Improved Efficiency and Accuracy in Collecting Home Medication Lists

by Steven Wade, RPh and Shondra Sholar, PharmD  

Prior to November 2007, Brookwood Medical Center in Birmingham, Alabama, used a shared, manual process, which included nurses, physicians, and pharmacists, to perform medication reconciliation. The core of the medication reconciliation process was the manual compilation of home medications through an interview of patients and their families upon admission to the hospital. Since it was a time-consuming process that involved several disciplines, few were willing to take responsibility for completing it. Furthermore, circumstances often hindered our ability to obtain a complete and accurate list of home medications: Patients and families were often anxious and omitted items; did not think that all items required disclosure; and, in some cases, may have been too embarrassed to include certain therapies. In addition, patients and family members regularly omitted drug allergy information. A review of our medication reconciliation process was performed as part of our quality assurance program to provide increased emphasis on the Joint Commission’s expectations. 

Identifying and Implementing the Solution
In researching solutions that could aid us in obtaining complete home medication lists from our patients, we discovered HealthCare Systems’ medication reconciliation solution, which extracts information from a database of
third-party payer prescription information to create a report of patients’ past and current home medications that can be used to facilitate the admission interview.
While pharmacy served as the contact for HCS, our information systems department coordinated the mechanics of the installation of the software. Once the initial set-up was completed with our server, pharmacy handled the changes in forms and processes.

Medication Reconciliation Now
Our actual medication reconciliation process is unchanged, however we now use the HCS report as a tool to compile a complete home medication list for each patient. When a patient is admitted, an automated request is sent to HCS with appropriate patient identifiers. HCS queries their database sources and returns a report per our pre-set data elements in about 30 seconds. Our home medication form is then populated with that information and prints to the nursing unit where the patient has been admitted. A copy of the data elements is stored on the local server, in case a second report is requested. 

Using the form as a tool, the health care professional interviews the patient to attempt to gain a more complete record of home medication use. Some medications may be discontinued, and some – such as over-the-counter medication and herbal supplements – may not be associated with third-party payers. The medication history interview allows us to identify these items and is crucial to validating the information on the list provided by HCS. The information obtained from HCS is of particular value in caring for our elderly population and patients with mental health issues. These patients are not always the best historians and their omissions of home medications during the interview process can result in interrupted therapies. Because the HCS list is generated from an extensive database, it is a useful starting point for the medication history interview process. 

Results
Using the HCS system has helped us standardize our process and provides a consistent method for gathering home medication lists across the hospital. The prescription history reports help us identify products that patients may have omitted, either accidentally or intentionally, during their admission interview – products that could conflict with newly prescribed therapies and lead to adverse drug events. The computer-generated forms have also improved the legibility of our home medication lists. The HCS system has improved the efficiency of our medication reconciliation program and the accuracy of our home medication lists.

 Steven Wade, RPh, has been the director of pharmacy at Brookwood Medical Center since June 2007. Prior to assuming his current post, he worked for the Department of Veterans Affairs for 30 years.

Shondra Sholar, PharmD, currently serves as the pharmacy manager for quality assurance at Brookwood Medical Cener. She graduated from the McWorter School of Pharmacy in Birmingham, Alabama.

Where to Find it: HealthCare Systems www.hcsinc.com  

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Automation to Streamline Medication Reconciliation

By Jack Bond, RPh, MHS, and James Rosendale

Wesley Medical Center is a 760-bed acute care facility serving Kansas and Northern Oklahoma. In October 2007, we installed Iatric Systems’ medication reconciliation solution to reduce errors and streamline our end-to-end medication reconciliation process. Prior to the implementation, medication reconciliation at Wesley was disjointed and fraught with opportunities for error. Home medications were entered as free-text into our MEDITECH nursing system, from which reports were printed. Patients’ active in-house medications were stored independently in our pharmacy system.

Discharge medications were entered into additional free-text fields in the nursing system and then printed for each patient. Nurses had to use yet another system to print drug monographs manually.We needed a solution that would streamline processes, as well as provide more integration between our nursing and pharmacy systems. Furthermore, we needed a system that would produce drug monographs and provide automatic faxing of medications to patients’ primary care providers upon discharge. Iatric Systems’ solution fulfilled all of these requirements.

 Implementation and Current Processes
The implementation was relatively quick and easy. A multi-disciplinary team, with members representing nursing informatics, pharmacy, health information management, and information services, participated in the system selection, redesigned workflow processes, and quickly installed the program. The software was piloted on one nursing unit and then rolled out house-wide.

Now, nurses document patients’ medication histories in the Iatric program and can select medications directly from our pharmacy drug dictionary. This information is used as the admission order. Whenever reconciliation needs to occur thereafter, medication history and active in-house meds can be viewed on one screen in Iatric Systems, and a hardcopy report is printed containing this and additional information, such as dietary and respiratory orders.
At discharge, we provide our physicians with a report that sorts the medication history and in-house orders by drug class and lists them in a side-by-side format. The Joint Commission identified this as a best demonstrated practice during our most recent survey. Physicians simply select which orders should remain effective upon discharge and indicate any new medications to be added, and nurses then choose those medications within Iatric Systems. A finalized medication list is generated for the patient, and corresponding drug monographs print automatically. The system also automatically faxes a discharge medication list to the patient’s primary care provider.

System Benefits
The Iatric Systems solution is integrated with MEDITECH without the need for interfaces, so users never feel like they leave the MEDITECH system. Users can access Iatric routines from wherever they need to – from within the MEDITECH Data Repository system, user menus, and documentation screens. We believe we have closed the medication reconciliation loop with the installation of the Iatric Systems solution. Using dictionary-driven fields instead of free-text has decreased errors, and our physician report, sorted by drug class, has improved decision-making at discharge.
Finally, the ability to automatically fax discharge medication lists to primary care providers (PCPs) has proven to be a very powerful tool. PCPs have become champions of the new process. Because hospitalists assume primary care for patients while in-house, many PCPs had difficulty knowing exactly what medications had been sent home with their patients upon discharge. Numerous PCPs have indicated how helpful it is to discuss the exact medication profile with their patients in their offices immediately after discharge. 

 
Jack Bond, RPh, MHS, is the director of pharmacy at Wesley Medical Center, where he has worked for 31 years. Prior to assuming this role five years ago, he served as the pharmacy manager and a staff pharmacist. Bond earned a BS in pharmacy from Kansas University, and a master’s degree in health sciences from Wichita State University.

James Rosendale has been a pharmacy data architect at Wesley Medical Center for six years. Over the course of his 20-year career in pharmacy, Rosendale has served as a pharmacy system specialist, a pharmacy technician coordinator, and a pharmacy technician.

Where to Find It: Iatric Systems, Inc. www.iatric.com  

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A Customized Software Solution for Medication Reconciliation

By Thomas Jacob Wessel, Jr, MD, ABFP

In 2005, Spartanburg Regional Medical Center’s medication reconciliation committee drafted a paper document for medication reconciliation, which the admitting nurse would use to manually record a patient’s home medications. Physicians would then use this form to reconcile inpatient medications and generate orders. The proposed transfer and discharge processes were similar. However, after giving it further thought, we judged this paper-based process to be too time-consuming and error-prone, due to the potential for copying mistakes and illegibility. To address these concerns, we sought a computerized process that would preserve our existing nursing workflow, reduce copying, eliminate handwriting, and decrease prescribing errors. At the time, we were unable to identify a commercially available solution to meet our needs and decided to create a custom software solution with the help of Healthtek, an established health care software vendor. We asked Healthtek to avoid HL7 interfaces, if possible, in order to reduce system complexity and maintenance. Instead, Healthtek developed the RxReconcile application, a Web-based front end to our McKesson clinical system.

Current Processes
For the past two years, we have used RxReconcile throughout Spartanburg Regional Medical Center (SRMC). Our rehab hospital, Spartanburg Hospital for Restorative Care, has also elected to deploy RxReconcile house-wide. While nursing is primarily responsible for reconciling home medications, RxReconcile is flexible enough that we could change our process to allow pharmacists or pharmacy technicians to take the lead role in medication reconciliation. The admission reconciliation proceeds as follows:
• The admitting nurse updates and confirms home medications in McKesson’s Horizon Clinicals system.
• The physician logs into RxReconcile and performs admission
reconciliation.
• The system flags potential duplicates and allergies.
• The physician prints the documentation of reconciliation and medication orders – one copy for the chart and another copy to be faxed to pharmacy.

The process is similar at transfer and discharge, except at discharge, prescriptions can be generated and the patient gets a universal medication form to take with them. All reconciliation reports are scanned into the online medical record, which is available remotely to providers with appropriate roles and security credentials.

System Benefits
Using RxReconcile, nurses save about 10 minutes per patient discharge, and medication regimen legibility has improved significantly. Because Rx Reconcile is easy
to use, physician participation in the medication reconciliation process has improved. Furthermore, our rehab hospital clinicians have found the new system to be fast and easy to use, and have noted that it promotes improved quality of care.

 
Thomas Jacob Wessel, Jr, MD, ABFP, is currently the medical information officer for the Spartanburg Regional Medical Center. He received a BS in chemistry from Furman University and a MD from the Medical University of South Carolina.

Where to Find It: Healthtek Software Solutions www.rxreconcile.com

To Find Other Medication Reconciliation Solutions go to www.findit.pppmag.com