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...

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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.