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IHI ExpeditionExpedition: Improving Medication Safety from the Patient’s Perspective

Session 4: Medication Reconciliation

April 9, 2015

These presenters have

nothing to disclose

Anne Myrka, RPh, MATJoelle Baehrend

Today’s Host2

Akiera GilbertProject Assistant

Institute for Healthcare Improvement

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Expedition Director6

Joelle Baehrend

Director

Institute for Healthcare Improvement

Today’s Agenda7

• Welcome & Introductions

• Action Period Debrief

• Medication Reconciliation – Anne

Myrka, RPh, MAT

• Action Period Assignment

Expedition Sessions

Session 1 – Improving PolypharmacyFaculty : Robert Feroli, PharmD and Amanda Brummel, PharmD, BCACP

Session 2 – Health Literacy and Medication SafetyFaculty : Gail Nielsen, BSHCA, FAHRA

Session 3 – Improving Medication AdherenceFaculty : William Strull, MD

Session 4 – Medication ReconciliationFaculty : Anne Myrka, RPh, MAT

Session 5 – Safe Management of Newly Released Anticoagulants and High-Alert

MedicationsFaculty : L. Hayley Burgess, PharmD

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Action Period Assignment Report Out

Assignment:

Have a conversation with a patient at discharge and ask:

(1) Do you know what the medication is for?

(2) Can you obtain the recommended medication?

(3) Do you know about the possible side-effects?

Report out:

What did you learn? Please chat in any reflections on the

exercise.

Survey Results - Current State

Medication Reconciliation: My hospital has a process to

reconcile medications at admission and all transitions of

care:

• Do not know current status of this practice: 5%

• Do not currently have this practice in place: 0%

• Have a process that supports this practice: 50%

• Process is reliably applied: 15%

• Need further clarification on this practice: 30%

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Faculty11

Anne Myrka, RPh, MATPharmacist

IPRO

Medication Reconciliation

Anne Myrka, RPh, MATIPRO

April 9, 2015

Objectives

Define medication reconciliation as a component of

medication management

Discuss on-going challenges of medication

reconciliation

Describe how technology can help improve

medication reconciliation

Describe the role of patients/families/caregivers in

medication reconciliation

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Poorly executed med

rec.

14

Medication Management, Medication Reconciliation and On-going

Challenges

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Medication Management

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Medication History

up-to-date listing of all prescription and over-the-counter

medications, herbal supplements and vitamins

Medication Reconciliation

comparison of one or more medication lists to new one

● resolve discrepancies

● identify and resolve medication related problems

should occur whenever there is a care transition, or change in

medications or diagnosis

Medication Adherence

Medication Reconciliation Challenges

In general, the creation and transition of an accurate

medication list remains a challenge for every care

setting

Systems lack the ability to document rationale for

changed medications leaving next provider to

“guess” whether changes where intended or

unintended

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Lack of standardized process and clear ownership

Communication failures

Coordination gaps

Non-formulary medications and therapeutic

interchanges

Lack of standardized medication list “source of truth”

document

Failure to identify and resolve medication related

problems

Failure to identify multiple existing sources for

medication lists

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No one person is accountable for med rec from ED to

admission and there are always discrepancies

The best possible medication list is not attempted

until discharge so this is when most problems are

found and require resolution

Med rec is time consuming, a comprehensive med

rec can take 60 minutes or longer

Hospitals using multiple EHR and/or paper based

systems are error prone (e.g., EHR in ED is not the

same system as the inpatient side, the pharmacy

system does not interface with EHR, etc…)

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Medication Reconciliation: Technological Solutions and Other

Interventions

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Medication ReconciliationHospital Interventions

Identify an accountable structure and support for med rec

throughout the continuum of patient hospital stay from

admission to discharge with multiple layers of verification

Use pharmacist & physician champions that can help address

problems

Use IT solution where able but don’t wait for “the next update”

Educate staff regarding avoidance of undesirable effects

caused by IT

Optimize use of electronic communication capabilities

Avoid using system that is driven by paper or requires

transcribing from one system to another

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Create EHR system fixes for documenting

rationale for medical decisions and ensuring

such documentation appears on the discharge

summary

Create the ability to scan documents that were

presented by the patient/family/caregiver into

the EHR

Use multiple sources to identify medication lists

for reconciliation

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25Am J Pharm Benefits. 2014;6(5):217-224

Background: Transitions between healthcare settings are vulnerable times for patients. Medication

discrepancies associated with transitions are particularly problematic. Combining medication history

information from various sources may improve the completeness and accuracy of medication

information, leading to improved safety outcomes.

Objectives: To evaluate the accuracy and completeness of patients’ medication history information at

the time of hospital admission from 3 different electronic sources, and to assess the

additive value provided by each source.

Study Design: Case study of admissions to 2 community hospitals in upstate New York between

September 2010 and April 2011.

Methods: Medication history information was obtained from the hospital’s electronic health record

(EHR), a commercial medication database, and a community wide health information exchange web

portal. Information from the sources was compared with the gold standard medication list generated as

part of the routine intake medication reconciliation process.

Results: We studied 858 patients, who collectively were on 7731 medications. The hospital EHR

captured 80% (n = 6152) of medications accurately, the commercial medication database captured

45% (n = 3464) accurately, and the community portal captured 37% (n = 2838) accurately. When all 3

sources of medication information were pooled, medication accuracy increased to 91% (n =

6997).


Obtain the most accurate medication history -

interviewing tools are available:

Certification for obtaining the best possible medication list:

Society of Hospital Medicine MARQUIS toolkit: Self Study

guide:

http://tools.hospitalmedicine.org/resource_rooms/imp_guides/

MARQUIS/MARQUIS_Certification_Simulation_Case_1_Final.p

df

Optimize use of pharmacists

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Allocation of Scarce Resources

Clinical Pharmacy Services (CPS)

Numerous studies have shown improved economic and health

outcomes when CPS is incorporated within collaborative patient

care team

CPS should be used for patients who are at high risk due to

medications, location or condition

Resolving medication discrepancies is only the tip of the

iceberg…pharmacotherapeutic interventions improve patient

outcomes even unrelated to ADEs

Challenge: cost of pharmacist is a perceived barrier

ROI calculations can be found in MATCH and MARQUIS toolkits

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Chisholm-Burns MA,, et al.. Med Care. 2010;48:923-33.

Chisholm-Burns MA., et al..Am J Health-Syst Pharm. 2010; 67:1624-34

Profiling Patient Risk for Intervention

Elderly

On high risk/high alert medication

ISMP High Alert Medication list

Institute for Healthcare Improvement High Alert drug classes:

Anticoagulants, opioid analgesics, insulin, sedatives

High risk drug classes for nursing home patients:

NSAIDs, digoxin, insulin, antipsychotics, sedatives/hypnotics,

anticoagulants

Budnitz, et al, 2011: anticoagulants, antiplatelets, insulin,

hypoglycemics, opioids

High risk location/transfer (i.e. nursing home to hospital, ICU to

floor)

Health history indicates high risk

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Boockvar KS, et. al. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009 February ; 18(1): 32–36.

Medication Reconciliation and Patient/Family/Caregiver Engagement

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Med Rec and Patient/Family/Caregiver Engagement: Role of the Provider

Collaboration with healthcare team with a focus on

increasing patient’s and caregiver’s ability to manage

their care

● Physicians

● Nurses

● Pharmacists

● Social workers

● Discharge planners

Ensures that patients and family/caregivers have the

knowledge and skills to recognize and address

health care problems as they arise

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Med Rec and the Role of Patient/Family/Caregiver

Two-way communication with provider during

medication reconciliation at times of transition

Learn medication management skills

Maintain accurate personal health record

Ensure timely medical follow up

Knowledge of “red flags” that indicate worsening

condition – and knowledge of action needed

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Med Rec and Patient/Family/Caregiver Engagement – Questions to Consider

Do you have a standardized process for conducting a patient

medication history interview on admission?

Are staff trained?

What do you do with patient artifacts (e.g. medication lists)?

Are they reviewed by the prescriber… and in a timely manner?

Included in the med rec process?

Added to the medical record?

Can they be easily retrieved for review?

Are they taken seriously? Do you discuss the artifact with the

patient/family/caregiver? Is the discussion documented?

Do you have a standardized process for medication counseling

on discharge? And are staff trained?

32


Is the patient/family/caregiver provided with an accurate

medication list? Do you know what to include?

● Don’t forget OTCs and herbals

● Be aware of: hospital formulary drugs vs. insurance formulary drugs, long

acting vs. short acting drugs

Does patient/family/caregiver know why each drug is being

used?

How does the patient/caregiver know it’s “working” and why

should they care? What are the patient’s goals?

Has the patient/caregiver been taught the common symptoms

of medication related problems?

Does the patient/caregiver know what to do if they encounter

these symptoms?

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Does the patient need any provider or laboratory follow up to

monitor medication therapy?

What time(s) should the patient take each drug and what

should they do if a dose is missed?

Does the patient/caregiver and the provider know that a

pharmacist can be contacted for questions about any drug?

How does the provider know that the patient/caregiver actually

understands the education provided? Can the patient/caregiver

demonstrate internalization of new knowledge?

34

Health Alliance Hospital of the Hudson Valley: Patient-Centric Medication Reconciliation

Provides

downloadable

medication

reconciliation

brochure with

medication list

3 domains:

What is med rec?

Your role in med rec

Medication safety

once you leave the hospital

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Summary

Overcoming barriers to the provision of high quality

medication reconciliation is possible with leadership

and optimization of resources – both technological

and human

Patient/family/caregiver engagement with medication

reconciliation and medication management should be

explicit and communication bi-directional

36

Resources

Society of Hospital Medicine MARQUIS Toolkit:

http://www.hospitalmedicine.org/marquis/

Medications at Transitions and Clinical Handoffs

(MATCH) Toolkit for Medication Reconciliation:

http://www.ahrq.gov/professionals/quality-patient-

safety/patient-safety-

resources/resources/match/index.html

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For more information

Anne Myrka, RPh, MAT

Pharmacist

(518) 320-3591

[email protected]

IPRO CORPORATE HEADQUARTERS

1979 Marcus Avenue

Lake Success, NY 11042-1002

IPRO REGIONAL OFFICE

20 Corporate Woods Boulevard

Albany, NY 12211-2370

www.atlanticquality.org

Template 9/23/14

This material was prepared by the Atlantic Quality Innovation Network (AQIN), the Medicare Quality

Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract

with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and

Human Services. The contents do not necessarily reflect CMS policy. 11SOW-AQINNY-TskC.3-15-16

Questions/Discussion39

Raise your hand

Use the chat

Action Period Assignment

Reflect on the audit and what you have heard from Anne

today and identify two challenges and two affordances

(things that help) in your medication reconciliation

process.

– Please be prepared to share what you come up with on our next

call.

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Expedition Communications

• All sessions are recorded

• Materials are sent one day in advance

• Listserv address for session communications:

[email protected]

• To add colleagues, email us at [email protected]

41

Session 5

L. Hayley Burgess, PharmDDirector of Clinical Pharmacy and Medication Safety

Hospital Corporation of America, Clinical Services Group

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Thursday, April 23rd, 1:00 – 2:00 PM ET

Safe Management of Newly Released Anticoagulants and

High-Alert Medications

Thank You!43

Joelle Baehrend

[email protected]

Dorian Burks

[email protected]

Please let us know if you have any questions or

feedback following today’s Expedition webinar.

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