Wednesday, January 30, 2008

Medication Reconciliation

One of the most challenging Joint Commission requirements for hospitals is supporting medication reconciliation workflow. This means that at every transition of care, providers must verify the medications that each patient is taking to ensure they are getting just the right dose of just the right medication. Why is this a challenge? Imagine that an 87 year old taking 14 cardiac medications visits an orthopedist for knee pain. The orthopedist must carefully record her current doses of Amiodarone, Lasix, Lipitor, and Zestril, examine her knee, prescribe medications, and document the visit, all within 12 minutes. For specialists, this may require a knowledge of medications they do not often prescribe and may take substantial effort if the patient has been referred from an outside provider and thus no medication history is available in the orthopedist's electronic health record.

To date, most hospitals and clinician offices have addressed this Joint Commission requirement by implementing paper processes. Very few vendors offer electronic solutions for medication reconciliation.

In July of 2007, BIDMC was visited by Joint Commission. We had been working on medication reconciliation workflow and software solutions for a year prior to this visit. During their visit, we were live with automated outpatient medication reconciliation, paper-based emergency department medication reconciliation, and paper-based inpatient medication reconciliation. The Joint Commission visitors were impressed with our software engineering but noted that we did not have 100% utilization of the software in our specialty clinics. We had 45 days to ensure 100% compliance, verified with an audit.

Over those 45 days, the Medical Executive Committee modified our clinical documentation policies to require medication reconciliation as part of retaining staff privileges. We assembled a multi-disciplinary committee to understand the workflow implications of medication reconciliation. We cleaned up historical medications by deleting all medications that had not been acted upon in three years. We temporarily hired 5 extra RNs to call patients at home and enter medication lists prior to their visits. When not calling patients, these RNs, who were located in our busiest clinics, cleaned up historical medication lists to ensure they were formatted properly for e-Prescribing renewals.

Our committee recommended hundreds of software changes to make the outpatient reconciliation process easier and we implemented all of them. Enhancements included the ability for any clinician in any clinic to quickly enter, update, or annotate (“patient is not taking as prescribed”) any medication, even if they were not the original prescriber. Of course all medication changes were documented in an audit trail. We enabled providers to enter patient self reported medications and we displayed an alert if the exact dose was unknown.

We modified our eprescribing systems to reflect community-wide medication history. This means that when a clinician writes for any medication, a history of every medication that has been dispensed at any US pharmacy appears and can be used as an aid to reconciliation.

We modified our emergency department clinical documentation system to support reconciliation of patient medications during ED evaluations and ensured all medications dispensed in the ED became part of the patient's active medication list.

On the inpatient side, we enabled discharge medications to be automatically converted to outpatient medications and made all discharge medication summaries available to every clinician. We are just finishing a completely automated inpatient medication reconciliation system which will enable physicians to verify all medications electronically while preparing the initial inpatient history and physical.

Our paper-based medication reconciliation processes will soon be retired.

The greatest challenge to implementing all these solutions was documenting the logical workflow required by clinicians, then getting the buy in of all the users of the system, given that it added substantial work to their day.

At this point, 5 months after our final joint commission audit, physicians are realizing the benefit of an up to date medication list and are saving time in the medication renewal process, receiving more accurate decision support when prescribing new medications, and have better documentation of patient compliance with their therapies. Patients are more satisfied as well, since they know all clinicians will use the same accurate medication list across our hospital and practices, making patient/provider communications about medications much easier.

It may have been one of our most challenging experiences, but in the end, all involved agree it was worth the pain.


Dr. Val said...

Do you think that it's feasible to establish a national ePharmacy process whereby all prescriptions can be tracked and uploaded to any PHR/EMR? (I know this is being tried in a few states with Allscripts). Is the major limitation the mom and pop pharmacies? Are there privacy concerns that limit this? Forgive me if you've addressed this already in your blog - I was just struck by how complicated it is to get all the meds reconciled and wondered how to handle this on a national level. :)

Don Lyons said...

Excellent comment on national standardization. I wonder how this might paly out in the patient safety arena, and save time and money?

I've been through so many hospital systems where everyone is faced with the same mess...

Anonymous said...

ugg bootsTHE SNOW wholesale ugg bootsSTARTED TO FALLWholesale handbags SEVERAL HOURS wholesale clothingBEFORE HER laborWholesale jewelry began.wholesale clothing A few flakes wholesale handbagsfirst, wholesale furniturein the dull Furniture Wholesalegray late-afternoon Wholesale jewelrysky,Ceramic tileand then Micro sd cardswind-driven swirls Wholesale clothingand eddies Wholesale Jewelryaround the edges Wholesale fashion jewelryof their wide Wholesale costume jewelryfront porch. ugg bootsHe stood by her wholesaleside at the windowwholesale electronics, watching sharp gusts of snow billow,skin care products
then swirl and drift to the ground. All around the neighborhood, lights came on, and the naked branches of the trees turned white.

Anonymous said...

ugg bootsOutside,uggs snow continuedHigh pressure blower to fall quietly throughIndustrial fan the darkness, Industrial bloweras bright and thick Commercial bloweras static in the wholesalecones of light castchina wholesale by the streetlights.wholesale shoes By the time he rosewholesale clothing and looked out watchesthe window, pressure blowertheir car had become a soft white hill on the edge pressure blowersof the Already his footprints blowers
in the driveway had filled and disappeared.

Anonymous said...

wholesaleShe looked up, wholesale atvsmiling, wedding dresseswhen he tuckedMP3 player
the blanketwholesale mp3 around her legs.Wholesale Mp4
"You know,digital camera wholesale I've been wondering consumer electronicswhat it's like,"mp5 player she said. memory cards"Before we're born,Car video players I mean. It's too bad we can't remember." gps devicesShe opened her robe and pulled up the bluetooth headsetsweater she wore underneath, revealing a Mp3 Wholesalebelly as round and hard asMp3 Wholesale a melon. Mp4 WholesaleShe ran her hand across its smooth surface, Mp4 Wholesalefirelight playing across her skin, casting reddish gold onto her hair.

Anonymous said...

This momentousdecree wow gold came as a great beacon gold in wow light of hope buy wow gold to millions of negroslaves wow gold kaufen who had been seared in the flames of withering injustice.maplestory mesos it came as a joyous daybreak to end the long night ofcaptivity.but one hundred years later,maplestory money we must face the tragic fact thatthe negro is still not free.maple money one hundred years later,sell wow gold the lifeof the negro is still sadly crippled by the manacles ofsegregation and the chains of discrimination. one hundred yearslater,maple story money the negro lives on a lonely island of poverty in themidst of a vast ocean of material powerleveling one hundred yearslater,maple story power leveling the negro is still languishing in the corners of americansociety and finds himself an exile in his own land. so we havecome here today to dramatize wow powerleveln an appalling a ms mesos sense we have come to our nation''s capital to cash a check.when the architects of our republic wow powerleveln wrote the magnificent wordsof the constitution and the declaration of independence, theywere signing a promissory note maplestory power leveling to which every american was tofall heir.

Anonymous said...

Catch the wow gold star that holds your gold in wow destiny,cheap wow gold the one that forever maplestory money twinkles within your heart. Take advantage of precious opportunities while they still sparkle before you. Always believe that your buy maplestory mesos ultimate goal is attainable cheap mesos as long as you commit yourself to it.maple money Though barriers may sometimes stand in the way of your dreams, remember that your destiny is hiding behind gold kaufen Accept the fact that not everyone is going to approve of the choices Maple Story Accounts you've made. Have faith in your gold farmen Catch the star that maple story money twinkles in your heart and it will lead you to your destiny's path. Follow that pathway and uncover the sweet sunrises that await you. Take pride in your accomplishments, as they are stepping stones to your dreams. Understand that you may make mistakes, powerlevelbut don't let them discourage mesos Value your capabilities and talents for they are what make you truly unique. The greatest gifts in life are not purchased, but acquired through hard work and determination.maplestory mesos Find the star that twinkles in your heart?for you alone maplestory powerleveling are capable of making your brightest dreams come true

Anonymous said...

DO you know Yiwu - the world's largest China wholesale market.

Anonymous said...

buy wow gold,cheap wow gold,wow power leveling.

Anonymous said...



Anonymous said...

China Highlights
China Highlights
China Tours
China Hotels
China Attractions
Beijing China Travel
Shanghai China Travel
Xian China TravelGuilin China TravelYangshuo China Travel
China custom toursChina special toursChina custom TravelChina special travel

Anonymous said...

I like play online game, I also buy mabinogi gold and mabinogi gold, the cheap mabinogi is very cheap, and use the mabinogi money can buy many things, I like mabinogi online gold, thanks, it is very good.

I like play online game, I also buy mesos and maple mesos, the cheap mesos is very cheap, and use the maplestory mesos can buy many things, I like maple story mesos, thanks, it is very good.

Anonymous said...

buy wow goldbuy wow goldbuy wow accountbuy wow gold

Anonymous said...

Tips of Warcraft, Warcraft 3 tips, tips Frozen Throne

Use of Warcraft tips: wow power leveling1, only in the single-player only useful when the tips of Warcraft, LAN games Warcraft tips can not be opened; wow gold2, directly copy the following code of Warcraft tips, in the Warcraft games press [Enter] key to enter the code or paste the code tips, and then return to the opening of the tips; wow power level3, If you want to abolish the tips, just re-enter the same gold cheap[Warcraft tips Invincible] whosyourdaddy ------------------------------------------- ---- all units invincible and can be any unit spike (the most invincible tips of Warcraft)
[Money tips of Warcraft] greedisgood ------------------------------------------- --------- the increase in gold and timber 500 (the value can be set, such as greedisgood 1000000) (money tips)
[WoW gold tips] KeyserSoze ------------------------------------------- --------- plus gold (such as KeyserSoze 100000)
[Timber tips of Warcraft] LeafItToMe ------------------------------------------- ----------- increase timber (such as LeafItToMe 100000)
[Warcraft population tips] PointBreak ------------------------------------------- increase the population limit -----------
[Map tips of Warcraft] iseedeadpeople ------------------------------------------- --- Show All Map
[Winner of Warcraft tips] allyourbasearebelongtous -------------------------------- win immediately
[The failure of Warcraft tips] somebodysetupusthebomb ------------------------------ immediately defeat
[Warcraft tips unbeaten] ItVexesMe ------------------------------------------ ------------ victory will not be found
[Warcraft power tips] StrengthAndHonor ------------------------------------------ not defeat will be determined
[Speed up the tips of Warcraft] thereisnospoon ------------------------------------------- ---- unlimited power, were able to release Magic
[Speed up the tips of Warcraft] WhoIsJohnGalt ------------------------------------------- ----- accelerate the pace of research, such as close combat weapons, upgrade, upgrade defense, etc.
[Construction tips of Warcraft] WarpTen ------------------------------------------- ------------- rapid construction
[Upgrade tips of Warcraft] SharpAndShiny ------------------------------------------- ---- upgrade buildings
[Technology tips of Warcraft] Synergy ------------------------------------------- -------------- technology full
[Time tips of Warcraft] RiseAndShine ------------------------------------------- into the dawn of time -----
[Time tips of Warcraft] LightsOut <------------------------------------------ ------------ time into the evening
[Time tips of Warcraft] DaylightSavings ------------------------------------------- - adjustment of time
[Jump clearance of Warcraft tips] Motherland ------------------------------------------ ---------- jump clearance (for example, jump directly to the fourth human 04 off)
my wow gold cheap wow power leveling buy wow gold

Anonymous said...

Anyway, one Eitrigg-Alliance wow gold of the things that's fascinated me about the Druid class since Burning Crusade is the growth in its popularity. Historically Eitrigg-Horde wow gold we have never been among the more commonly-played classes, and for a wide swathe of classic WoW and BC, were actually the least-played class or within the bottom 3. While there are various reasons for this (and I could devote a column to Eldre'Thalas-Alliance wow gold how this probably happened), Druids became more popular as time went on, and an increasing number of people began to play the class without knowing just how far it's Eldre'Thalas-Horde wow gold come.

Because of dalaran mage extravagant use of magic, Elune-Alliance wow gold some in the well of eternity was banished collapse of the burning legion was to lead to a pawn in this world. Elune-Horde wow gold Although these relatively weak demons and no large, but they still appear in dalaran caused some confusion. Most of the demons is some of the events, and scattered in the office, otherwise carat parliament did his best to these events from Emerald-Dream-Alliance wow gold the public's eyes covered up. Some of the most powerful sorcerer, was sent to capture the sly devil, but usually they will find these powerful Emerald-Dream-Horde wow gold though claws of the burning legion alone, but far stronger than they can handle the limit.

Affordable Luxurious Wedding Dress Blog said...

cheap wedding gowns,
discount bridal gowns,
China wedding dresses,
discount designer wedding dresses,
China wedding online store,
plus size wedding dresses,
cheap informal wedding dresses,
junior bridesmaid dresses,
cheap bridesmaid dresses,
maternity bridesmaid dresses,
discount flower girl gowns,
cheap prom dresses,
party dresses,
evening dresses,
mother of the bride dresses,
special occasion dresses,
cheap quinceanera dresses,
hot red wedding dresses

Football Matches said...

The greatest challenge to implementing all these solutions was documenting the logical workflow required by clinicians, then getting the buy in of all the users of the system, given that it added substantial work to their day.