Optimize Discharge Medication Reconciliation

October 2011 - Vol.8 No. 10 - Page #30

Q&A with Laura Britton, 


Pharmacy Purchasing & Products: What is the ideal role for pharmacy in medication reconciliation?
Laura Britton: Relying solely on pharmacists to manage medication reconciliation can create staffing challenges, but as the medication experts, pharmacists are in an ideal position to spearhead the process. At University of Utah Health Care, pharmacy interns perform the admission medication reconciliation, with inpatient pharmacists’ oversight, and outpatient pharmacists from our hospital outpatient pharmacy are responsible for the discharge medication reconciliation. If the patient desires, prescriptions are filled at the outpatient pharmacy and are delivered to the patient’s hospital room where counseling by the outpatient pharmacist takes place, although the pharmacist will counsel regardless of whether the patient fills the medications in our pharmacy. Technicians assist the outpatient pharmacist in gathering insurance information, obtaining prior authorizations, facilitating patient assistance, picking up and delivering prescriptions, and other technical duties. 

When conducting a comprehensive medication history, simply asking the patient, “What are you taking?” rarely results in a sufficiently detailed medication list. A thorough medication history must elicit not only prescription medications, but also vitamins, over-the-counter drugs, and herbal products that could potentially influence the metabolism of drugs prescribed during the patient’s hospital stay. Once an accurate and complete drug history is taken, it is vital that those medications are reconciled. This involves checking the medication list for duplicate medications, missing medications, adverse effects, drug interactions, compliance, and drug errors. During this process it is beneficial to identify the most effective medication on formulary, and also be aware of what the patient’s insurance will cover as well as any cost barriers that may affect the patient’s access to medication. 

Although a physician, pharmacist, pharmacy intern, or nurse must perform the actual reconciliation, pharmacy technicians can be valuable assets when gathering information. At University of Utah Health Care, pharmacy technicians perform an extremely important role by assisting the pharmacists in the discharge process. We are currently actively involving technicians in expanded roles both on discharge and in the community. It is part of our strategic plan to continue to work on this with our board of pharmacy to meet the needs of the evolving health care system and to improve job satisfaction for technicians. Although technicians are valuable in the reconciliation process, pharmacists are the ideal health care professional to investigate any possible medication safety concerns and make recommendations to the prescribing physician. 

PP&P: What is the process for ensuring timely discharge reconciliations?
Britton: Because outpatient pharmacists are not on the floor doing rounds, it can be challenging to ascertain when a patient will be discharged. Initially, outpatient pharmacists relied on a manual system of clipboards, wallboards, and notifications from the physician or the nurse. Because this information was not available in real time, test delays and changes in medical status often were not relayed, making the system cumbersome and error-prone. There were also communication problems between nursing and pharmacy. To remedy this we performed a number of in-services on all units, but still the perception remained among nursing that we were delaying discharges by adding steps to the process. In actuality, the average time to fill was only 30-40 minutes including working through all patient drug access issues; the service is a highly effective safety measure.

With the recent implementation of computerized physician order entry (CPOE), we established a new system whereby a page is sent directly to the discharge pharmacists and pharmacy technicians whenever a discharge order is placed. This simple step has exponentially increased our ability to quickly identify discharge patients and avoid missing discharges. And as a result of this success, communication among the inpatient physicians, nurses, and pharmacists also has improved. Over time, the service has become an expected and desired step in the discharge process.

PP&P: How does pharmacy verify discharge orders? 
Britton: Currently, discharge orders are written in the patient’s chart, although we are in the process of developing an electronic discharge method. The physician fills out the discharge form, which was developed in consultation with the pharmacy department, and includes sections for the medications the patient has been taking, any medications that will be discontinued, new medications, and any dose changes, as well as the scheduled time for the patient’s next dose. The medication reconciliation form also incorporates the patient’s prescription that they can take to a pharmacy to be filled. After the physician completes the form, pharmacy enters the information into our electronic template. This step became necessary because the physician’s form is often difficult to read, and using a pharmacy template ensures the data is easy to read and is incorporated into the electronic medical record. The paper version is also updated with any necessary corrections, but this can get messy when multiple changes are needed.

The intake medication reconciliation is reviewed first, and any special counseling and logistical issues, such as when the patient’s next blood test is scheduled, are noted. For compliance reasons, pharmacy documents immunizations given during hospitalization; this has lead to fewer drug errors related to failure to give ordered immunizations prior to discharge. The physician notes are reviewed to assist in determining why changes in care have been made; if the pharmacist has any questions, the physician is contacted directly to clarify. This is also an excellent time to delete unnecessary or duplicate data, so the medical record reflects only relevant patient information. 

During the course of performing the discharge medication reconciliation it is vital to coordinate closely with case managers and discharge planners, who keep pharmacy up-to-date on patient needs after discharge. For example, a patient may require an injectable that requires prior authorization, or need assistance paying for an expensive medication. Because our pharmacy technicians are especially adept at obtaining prior authorization, we are able to manage the discharge process efficiently. Ideally, discharge medication reconciliation and prescription services would be performed with pharmacists and technicians working as a team for maximum efficiency and effectiveness. 

PP&P: How can pharmacy impact medication adherence after discharge?
Britton: Too often patients leave the hospital with a prescription that is never filled. For example, we have had cardiac stent patients discharged with prescriptions for clopidogrel that they did not fill due to the drug’s high cost. Unfortunately, some of these patients had severe outcomes as a result. To ensure better access to prescription drugs, we now offer a drug delivery service directly to the patient room upon discharge. By offering to fill prescriptions in-house, fewer patients are at risk for the potentially lethal effects of medication noncompliance, not to mention saving them an extra stop at another pharmacy on the way home. Our access to providers and technician assistance puts our pharmacy in a strong position to facilitate the prescription filling process when compared with an outside pharmacy.

In cases where patients cannot afford their drugs, the discharge medication reconciliation pharmacist and technicians work with their case managers or drug companies to find a solution. One unique feature of our service is the dedicated patient assistance staff that specializes in obtaining vital medications for patients in need. The patient assistance team provides in-house expertise, making it easier to navigate the multiple, differing eligibility requirements and application processes from the drug company patient assistance programs. 

PP&P: What challenges have you experienced during the discharge medication reconciliation process?
Britton: As most physicians enter discharge orders immediately after rounds, it is not unusual to have groups of patients simultaneously requiring discharge services. To manage this, we match the discharge team staffing levels to physician round schedules. Given most teams have separate schedules for rounds, we can stagger our staffing to match. For example, surgeons round in the early morning, while internal physicians round later in the day. Advanced planning and staffing, as well as increased vigilance regarding team schedules, have minimized the discharge medication reconciliation time crunch. Good communication with physicians, nurses, discharge planners, and inpatient pharmacists has also been a tremendous help. We attend daily discharge rounds with the nursing and case management staff and are thus less likely to be unaware of a pending discharge.

The discharge medication delivery service introduced new challenges. While patients appreciate the convenience of having the medications delivered directly to their rooms, those with copays (having left their personal belongings at home, per hospital policy) are often without credit cards or money to pay. To remedy this our pharmacy-run billing department stepped up and took on the role of processing copay bills and mailing them to the patient’s home shortly after discharge, as a completely separate bill from the other hospital charges. We are in the process of implementing a bedside credit card payment device for patients who are able pay at the time of service. This should increase our capture rate. 

One continuing challenge is the lack of an electronic solution, as we currently use the paper discharge forms and our free text electronic templates. We have yet to find a vendor solution that will satisfy all our needs to perform the medication reconciliation electronically upon discharge. The community electronic medical record contains this functionality, but prescriptions need to be input in lay terminology so that the medication instructions appear in patient-friendly language. As so many prescriptions are not done this way, the instructions must be rewritten and communicated to patients during the reconciliation process. Automating this operation would enhance productivity and patient safety.

A final challenge is providing discharge medication reconciliation services around the clock. Given the clear impact reconciliation has had on patient care, the administration recently authorized additional staff to provide reconciliation services on the weekend, but it is still not available for evenings and holidays. 

PP&P: What have been the results of this improved focus on discharge medication reconciliation?
Britton: Before outpatient pharmacists assumed responsibility for performing the discharge medication reconciliation, approximately 30% of prescriptions were captured on discharge. As a result of recent pharmacy initiatives, we now capture more than 80% of discharge prescriptions. The services are on most of the discharging hospital units, with the exception of OB/GYN and nursery where reconciliation is not as necessary. A close evaluation of finances revealed that the initiatives are cost-effective. In fact, with each additional pharmacist and technician position, we have realized at least that amount back—if not more—in returns, due to the revenue gains from the outpatient pharmacy prescriptions. 

An evaluation of quality data determined that about 60% of patients had medication problems at discharge that needed to be addressed; at our cancer hospital, the rate of patients with medication issues at discharge is 100%. The types of errors caught are fairly consistent: drug omission is the most common, followed by uninsured patients with an inability to pay for their prescriptions. Other common problems include patients needing additional education, medications need to be added, patients continuing medications they should not be or changing to alternative medications, and patients with untreated indications. Even after adding the enhanced discharge medication reconciliation steps, we have been able to maintain our 30-40 minute average fill time. Initially there was a perception problem, mostly on the part of nursing and physicians, that pharmacy’s procedures were significantly slowing down the discharge process. But because we have been able to consistently deliver medications in a timely manner and document this for administration, the perception has changed. 

One of the most positive and unexpected results is that two questions on the inpatient satisfaction survey—opportunity to talk to a pharmacist and wait time for medication—have been scored consistently high by patients. After adding the discharge medication counseling service to the survey, patient satisfaction scores improved notably—to the point that opportunity to talk to a pharmacist is one of the top three questions driving our institution’s overall survey score. Even a slight change in this question’s rating affects the overall inpatient satisfaction survey score significantly. This recognition has dramatically boosted the perception of the ambulatory program by administration, and the fact that patients notice and value our services improves morale and validates our efforts to continue to improve patient safety at discharge.

Laura Britton, PharmD, BCPS, CACP, supervises ambulatory clinical pharmacy programs and coordinates ambulatory student and resident rotations at University of Utah Health Care in Salt Lake City, Utah. She is actively involved in expanding medication therapy management, collaborative practice agreements, supporting the discharge medication reconciliation service, and reporting on pharmacy outcomes. Laura is a member of the ASHP Section Advisory Group (SAG) on Clinical Practice Advancement (formerly the SAG for Cognitive Reimbursement.)


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