Monday, November 22, 2010

Smart Medication Reconciliation and Problem Lists

Last week, I spent a few days in California when both my parents ended up in the hospital with different issues.   They're home, settled and doing well at this point.

Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.

As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.

Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family.   What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.

My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.

Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.

The result is that my parents received unnecessary medications as well as did not receive necessary ones.

The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.

How do we solve this?

1.  Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.

2.  Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes.  Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.

3.  At its very simplest, carry a wallet card with an active medication list and problem list.

While in California, I isolated every medication in the house, current and historical.   I documented active medications, active problems and the relationship between the medications and the problems.   I reviewed the resulting lists will all family members (with their consent).   My parents will ensure all their clinicians update their records to reflect this accurate information.   They will carry with them to any future hospitalizations.    I disposed of historical medications (safely) to prevent any future confusion.   I isolated medications for each person so there would be no accidental taking of medications intended for other people.

Admittedly as a clinician, I have the training that enables me to do this.

For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.

As we build electronic systems, the outpatient to inpatient transition will  become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.


Donald Green MD said...

The clinical judgment you exercised helping your parents is the same that should be done when patients and their providers interact. The doctor does not just make lists but also determines the degree of competency and abilities of the patient. If any capacity is missing then identifying a support person or persons who give contact numbers, provide reasonable availability, and understand the issues becomes extremely important.

It is this ground level management that must be solid. Any electronic record will only be as accurate as what careful effort was taken to ensure it is so. I am sorry for your parents' problems. It seems the efforts you took on their behalf should have also been done professionally.

Keith W. Boone said...

There are some things that HealthIT can do to help. IHE is working on a profile for reconciliation

Doug Mitchell, MD said...

National pharmacy chains could add value by giving updated medication cards to customers with each visit.

Also, at least one such pharmacy lets customers create online accounts. These could serve as active medication lists (assuming the patient were using that pharmacy exclusively).

Anonymous said...

It's interesting to me that every time we offspring-M.D.'s have such an encounter with our medical system, we invariably come away with such lessons. It's a humbling insight into what patients without such family expertise cope with every day. It's incumbent upon us to try to fix it ASAP - as e-patient Dave has said, with a sense of urgency, not just 'some day, maybe.'

bev M.D.

Bush here said...

Hello Doc Halamka,
At every visit to primary Physician a list can be printed with all the medications and confirmed with patient.Doctor assistant can do this and then doctors can review and send the patient with.Your suggestion of taking all the medications in a bag for each visit is excellent.My physician asks all patients to bring them.
Availability of the medication list is essential and should be auto matic and not dependent on patient.

Medical Quack said...

Great post and I have a 86 year old mom too and have worked hard to get her PHR (we use HealthVault) updated as best we can. Granted she wouldn't have this without my help but it has proven useful. Certainly we have used it to store vital information and documents.

At 86 Mom is not a geek by any means, but she knows how to go to a web browser, sign in and access the information and at worse, she could print it out and hand it to a provider. Being that said she has woken up a physician or so with just doing this simple procedure. We have manually entered some information such as her current meds and granted we do not have a complete file as we would like but we are getting there a little at a time. Just having a 2 year old pathology report available has value.

Like yourself I am not in the same area as Mom and having her advanced directive stored there doesn't hurt either as I am listed on her account to have access as well. We are about ready to import her Caremark records soon as she recently had a change in PBM companies. It takes time and someone to help out and family is the best by far as nobody knows someone like family.

When all else fails with having records available I call the PHR the patient back up system as at least we do have allergies and meds addressed for sure. Again great post and thanks for sharing the experiences of the "real" world.

Jeff Harris CIO said...

Great post!
In 2009 I made a video titled "waite, waite, don't kill me" just prior to visiting the local OR for fusion of c-3-7. For this patient: Life with chronic disease is alot of work! Diabetes, sp TIA, chronic Hep C etc. It took as long to prepare a risk factor summary as the operation.

So, after learning about brown bag reviews in 1991 in Rehab. Medicine; trying to simplify and standardize on Web in 2000 (Lotus Notes over Domino)I find myself in 2010 doing the following.

I subscribe to HealthVault which is connected to Quest and CVS. I fill all of my prescriptions at same place (six of them insulin pump etc.etc.)then I dump the contents with a verbbal translation into a word documemt. Cary the document on a flash drive titled JEFFS MEDICAL ALERT with a web address and the document as well as a note in my wallet pointing to my vault.

I do this because I take trips on my motorcycle (riding since 14) and know I could wind up anywhere subject to a therapeutic misadventure.

Sorry to hear about your Mom and Pop. I went through same with my Dad during his brain surgery in 2007.

Simplify said...


While we technologists are immediately inclined to tech solutions, I have seen simpler solutions - like a self scribbled wallet medical summary including age, blood group, chronic conditions and significant medical incidents.

Granted that there will always be doctors who will be wary of the authenticity and completeness of such information, in my experience, these are more than what they typically have access to currently about a patient being rushed in in ER by paramedics.

I am aware of incidents where my friends literally saved their lives by flashing their medical summary wallet cards when paramedics arrived on the scene.

Richard Orlowski said...

It would be nice if prescription bottles had bar coded information on them so that the information could be entered more efficiently into the EMR. Going through a bag of meds and manually typing in the info is time consuming and thus expensive in an office that is very busy and under increasing financial constraints.