HealtH Care & law
176 P&T® • March2016 • Vol.41No.3
Keywords: medication reconciliation, pharmacist, health plans, physicians, nurses, P&T committees, hospitals, liti-gation, competency, standards of care
INTRODUCTIONMedication reconciliation has increased
in importance since the passage of the Patient Protection and Affordable Care Act in 2010. Because of the ripple effects that occur when medication-related issues reduce quality of care while causing the U.S. health system to pay more avoidable costs at a time of risk-sharing arrange-ments or decreasing revenues for most organizations, medication reconciliation has become a higher priority.
Medication reconciliation has been available since 2005, but its adoption has lagged. The Institute of Medicine esti-mates that at least 1.5 million preventable adverse drug events occur within the health care system each year, and the estimated cost is greater than $4 billion annually.1 The process of medication reconciliation involves a “qualifi ed indi-vidual” comparing the medications that should be ordered for a patient to the new medications that are currently ordered and resolving any differences.
For accredited health systems and hos-
pitals, the Joint Commission (JC) includes medication errors of omission, contraindi-cations, and duplication as well as errors involving drug–drug and drug–disease interactions.2 One of the JC’s National Patient Safety Goals, NPSG.03.06.01, is to “record and pass along correct infor-mation about a patient’s medicines” and review safe practices for medication rec-onciliation. In addition to reconciliation, patients should be educated on using med-ication safely and communicating medica-tion information to their care providers.
Under various risk-sharing arrange-ments, the fi nancial health of providers, hospitals, and to an extent health plans is tied to quality outcomes and performance metrics. For health care systems today, not only is reimbursement at risk but penalties for substandard care come into play. So what is medication reconciliation, who provides it, and what is its value?
THEPROCESSOFMEDICATIONRECONCILIATION
Optimizing outcomes while reducing costs is key for medication management in today's health care environment, and medication reconciliation has been over-looked outside of the hospital.
The American Society of Health-System Pharmacists (ASHP) believes that phar-macists should have key roles in the medication reconciliation process.3 The responsibilities ASHP describes are:
• Providing leadership in designing and managing patient-centered medication reconciliation systems.
• Educating patients and health care professionals about the benefi ts and limitations of the medication recon-ciliation process.
• Serving as patient advocates throughout transitions of care.
The pharmacist should provide leader-ship in developing medication reconcilia-tion policies and procedures, implement and improve medication reconciliation activities, train staff involved in the medi-cation reconciliation process and ensure
their competence, help develop informa-tion systems for data extraction regarding medication reconciliation activities, and advocate medication reconciliation services to providers, nurses, and the community.
IMPROVEDACCURACYFewer errors are found when a pharma-
cist, rather than a physician, completes a patient’s medication reconciliation. Fifty-fi ve patients were included in an evaluation comparing physician-obtained medication histories to pharmacist-obtained medica-tion histories. Pharmacists in this study identifi ed 353 discrepancies, 58 of which had not been found by physicians.4 Another study focused on the emergency depart-ment, where the intervention of pharma-cists reduced overall medication reconcili-ation discrepancies by 33% (P < 0.0001).5
Other studies have documented that, compared with nurses, pharmacists iden-tifi ed a signifi cantly higher number of medications taken per patient, including more over-the-counter and herbal medica-tions (P < 0.001). Pharmacists also con-tacted patients’ outpatient pharmacies signifi cantly more often than nurses did. (P < 0.001). This study concluded that the amount of time pharmacists spent complet-ing medication histories was both effi cient and worthwhile to the patients’ care.6
Pharmacists’ resources are con-strained; however, pharmacists can utilize properly trained pharmacy students, residents, and technicians in complet-ing this task. ASHP cited a study that found potential errors were reduced by 82% when trained pharmacy techni-cians obtained medication histories.7 The errors included incomplete or incorrect information, illegible orders, and serious drug interactions.
DECREASEDMORTALITYIn 2007, Bond and Raehl authored a
paper to determine which hospital-based clinical pharmacy services were associ-ated with mortality rates.8 When pharma-cists provided admission drug histories, 3,988 deaths were avoided (Table 1).
ValueofthePharmacistintheMedicationReconciliationProcessJennifer Splawski, PharmD, BCPS; and Heather Minger, PharmD, BCPS
Dr. Splawski is an Emergency Medicine Clini-cal Pharmacist at MacNeal Hospital in Berwyn, Illinois. Dr. Minger is a Clinical Pharmacist at NorthShore University HealthSystem in Glen-view, Illinois. F. Randy Vogenberg, the editor of this column, is a pharmacist with a doctorate in health care management. He is a member of P&T’s editorial board and a Fellow of the Ameri-can Society of Health-System Pharmacists. He has lectured on health care policy and law and has presented continuing education seminars on risk management in the health professions throughout his career. Dr. Vogenberg is Princi-pal at the Institute for Integrated Healthcare in Greenville, South Carolina, and Adjunct Assis-tant Professor of Pharmacy Administration in the Department of Health Economics Research at the University of Illinois College of Pharmacy in Chicago, Illinois. His email address is [email protected].
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Vol.41No.3 • March2016 • P&T® 177
ALLERGYIDENTIFICATIONA pharmacist is uniquely suited to
interview patients about their aller-gies. In one study in which pharmacists obtained medication histories, the time from admission to recording of allergy information decreased when a pharma-cist conducted the history versus a nurse. This process also decreased delays in drug dispensing that resulted from await-ing an allergy clarifi cation.6
DISCHARGEMEDICATIONRECONCILIATION
Medication discrepancies that occur at transitions of care can negatively impact patient care. Farley and colleagues com-pared a control group (nurse- or physician-managed medication reconciliation) with minimal involvement of a pharmacist case manager (PCM) (medication counseling and detailed medication reconciliation) and enhanced intervention with a PCM (everything that was done in the minimal-intervention group plus faxing the plan to the patients’ community physician and
pharmacy).9 In the enhanced interven-tion group, it was shown that medication discrepancies of high signifi cance in phy-sician records were lower after 30 days (P = 0.013)—demonstrating the impact pharmacists can have on medication-specifi c outcomes after discharge.
TRANSITIONSOFCARE The National Transitions of Care Coali-
tion (NTOCC) defi nes transitions of care as the movement of patients from one practice setting to another.10 Medication-related problems are likely to occur when there is a lack of consistency collecting and documenting medication histories and performing medication reconciliation. One institution’s chart audit discovered that 60% of medication errors occurred at the transition-of-care point.11 The NTOCC has provided intervention strategies (Table 2) to improve care transitions.12
Further evidence is provided by a study in which telephone calls from a pharma-cist to a patient within 24 days following discharge signifi cantly reduced both
30-day hospital readmission rates and emergency room visits compared with a group of discharged patients a pharma-cist was unable to contact (P < 0.001).13
Another study found that a model involv-ing the combined efforts of pharmacists and social workers at transition-of-care points signifi cantly reduced 30-day, all-cause readmission rates (P = 0.012).14
Overall, these fi ndings highlight the importance of creating a patient-safety-focused medication reconciliation program.
CONCLUSIONIn the hospital and institutional settings,
the P&T committee serves an essential role in medication decisions. The P&T committee is responsible for ensuring that the National Patient Safety Goals (NPSGs) are met within the organization and that the medication reconciliation process is subsequently carried out satisfactorily. This helps protect patients’ safety and the organization’s standards of care.
Health plans and other plan sponsors need to support medication reconcili-ation efforts. This has gained impor-tance under alternative reimbursement schemes in both the public sector (through the Centers for Medicare and Medicaid Services) and in private-sector insurance programs. Key organizations’ positions and recommendations on medi-cation reconciliation are summarized in Table 3.
P&T committees in any organization need to identify and promote similar standards across the continuum of care related to medications. NPSGs and Joint Commission guidance have established this issue’s importance. Failure to meet this responsibility may expose an orga-nization to liability.
As the medication expert, the pharma-cist contributes value in the medication reconciliation process at multiple points of patient care. Comprehensive, collab-orative process and policies should be established for medication reconciliation. The role of each health care provider, including the pharmacist, in the medica-tion reconciliation continuum should be clearly defi ned and the executive suite should support this effort. With the goal of medication reconciliation achieved, our systems of care will be in a better position to achieve their metrics in the new environment of payment reform.
Table1PharmacistContributiontoDecreasedMortalityWhenCompletingMedicationAdmissionHistories8,a
Annual number of admissions per hospital with pharmacist-provided admission drug histories (mean ± standard deviation [SD])
11,239 ± 4,462
Annual number of deaths per 1,000 admissions at a hospital with pharmacist-provided admission drug histories (mean ± SD)
38.29 ± 19.67
Annual number of deaths per 1,000 admissions at a hospital without pharmacist-provided admission drug histories (mean ± SD)
47.88 ± 40.18
Reduction in the number of deathsb 3,988
Reduction in the number of deaths per hospital (mean ± SD) 107.78 ± 87.6 (20.2%)a Researchers compiled data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14
clinical pharmacy services were compared with data from hospitals that did not have these services.b Diff erence in death rates multiplied by number of admissions per year multiplied by number of hospitals.
Table2SummaryofNationalTransitionsofCareCoalitionStrategiestoImproveCareTransitions12
1. Assess the safe use of medication management by the patient and the family.2. Ensure a formal process is in place for the safe transition of patients.3. Actively engage the patient and his or her family in the decision-making process through
education and counseling.4. Transfer and share important information in a timely manner between the patient and other
health care providers.5. Facilitate follow-up care of the patient.6. The health care provider must be actively engaged in the ownership of the health care of
the patient.7. Accountability for the care of the patient is shared between both the transitioning provider
and the receiving provider.
178 P&T® • March2016 • Vol.41No.3
REFERENCES1. Food and Drug Administration. Safe use
initiative fact sheet. May 6, 2015. Avail-able at: www.fda.gov/Drugs/DrugSafety/ucm188760.htm. Accessed September 12, 2015.
2. Joint Commission. National Patient Safety Goals, 2015. Available at: www.jointcom-mission.org/standards_information/npsgs.aspx. Accessed August 10, 2015.
3. American Society of Health-System Phar-macists. ASHP statement on the pharma-cist’s role in medication reconciliation. Am J Health Syst Pharm 2013;70(5):453–456.
4. Reeder T, Mutnick A. Pharmacist- versus physician-obtained medication histories. Am J Health Syst Pharm 2008;65(9):857–860.
5. Becerra-Camargo J, Martinez-Martinez F, Garcia-Jimenez E. A multicentre, double-blind, randomised, controlled, parallel-group study of the effectiveness of a pharmacist-acquired medication history in an emergency department. BMC Health Serv Res 2013;13:337. doi: 10.1186/1472-6963-13-337.
6. Nester T, Hale L. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm 2002;59(22):2221–2225.
7. Michels R, Meisel S. Program using pharmacy technicians to obtain medica-tion histories. Am J Health Syst Pharm 2003;60(19):1982–1986.
8. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hos-
pital mortality rates. Pharmacotherapy 2007;27(4):481–493.
9. Farley TM, Shelsky C, Powell S, et al. Effect of clinical pharmacist interven-tion on medication discrepancies follow-ing hospital discharge. Int J Clin Pharm 2014;36(2):430–437.
10. National Transitions of Care Coali-tion. 2015. Available at: www.ntocc.org. Accessed December 21, 2015.
11. Rozich JD, Resar RK. Medication safety: one organization’s approach to the challenge. J Clin Outcomes Manage 2001;8(10):27–34.
12. National Transitions of Care Coalition. Care transition bundle: seven essential intervention categories. 2011. Available at: www.ntocc.org/portals/0/pdf/com-pendium/sevenessentialelements.pdf. Accessed December 21, 2015.
13. Sanchez GM, Douglass MA, Mancuso MA. Revisiting Project Re-Engineered Discharge (RED): the impact of a phar-macist telephone intervention on hospi-tal readmission rates. Pharmacotherapy 2015;35(9):805–812. doi: 10.1002/phar.1630.
14. Gil M, Mikaitis DK, Shier G, et al. Impact of a combined pharmacist and social worker program to reduce hospi-tal readmissions. J Manag Care Pharm 2013;19(7):558–563.
15. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and neces-
sary first steps. J Hosp Med 2010;5(8):477–485. doi: 10.1002/jhm.849.
16. Centers for Medicare and Medicaid Ser-vices. Eligible professional meaningful use menu set measures, measure 6 of 9. May 2014. Available at: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/7_Medication_Reconciliation.pdf. Accessed December 20, 2015.
17. Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse. Medication reconcilia-tion post-discharge: percentage of dis-charges from January 1 to December 1 of the measurement year for patients 66 years of age and older for whom medi-cations were reconciled on or within 30 days of discharge. Available at: www.qualitymeasures.ahrq.gov/content.aspx?id=48847&search=medication rec-onciliation. Accessed December 20, 2015.
18. Institute for Healthcare Improvement. Medication reconciliation to prevent adverse drug events. 2015. Available at: www.ihi.org/topics/adesmedicationrec-onciliation/Pages/default.aspx. Accessed December 20, 2015.
19. Department of Veterans Affairs. VHA di-rective 2011-012, medication reconcila-tion. March 9, 2011. Available at: www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3133. Accessed December 20, 2015. n
Table3MedicationReconciliationPositionsofKeyOrganizations
Organization Rationale Recommendation Goal
The Joint Commission2
Many patients take large amounts of medication involving complex regi-
mens. Managing these medications is an important safety issue.
National Patient Safety Goal 03.06.01: document and pass along information
about patients’ medications; review safe practices for medication reconciliation.
Reduce negative outcomes associated with medication discrepancies.
Centers for Medicare and Medicaid Services16
The eligible professional (EP) who receives a patient from another set-
ting or provider of care or believes an encounter is relevant should perform
medication reconciliation.
The EP performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into
the EP’s care.
Achieve meaningful use stage 2 core measure for electronic health records.
Agency for Healthcare Research and Quality17
Adverse medication events in the elderly are an important avenue
for quality improvement due to the potential number of such events.
Assess the percentage of discharges with medication reconciliation from January 1 to December 1 of the measurement year
for members 66 years of age and older in Medicare Special Needs Plans.
Effective communication and care coordination, prevention and
treatment of leading causes of mortality, and safer care.
Institute for Healthcare Improvement18
Poor communication of medical information at transition points is
responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital.
Reconcile medications at admission, transfer, discharge, and in outpatient
settings.
Decrease medication errors and harm.
Department of Veterans Affairs (VA)19
Accurate medication information impacts the care of veterans.
Systemwide approach to managing patient medication information by reconciling medications across the
continuum of care.
Local VA facilities to create policies; lead-ers to ensure appropriate medication
reconciliation at all transitions of care in the VA and with outside providers.
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