Medication Reconciliation: Still Under Construction
Providers face new pressure from pay-for-performance models of care, under which Medicare and Medicaid no longer reimburse for avoidable medication errors. At the same time, physicians are treating more patients who are taking increasingly complex medications. Medication reconciliation is more vital than ever, but is still a tough pill to swallow for many reasons.
Proposed meaningful use menu measures for eligible providers and hospitals in Stage 2 Meaningful Use require a receiving provider to conduct medication reconciliation on 80 percent of care transitions when patients arrive from another care setting or from another provider. That threshold would increase to 90 percent in Stage 3's proposed measures.
Yet medication reconciliation remains a work in progress at many facilities, often because the tools are not yet in place to make it happen. For example, many clinical decision support (CDS) systems—cornerstones of the medication management and reconciliation process—don't reliably identify clinically relevant drug-drug interactions, according to a study published in Health Affairs online Dec. 3, 2010.
It's the provider's responsibility to perform the medication reconciliation process, says Eliot Heller, MD, CMIO at BLHC. "That's part of being a licensed provider. The responsibility is on the provider because they are writing the medication and therefore they should be doing the reconciliation," says Heller.
BLHC uses the Sunrise orders reconciliation manager to reconcile medications with patient's admittance, transfer and discharge, according to Heller.
"As someone who has the responsibility to prescribe medicine, the concept of medication reconciliation is a no-brainer," he adds. "When giving medication, you should be aware of the patient's underlying conditions, medications he or she takes, allergies and, if a female of appropriate age, are they pregnant."
BLHC providers are 100 percent compliant with reconciling inpatient medication orders, but work still needs to be done in the outpatient setting, Heller says. "I'd like to see medication order entry always done within a medication reconciliation window, but I don't know of any product that's there yet," he says.
The web portal gives patients access to PeaceHealth's internal EMR (GE Healthcare) and to their medical records. Under the "MAP Your Meds" initiative ("MAP" stands for "Monitor. Ask. Prevent."), patients can see their medication lists by accessing PatientConnection on their computer. If their medications are not on the list or if they take a different dosage than the list indicates, patients can send a message through the portal to their provider to update their list with the correct dosage.
PatientConnection's information is integrated into the system's EMR but providers cannot send messages to patients from the portal, says Laiho.
The medication list is promised to be updated within 24 business hours. The system has changed some physicians' workflow in that they print out patient's medication list the evening prior to the visit the following day, Laiho says.
"We've been using electronic medication administration services including barcoding at bedside since 2001," says Lisa Bewley, MSM, CPNP, vice president of IT at the medical center.
However, medication reconciliation is currently a paper-based process at RWMC, with three nurses dedicated to the front end administration part of the reconciliation process and discharge nurses dedicated to the back end part of the process, says Shirley Knodel, RN, MS, vice president of patient care and CNO at RWMC. The initial process averages 30 to 60 minutes from the collection of medication lists to validation. As a Level 2 trauma unit, a fourth dedicated nurse is currently being sought to assist with the front-end paper-based medication reconciliation, Knodel reports.
The rollout of the McKesson medication reconciliation software is planned for fall, and RWMC is going to great lengths to make sure the integration will be seamless. "We have a shared governance committee with co-chairs representing the pharmacy and nursing sides who meet monthly and proactively identify problem areas which will include the rollout," Knodel says.
Nevertheless, in the transition from paper to an electronic process, Knodel anticipates a shakeup as more accountability for medication reconciliation transfers to physicians. "That's going to be a process change that will require support to maintain their efficiency," she says.
Proposed meaningful use menu measures for eligible providers and hospitals in Stage 2 Meaningful Use require a receiving provider to conduct medication reconciliation on 80 percent of care transitions when patients arrive from another care setting or from another provider. That threshold would increase to 90 percent in Stage 3's proposed measures.
Yet medication reconciliation remains a work in progress at many facilities, often because the tools are not yet in place to make it happen. For example, many clinical decision support (CDS) systems—cornerstones of the medication management and reconciliation process—don't reliably identify clinically relevant drug-drug interactions, according to a study published in Health Affairs online Dec. 3, 2010.
'A no-brainer' concept
Providers are taking different approaches to meet the medication reconciliation challenge. Bronx-Lebanon Hospital Center (BLHC) in New York decided to store a patient's home medication details in one location (Prescription Writer) integrated into its Allscripts Sunrise EMR system.It's the provider's responsibility to perform the medication reconciliation process, says Eliot Heller, MD, CMIO at BLHC. "That's part of being a licensed provider. The responsibility is on the provider because they are writing the medication and therefore they should be doing the reconciliation," says Heller.
BLHC uses the Sunrise orders reconciliation manager to reconcile medications with patient's admittance, transfer and discharge, according to Heller.
"As someone who has the responsibility to prescribe medicine, the concept of medication reconciliation is a no-brainer," he adds. "When giving medication, you should be aware of the patient's underlying conditions, medications he or she takes, allergies and, if a female of appropriate age, are they pregnant."
BLHC providers are 100 percent compliant with reconciling inpatient medication orders, but work still needs to be done in the outpatient setting, Heller says. "I'd like to see medication order entry always done within a medication reconciliation window, but I don't know of any product that's there yet," he says.
Patient participation
PeaceHealth Medical Group, a health system spanning Washington state, Oregon and parts of Alaska, has given patients a more active role in medication reconciliation. Systemwide, 20,000 users (approximately 5 percent of PeaceHealth's patient population) have signed up for a web portal service called PatientConnection. The system, which went live in 2001, proactively uploads their medication information to ensure their medication lists are up-to-date prior their appointment, says Judy Laiho, RN, CHR, provider support analyst at PeaceHealth Medical Group of Eugene/Springfield Ore.The web portal gives patients access to PeaceHealth's internal EMR (GE Healthcare) and to their medical records. Under the "MAP Your Meds" initiative ("MAP" stands for "Monitor. Ask. Prevent."), patients can see their medication lists by accessing PatientConnection on their computer. If their medications are not on the list or if they take a different dosage than the list indicates, patients can send a message through the portal to their provider to update their list with the correct dosage.
PatientConnection's information is integrated into the system's EMR but providers cannot send messages to patients from the portal, says Laiho.
The medication list is promised to be updated within 24 business hours. The system has changed some physicians' workflow in that they print out patient's medication list the evening prior to the visit the following day, Laiho says.
Diving in
Although Regional West Medical Center (RWMC) in Scottsbluff, Neb., has used an EMR (McKesson) for the past 10 years, the 184-bed community hospital is gearing up to add a medication reconciler (McKesson) to its clinical infrastructure."We've been using electronic medication administration services including barcoding at bedside since 2001," says Lisa Bewley, MSM, CPNP, vice president of IT at the medical center.
However, medication reconciliation is currently a paper-based process at RWMC, with three nurses dedicated to the front end administration part of the reconciliation process and discharge nurses dedicated to the back end part of the process, says Shirley Knodel, RN, MS, vice president of patient care and CNO at RWMC. The initial process averages 30 to 60 minutes from the collection of medication lists to validation. As a Level 2 trauma unit, a fourth dedicated nurse is currently being sought to assist with the front-end paper-based medication reconciliation, Knodel reports.
The rollout of the McKesson medication reconciliation software is planned for fall, and RWMC is going to great lengths to make sure the integration will be seamless. "We have a shared governance committee with co-chairs representing the pharmacy and nursing sides who meet monthly and proactively identify problem areas which will include the rollout," Knodel says.
Nevertheless, in the transition from paper to an electronic process, Knodel anticipates a shakeup as more accountability for medication reconciliation transfers to physicians. "That's going to be a process change that will require support to maintain their efficiency," she says.