions on the change Have in writing Have patient teach back the new change

Challenges

Who owns the process? Doctor, nurse, MA, pharmacist

No standardized process for home med list

Doctors won’t order meds they did not give

Time Just another form Patients without knowledge of meds

Blue pill, heart pill, “I don’t know, don’t you know”

Link of Current Med list to Order screen

Challenges

Very little data to compare Different processes/solutions

Time/Labor intensive Hiring discharge advocate/pharmacist

Hard to study Different EMR systems Many studies outside of US

Well Designed Process

Patient Centered Easy to complete for all Home list is available when prescribing

meds Patient gets up-to-date list All providers are aware of changes

How to Succeed

Agree on definitions Get buy in from leadership No one size fits all approach

Inpatient vs. surgery vs. ER vs. outpatient settings

Limit number of processes Defects found are part of the larger

system Not by-product of process

Specify who is responsible Hold them accountable

How to Succeed cont.

Develop a process May include forms

Establish communication Across spectrum of care

Nursing homes, Long term care facilities, clinician offices, specialists, home health agencies

Don’t do in committee—Engage stakeholders

Use Model for Improvement Strategy PDSA, etc.

How to Succeed Cont.

Process should identify failure of system and help correct the failure

Train staff Develop guides for patients/staff Involve patients in design of medication

list card—can there be universal card in your area?

If form not used in intended way Ask why? Does form need to be changed? Does their need to be more training

Next Steps

Do a small pilot program Start in one clinical area Use specific high risk patients

Age >65 4+ chronic medications

High risk medications 3+ chronic medical conditions

Does any of this work?

Inpatient studies1. 70% decrease in medication

errors15% decrease in adverse drug

events2. Decrease amount of time spent to

rework3 Discharge Advocate and pharmacy phone calls decreased 23.8% decrease

in hospital utilization 30 days post discharge

Does this work?

Little data on outpatient Clinical pharmacists with most data

Meet with patients in the office Reconcile meds

Saved money Billing by pharmacist?

UPMC

Depart Process Med Rec at admission, transfer, discharge “Patient Friendly” Summary given

Email generated to PCP (if in system)

Residency PracticePharmD Resident calls patient at d/cReviews meds/arranges f/u

Depart

Challenges

Dependent on Admission Rx to be accurate Dependent on the correct PCP in computer Dependent on patient understanding med list

Health literacy Large d/c packet—too much information Teach back

Outpatient EMR and Inpatient EMR Dependent on f/u phone call

Numbers not accurate

Resources

IHI How to Guide www.ihi.org

Project RED http://www.bu.edu/fammed/projectred/

AHRQ Free tool kit--MATCH www.AHRQ.gov

Objectives

Define the components of an accurate medication reconciliation

Recognize gaps and inconsistencies in the medication reconciliation process

Identify next steps in your practice to improve medication reconciliation

THANKSAmy Haugh, MLSDirector, Medical Library ServicesUPMC St Margaret

References

How-to-Guide: Prevent Adverse Drug Events by Implementing Medication Reconciliation. Cambridge, MA. Institute for Healthcare Improvement; 2011 (www.ihi.org)

2013 Hospital National Patient Safety Goals (www.jointcommission.org)

Van Sluisveld et al. BMC Health Services Research 2012, 12:170 http://www.biomedcentral.com/1472-6963/12/170

References cont

Greenwald, et al. Medication Reconciliation: A Consensus Statement from the Stakeholders. Journal of Hospital Medicine 2010 5(8) 477-485

Smith, M, et al. In Connecticut: Improving Patient Medication Management in Primary Care. Health Affairs 2011 30(4) 646-654

Mueller, S, et al. Hospital Based Medication Reconciliation Practices: A Systematic Review Arch Intern Med. 2012;172(14):1057-1069.