AMDIS: Medication reconciliation remains challenging
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In 2005, Partners HealthCare, which includes Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, assumed its medication reconciliation process was acceptable, according to Hamman. However, the Joint Commission’s 2006 mandate caused the IT team to “get religion, as medicine reconciliation was no longer for amateurs,” said Hamman, who is assistant medical director of IT projects at Mass General.
Partners recognized its need for a more upfront effort to produce downstream teamwork savings and improved patient safety, which, according to Hamman, required in-house web service development and workflow transformation over five years.
The organization first developed a pre-admission medication list (PAML), which required enterprise clinical, IT and research collaboration. The PAML was integrated with medication orders. Then the researchers learned the power of the hard stop, which mandated the use of the system to process the patient. “Of course, as with almost all technologies, it was 10 percent functionality and 90 percent process,” Hamman said.
As of 2011, Partners has 98 percent adherence to its medication reconciliation process. However, the health system is still working on tracking accuracy and implementing a quality improvement program. Hamman attested that Partners has improved discharge reconciliation, mainly due to nurses and better global medication-by-medication reconciliation.
In addition, Partners added a second hard stop at discharge that included patient education, which has enabled dissemination of medicine reconciliation across the continuum of care. The initiative was kicked into high gear by meaningful use standards, which require a patient discharge medication list for those who require rehabilitation. Hamman reported that this population is about 30 to 40 percent of the system’s patients. The meaningful use standards currently designate medicine reconciliation a menu item for Stage 1, and a requirement for 50 percent of patients at Stage 2 and 80 percent at Stage 3.
Currently at Partners, there is a post-discharge medication list (PDML) for patients and post-discharge medicine reconciliation at the first office visit. Initially, the latter part is meeting with low acceptance, but it will soon be a practice-wide rollout, he said.
Ongoing challenges at Partners include vestigial paper documents, improving clinician accuracy and getting "a better big picture of patients post-discharge," such as pharmacy, rehab and home care data. Homegrown IT systems that lack interoperability across the enterprise are also an issue, said Hamman.
“Medicine reconciliation is incredibly hard to implement, particularly because of its lack of an understandable definition,” said Hamman, adding that the Joint Commission or CMS have failed to define it despite the expectations associated with the process.
As audience member, Peter Basch, MD, medical director of e-health at MedStar Health in Washington, D.C., concurred: “While medicine reconciliation is not a new term, it is really one that has failed to be defined. This new meaningful use standard may therefore present [CMIOs and IT leaders] with an opportunity to take the time to truly define the term, and how it can improve patient care.”