By Janice Dunsavage, Erik Hernandez, and Rita Overcash
Although the benefits of medication reconciliation are well recognized, many hospitals continue to struggle with meeting the criteria put forth in NPSG 8. In fact, 20% of hospitals surveyed in 2007 received a Requirement for Improvement (RFI) for their medication reconciliation programs. Often, inaccurate or incomplete medication histories serve as an obstacle to successful implementation of an effective medication reconciliation program. While TJC has temporarily halted scoring hospitals for NPSG 8 as the agency evaluates and refines expectations, organizations should continue to address medication reconciliation. A revised version of the goal is expected sometime in 2010.
Creating a Workable Program
Beginning in 2005, Pinnacle Health, a health care system in central Pennsylvania, made several unsuccessful, often frustrating, attempts to implement a medication reconciliation program that would effectively meet the objectives of NPSG 8. Our first attempt focused on encouraging prescriber buy-in by using a patient’s medication history document as an order form. However, this method was riddled with issues: The fact that there were often several different histories in a patient’s chart caused confusion, and problems resulted from illegibility, incompleteness, inconsistency, and conflict with pre-printed order forms and established order sets. By mid-2007, anticipating a visit from TJC, we set out to quickly redesign our initial program without adding FTEs. We determined it would be optimal to have pharmacy oversee the entire process, but because there were no allocated FTEs, pharmacy would continue to share responsibilities with nursing and prescribers. With the new program, the “official” medication history would continue to be collected by a nurse during the patient interview, followed by manual entry of the information into an electronic database by that same nurse. Electronic medication histories had been in place for a few years and were available to all practitioners involved in the medication-use process. We decided that prescribers would now write admission medication orders separate from the electronic documentation entered by the nurse. Finally, a pharmacist would complete a manual reconciliation of the home medication list against admission medication orders and provide a hand-written summary of the information to the prescriber; it was this part of the process that was cumbersome and fraught with error.
Despite these efforts, Pinnacle Health was issued an RFI in November 2007 for NPSG 8 “for lack of consistency and predictability in medication reconciliation.” As a result, we decided to refine and automate as many steps in the process as possible. We wanted to implement an electronic program capable of providing a good starting point for a more accurate medication history, eliminating potential confusion from multiple medication histories, and one that facilitated a more efficient reconciliation process. We also wanted to implement a program that would not require additional FTEs. Following a thorough review of the available medication reconciliation vendors, we chose Health Care Systems (HCS).
With the medication reconciliation software solution, a Medication History Worksheet is automatically generated—within minutes of admission—for a patient on the appropriate nursing unit and incorporated into the admission process. This worksheet is created from information in our vendor’s multiple third-party payer prescription databases and is populated with medication name, dosage strength, quantity supplied, initial fill and refill history, as well as information identifying the prescriber and dispensing pharmacy for each medication obtained. The query timeframe is configurable between four to 12 months. We chose to see nine months of data based on requests from our OB/GYN prescribers to review all medications taken during pregnancy. On average, medication history information from the vendor’s databases is found for at least 80% of our patients.
Patients admitted directly to surgical and cardiac areas on the day of their procedure are interviewed either by telephone or during the pre-admission appointment at least one day in advance to complete an admission history, including collection of a home medication list. In these cases, the nurse queries the software system to produce a Medication History Worksheet using a pre-registration number. All worksheets are stored simultaneously in our electronic data repository in the event that additional copies are needed.
Interviewing the patient to obtain a home medication list can be difficult depending on the patient’s condition and/or lack of family present at the time of admission. As a result, medication histories are often inaccurate, incomplete, or simply not acquired. Having access to the Medication History Worksheet offered us a starting point to verify the patient’s current medication information—including discontinued medications, dosage changes, etc—significantly improving the process. However, it is important to note that this tool is not all-inclusive. Information that has not been submitted to third-party prescription plans, including prescriptions purchased out of pocket, over-the-counter medications, dietary supplements, and sample medications, is not captured and must be manually collected and documented as part of the interview. Although there are several approaches to updating the electronic history, Pinnacle Health chose to have the nurse provide a copy of the completed worksheet to the pharmacy. The original is placed in a separate medication reconciliation section of the medical record.
Upon receipt of a completed Medication History Worksheet, the information obtained by the nurse is electronically transcribed into the medication reconciliation software system by a pharmacy technician. This represents a new role for pharmacy technicians at our organization. Once confirmed by a pharmacist, an updated electronic home medication list is accessible to all practitioners involved in the care of the patient. The prescribed admission medication orders are independently entered into the pharmacy information system. Via an interface, the software program provides a four-quadrant electronic display (see Figure 1) of home medications, current medication orders, color-coded reconciliation between home and current meds, and status of the medication reconciliation process. The color-coded reconciliation includes blue medications, which signify an exact match between home and inpatient medications; green medications, new medications not on the home medication list; red medications, home medications not ordered on admission; and purple medications, which indicate a change between home and current medications, such as dose, route, frequency, etc. Focusing on red and purple medications, our pharmacists determine whether each variance is “explainable” or “unexplainable.” Explainable variances are those that make sense based on the patient’s clinical profile, such as a warfarin patient admitted with a GI bleed. This type of variance is accompanied by notes to the prescriber from the pharmacist. At the request of our pharmacists, commonly used variance notes, such as “patient not taking oral medications,” have been pre-scripted into the software system to maximize efficiency and consistency. We also incorporated our extensive therapeutic interchange list into the software program allowing for matching of approved formulary alternatives. The pharmacist notes this as “therapeutic interchange.” “Unexplainable” status is selected whenever a variance cannot be justified with a clinically relevant reason for omission of the medication. All discrepancies are printed on a variance report titled the Admission Medication Reconciliation Form. These forms are automatically printed on the unit and placed in the order section of the patient’s chart for the prescribers to review. The form can be used as an order and is saved electronically to the clinical repository.
As part of our shared-responsibilities approach, prescribers currently perform discharge medication reconciliation at Pinnacle Health. Prescribers have the ability to access a Discharge Medication Worksheet from the medication reconciliation system. This information is currently used to assist with the prescribing of discharge medications and corresponding reconciliation. The document compares the original home medication list against the current medications at the time of discharge. The patient’s medications are summarized into one of four categories: Home Medications Ordered and Active at the Time of Discharge, Home Medications Altered During the Inpatient Stay, Medications Added During the Inpatient Stay, and Home Medications Not Ordered During the Hospital Stay.
Home medications therapeutically interchanged in the hospital are identified as “altered during the inpatient stay,” reminding the prescriber to reorder the correct home medication upon discharge. Other opportunities we are looking into with our software include e-prescribing and electronically sending discharge medication summaries to the next provider.
After working with the electronic medication reconciliation tool for almost 18 months, it is easy to see other possibilities that could be developed. For example, we are currently testing a Warfarin Flowsheet that was developed with our vendor based on feedback from our prescribers who wanted a solution for managing warfarin after discharge. One of the primary complaints is that it is difficult to determine how their patients were anticoagulated while in the hospital. To address this, we developed a five-day flowsheet to display daily INR values and doses administered directly on the Medication Reconciliation Discharge Medication Worksheet; this solution will be implemented soon.
While implementing a successful medication reconciliation program was a long, arduous journey, it has proven well worth the effort; both staff satisfaction and patient care have been substantially positively impacted since instituting our latest program.
The keys to our success with medication reconciliation were instituting an automated solution and getting staff buy-in by effectively communicating the importance of properly performing medication reconciliation. Using automation helped us standardize the medication reconciliation process by providing a consistent workflow for duties such as gathering home medication lists, and by assuring the appropriate documents are electronically stored as part of the patient’s medical record.
Janice M. Dunsavage, RPh, MAS, is the director of pharmacy for Pinnacle Health, a position she has held for 14 years. She previously served in various leadership capacities in other hospitals. She also serves on the Board of Trustees for the Institute for Safe Medication Practices. She received a BS in pharmacy from the Philadelphia College of Pharmacy, now the University of the Sciences of Philadelphia, and an MAS from Johns Hopkins University.
Erik M. Hernandez, RPh, PharmD, is the clinical pharmacy coordinator for Pinnacle Health. He previously was employed as a pharmacy student, staff pharmacist, and clinical pharmacist for Pinnacle Health. He earned his PharmD from the Ernest Mario School of Pharmacy at Rutgers University.
Rita J. Overcash, RN, BSN, MSHA, is the pharmacy clinical implementation coordinator for Pinnacle Health. She has 13 years experience in nursing management, during which time she spent nine years co-chairing Pinnacle Health’s Nursing Pharmacy Committee. She previously served in various other nursing positions. She is the current president of South Central Organization of Nurse Leaders. Rita received her BSN from York College of Pennsylvania and her MHA from University of St. Francis.
Improving Workflow with Electronic Reports
Our medication reconciliation vendor afforded us the opportunity to refine our workflow using electronic reports to support all parties involved in the medication reconciliation process. These reports serve as reminders to ensure that each step of the medication reconciliation process is completed as timely as possible.
WHERE TO FIND: Medication Reconciliation Software
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