Facilitation of Medication

Reconciliation Process

by

Gary L. Hamilton, Michael Lim,

Mari Pirie-St. Pierre and Diane Tobin

Clinical Thinking

Course Project Presented on June 1, 2009

Introduction

• Clinical Care Scenario – Medication Reconciliation in the outpatient behavioral healthcare setting

– Patient has numerous healthcare providers

– Patient has numerous diagnoses

– Patient is taking numerous medications

• How to Reduce Medication Discrepancies

– Best Possible Medication History (BPMH)

– Paper record (MR)

– EMR/CPOE

– ePrescibe

• Suggested Approaches Toward Process Enhancement

• Metrics – Measurement of Success

A Clinical Case Study Example–

Problem List • Mrs. Folle, is a 50 year old white female with diagnoses of:

– Axis I: Paranoid Schizophrenia

Anxiety Disorder, NOS

Nicotine Dependence

– Axis II: No Diagnoses

– Axis III: Type II Diabetes

Obesity

Hypertension

Migraine Headaches

Pernicious Anemia

Asthma

Axis List used by the DSM-IV TR (Diagnostic and Statistical Manual)

• Axis I – Clinical Disorders, including major mental

disorders, as well as developmental and learning

disorders.

• Axis II – Underlying pervasive or personality

conditions, as well as mental retardation.

• Axis III – Acute medical conditions and physical

disorders.

• Axis IV – Psychosocial and environmental factors

contributing to the disorder.

Current Medications (for which conditions)

• Dr. Freud – Psychiatrist – Clozaril, 150 mg., twice daily (schizophrenia)

– Xanax, 0.5 mg, three times daily (anxiety)

• Dr. House – Primary Care Physician – Metformin, 850 mg. Once a day (diabetes)

– Albuterol, 2 puff, every 4-6 hours (asthma)

– Vitamin B-12 injections, annually (anemia)

– Furosemide, 40 mg, twice a day (hypertension)

• Dr. Carter – Urgent Care – Topomax, 200 mg, twice a day (migraine)

– Mellaril, 50 mg, three times a day (schizophrenia)

Medications – (continued)

• Herbal Supplements

– Grapefruit Seed, 1 capsule, daily

• Vitamin B supplement

• Increase metabolism

• Over the Counter (OTC)

– Advil, PRN

• Headaches

• Number of medications for a behavioral health patient

– Average: 9 (According to NYS – Office of Mental Health)

Quality Concerns

• Herbal Supplement – Grapefruit – Certain medications may be activated or deactivated

– Grapefruit contains furocoumarins

www.herbalextractsplus.com/grapefruit-seed.cfm

• Clozaril – High risk medication - should be highly scrutinized when being

prescribed as it may indicate an increase risk of Metabolic Syndrome (MetS)

• Polypharmacy – Clozaril

– Mellaril

Metabolic Syndrome

Impact on Mental Health Consumer

The following medications should be highly scrutinized when being prescribed as they indicate an increase risk of MetS.

• High Risk:

– Clozaril

– Zyprexa

• Moderate Risk:

– Seroquel

– Thorazine

– Mellaril

Following conditions in conjunction with antipsychotic meds pose a risk for MetS

- Hypertension

– Any Ischemic Vascular Disease

– Hyperlipidemia

– Diabetes

– Obesity psyckesmedicaid.omh.state.ny.us/Common/QualityIndicators.aspx

Quality Concerns

• Psychotropic medications are not benign compounds, and polypharmacy has serious potential risks:

• The possibility of higher than necessary total dosages

• Increased acute and/or chronic side effect burden

• Adverse drug-drug interactions or effects (ADEs)

• Increased rates of non-compliance

• Higher cost of treatment

• Difficulties in determining the impact of multiple treatments

• Higher rates of cardiometabolic disorders compared to the general population

• Increased risk of mortality

Evidence Based Medicine

for Reducing Polypharmacy

• When switching medications, cross taper medications over a period of several months.

• Combine medications from same drug class after a scenario of failed monotherapy trials.

• For patients receiving more than one agent from the same class, periodic efforts should be made to streamline the regimen and reduce polypharmacy.

• Medications should be tapered, slowly over time, patients being monitored closely for early warning signs of relapse.

psyckesmedicaid.omh.state.ny.us/Common/QualityIndicators.aspx

Evidence Base Medicine

for Reducing Cardiometabolic Risk

• Developing care management processes that will identify consumers who could benefit from a modified medication regimen.

• Prescribers, staff ,and consumers should be aware of MetS profile, as well as high and moderate risk antipsychotic meds.

• For those with MetS, consider switching to a low risk antipsychotic med.

• Provide increase monitoring for metabolic abnormalities.

psyckesmedicaid.omh.state.ny.us/Common/QualityIndicators.aspx

What is Medication Reconciliation?

• The process of comparing what medication the patient is currently taking with what the organization is providing to avoid errors such as conflicts or unintentional omissions.

• Goal

– Accurately and completely reconcile medications across the continuum of care

– Reduce the potential for Adverse Drug Events (ADEs)

– Eliminate

• Undocumented intentional discrepancies, and

• Unintentional discrepancies

Out-Patient Medication History (OPMH)

• An initial medication history taken at time of visit, generally by a physician or nurse.

• Sources of information may include:

– patient/family interviews

– review of medication lists or vials

– follow up with the community pharmacist or primary care physician

Best Possible Medication History (BPMH)

• A medication history obtained by a clinician which includes a thorough history of all regular medication use (prescribed and non-prescribed).

• Forms the basis of reconciliation.

• Sources of information: – Patient or caregiver interview

– Inspection of medication vials and other containers

– Review of a personal or clinician provided medication list

– Follow-up with community pharmacist or Primary Care Phy.

– Review of personal medication list printed by the community pharmacy.

– *In home medication inspection

Medication Reconciliation Process – Out-Patient Scenario, Part 1

Medication Reconciliation Process – Out-Patient Scenario, Part 2

Best Possible Medication Plan (Reconciled Medication Orders for Mrs. Folle)

Medications

Taken at Home

What it is Used

For

Dosage Frequency Instructions (Continue /

Discontinue / Change)

Clozaril schizophrenia 150mg BID Continue

Xanax anxiety 0.5 mg TID Continue

Metformin diabetes 500mg QD Change

Albuterol asthma 2 Puffs Every 4-6 hrs Continue

Vitamin B-12

injection

anemia 1000 mcg Annual Continue

Topomax migraine 200mg BID Continue

Mellaril schizophrenia 50mg TID Discontinue

Grapefruit Seed Dietary

Supplement

1 Capsule QD Discontinue

Advil headaches 200mg Q 4 hrs. PRN Continue

Failure Mode & Effects Analysis

General Themes

• Inaccurate, incomplete and/or missing

information on patients’ medication histories

• No formalized approach for obtaining and

documenting medication histories within patients’

medical records

• Inconsistencies between histories obtained by

various disciplines and documentation throughout

patients’ medical records

Failure Mode & Effects Analysis

(continued)

• Accuracy of medication lists relies heavily on

patient-shared information

– In home medication inspection may be more

accurate than patients report.

Who is responsible for Medication

Reconciliation?

• All providers including:

– Patient / Care Giver

– Pharmacist

– Primary Care Physician

– Specialists

• Behavioral Health Professional

– Nurse

How to Reduce Discrepancies?

• Interoperable EHR

• Standardized Documentation (Electronic or Paper)

• Use of medication cards

• Nurse or software-aided collection of medication lists

• Letters & phone calls to remind patients to bring all their medication bottles or an updated medication list to their clinic visit

• Patient education on the importance of using a medication wallet card and bringing their medications to the healthcare visits

• Verification and correction of the most recent medication list in the EMR by the patient.

Challenges in Out-Patient Medication

Reconciliation

• No clear owner

• No defined process for medication reconciliation.

• Patients not aware of the necessity for them to know the names of drugs they are taking. (frequency, dosage, side effects)

• Possible Owners: – Pharmacist

– Primary Care Physician (Medical Home)

Tips to remember when interviewing

patients for BPMH • When asking about all medications, be sure to get the name,

dosage form, dosage, dosing schedule, and last dose taken – be as specific as possible about prn (as needed) medications.

• Use open-ended questions (what, how, why, when) and balance with yes/no questions.

• Use nonbiased questions which do not lead the patient into answering something that may not be true.

• Ask simple questions, avoid using medical jargon, and always invite the patient to ask questions.

• Pursue unclear answers until they are clarified.

Continued…

Tips to remember when interviewing

patients for BPMH (continued)

• Educate the patient on the importance of using one central pharmacy/pharmacist.

• Educate the patient on the importance of using a medication wallet card and bringing their medications to the healthcare facility, physician’s office, etc.

• Prompt the patient to try and remember patches, creams/ointments, eye/ear drops, inhalers, sample medications, shots, herbals, vitamins, and minerals.

• When discussing allergies, educate the patient on the difference between a side effect and a true allergy — e.g., rash, breathing problems, hives.

• Have patients describe how and when they take their medications, and if they ever have difficulty taking their medications or remembering to take their medications. Vague responses may indicate non-compliance.

Steps to take if the patient cannot remember a

medication or if clarification is needed

• Obtain a detailed description of the medication from the patient or a family member—dosage form, strength, size, shape, color, markings.

• Talk to any family members present or contact someone that could possibly bring in the medication or read it over the phone.

• Call the patient’s pharmacy to obtain a list of medications the patient has been regularly filling.

• Contact the patient’s physician(s) to get an accurate listing of their current medications.

• Obtain previous medical records.

Current Best Possible Medication

History (BPMH)

• Current state of medication reconciliation

– Interoperable Technology Solutions – IT

• IT solutions only as good as the

manual processes they were designed to

support

• IT cannot effectively remove inefficiencies or errors in the medication reconciliation process; important to address , understand & investigate each component involved in process

– Paper record (MR) – Initial medication history

– EMR/CPOE – Manual process combined with IT component

– ePrescibe – Improves drug safety by avoiding drug-drug interactions, drug-disease interactions & other potential drug safety issues.

Current Best Possible Medication History

(BPMH)

Gaps - Discrepancies in

medication reconciliation process

• Disjointed medical system

• Inaccurate histories/lists – Use of multiple pharmacies, mail order pharmacies,

samples, foreign purchases

– Rapid introduction of new medications, formulary changes

– Care team may deliberately focus on other essential tasks & believe that someone else will compile or revise medication list

• Medication reconciliation is complex and requires multidisciplinary effort

Discrepancie

s

Identified

Unique Attributes

Collaborative Filtering Approach

• Seeks to detect omissions of medications from a patient’s

list based on Collaborative Filtering (CF)

• Collaborative Filtering – set of methods for processing

information about users in order to make inferences or

predictions about the information of other users. • CF methods are used to answer the following question: if a

patient’s medication list is incomplete, what drugs are most

likely to be missing?

Medication

Reconciliation

Unique Attributes

Narrative compilation

• Narrative physician notes are a rich but untapped source

of medication information

• Discontinued medications are frequently not removed

from EMR medication lists—a patient safety risk.

Narrative compilation was used to define an algorithm

to identify inactive medications using the text of narrative

notes in the EMR.

• This technology could be employed in real-time patient

care as well as for research and quality of care monitoring.

Unique Attributes Medication

Reconciliation

Unique Attributes

NLP – using natural language information

extraction to obtain medication information for

reconciliation processes • Medication information may only be available

in narrative format and some form of information

extraction will be necessary

• Medication Extraction and Reconciliation

Knowledge Instrument (MERKI) Open source tool

available at : www.dbmi.columbia.edu/merki

• Tool shows a precision of 94% and recall of 83% in the

extraction of medication information

Unique Attributes

NLP – MLP using natural language information

extraction or medical language processing to obtain

medication information for reconciliation processes • Medication information may only be available in narrative format and

some form of information extraction will be necessary

• Natural Language parser that extracts structured medication event

information from discharge summaries –Next generation parser Built

upon the larger project model: Medication Extraction and

Reconciliation Knowledge Instrument (MERKI) Open source tool

available at : www.dbmi.columbia.edu/merki

• Tool shows a precision of 94% and recall of 83% in the extraction of

medication information

Gold, S., et al. Extracting Structured Medication Event Information from Discharge Summaries. AMIA Annu Symp Proc. 2008; 2008: 237–241. Published online 2008. PMCID: PMC2655993. 16 May 2009.

www.pubmedcentral.nih.gov.ezproxy.galter.northwestern.edu/picrender.fcgi?artid =2655993&blobtype=pdf

Unique Attributes

• PHR – Personal Health Records

• MyMedicationList is a prototype application:

mml.nlm.nih.gov.ezproxy.galter.northwestern.edu

• Developed at the National Library of Medicine

that assists users in compiling a medication list and

makes this record readily available when needed: Free to the general public

Adequately protects users’ personal information

Based on standards for terminology and documents (XML export)

Independent from any health institutes, organizations or platforms

Communicate the Best Possible Medication Plan

– Important to address , understand & investigate each

component involved in process (Patient, Pharmacist

Physician, Alternative care facilities or services)

– There should be a greater awareness and emphasis that

accuracy in medication history is part and parcel of total

care.

– Will likely require a new combination of IT solutions and

manual processes

Communicate the Best Possible

Medication Plan

Patient, Pharmacist, Physician,

Alternative care Facilities or

Services

Metrics This section is ―outside‖ of our individual patient example…

To implement medication reconciliation, you need to do the following steps:

• Secure Senior Leadership Commitment to begin.

• Form a Team to implement the process.

• Define the Problem and Collect Baseline Data to be used.

• Start with Small Tests of Change & Build Expertise in Reconciling Medications.

• Evaluate the Improvements Being Made—that is, Collect and Submit Data to be analyzed. This is the improvement data.

• Spread where you work to close the gap between best practice and common practice by using your ideas to implement innovations and new ideas.

Two of these activities involve Metrics or Collecting measurable Data—the Baseline Data & the Improvement Data.

Metrics

• Metrics involves collecting data to measure your

implementation and success in Medical Reconciliation.

• In order to collect your this, data need to be collected and

evaluated for both short-term and long-term goals.

•There are several core measures that need to be worked with in

order to do this. The calculation of these can be done

through Excel spreadsheets that are then entered into a

data base software system including HCIS.

• Examples of these Excel spreadsheets to do the calculations

can be found already set up for use (for example at:

www.saferhealthcare.ca).

Metrics

In order to measure the success of medication reconciliation, you need to focus on a consistent set of core measures which represent the minimum measures required to evaluate success of medication reconciliation. (The main source of much of this ―metrics‖ section: Safer Healthcare Now! Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events “How-to Guide” [www.saferhealthcare.ca].)

These include the following 3 measures:

• Intentional Discrepancies

• Undocumented Intentional Discrepancies

• Unintentional Discrepancies

Metrics To define these three core terms:

• Intentional Discrepancy is one where the prescriber has made an intentional choice to add, change, or discontinue a medication and their choice is clearly documented.

• Undocumented Intentional Discrepancy is one where the prescriber has made an intentional choice but it is not clearly documented.

• Unintentional Discrepancy is one where the physician unintentionally changed, added, or omitted a medication the patient was taking prior to admission.

This is important because this is what can lead to ADEs (adverse drug events) which is a major problem and is one reason why you do medication reconciliation.

Metrics The first of these is Undocumented Intentional Discrepancies:

The second of these is Unintentional Discrepancies:

The third of these is Patients Reconciled at Discharge:

where BPMDP = Best Possible Medication Discharge Plan

# of unintentional discrepanciesMean # of unintentional discrepancies

# of patients

# of undocumented intentional discrepanciesMean # of undocumented intentional discrepancies

# of patients

# of patients with completed BPMDPMean # of reconciled at discharge x 100

# of patients discharged in the sample

Metrics

There are also several optional measures which can be taken:

• Mean Number of Discrepancies Resolved which is used to track the number of discrepancies that are being resolved per patient.

• Time it takes to conduct a BPMH (Best Possible Medication History)

• Patient and Staff Satisfaction probably through surveys or questionnaires.

• Time from Admission to Reconciliation measured from charts or HCIS.

• Number of Med Histories on the chart before medication reconciliation vs. documentation of BPMH first (that is, reduction in duplication)

• Rate of Potential Harm which is the percentage of patients with one or more intentional discrepancies (a Type 3 Error)

• The Medication Reconciliation Success Index which refers to the total percentage of ―good‖ or acceptable errors. With experience and the right tools, the process will lead automatically to fewer unintentional discrepancies and intentional discrepancies.

Metrics A quick review of Error Types applicable to metrics:

• Type I error, also known as an ―error of the first kind,‖ an αerror, or a “false positive”: the error of rejecting a null hypothesis when it is actually true. Plainly speaking, it occurs when we are observing a difference when in truth there is none. An example of this would be if a test shows that a woman is pregnant when in reality she is not. A Type I error can be viewed as the error of excessive credulity.

• Type II error, also known as an ―error of the second kind,‖ a βerror, or a “false negative”: the error of failing to reject a null hypothesis when it is in fact not true. In other words, this is the error of failing to observe a difference when in truth there is one. An example of this would be if a test shows that a woman is not pregnant when in reality she is. A Type II error can be viewed as the error of excessive skepticism.

• Type III error, also known as an ―error of the third kind,‖ a γerror: the error of correctly rejecting the null hypothesis for the wrong reason.

These Error Types are needed for the Mean Number of Discrepancies Resolved optional metrics measurement on the next slide.

Metrics

Three of these optional metrics measures have the following

definitions:

• Mean Number of Discrepancies Resolved

• Rate of Potential Harm (%)

• The Medication Reconciliation Success Index

# of patients with 1 or more unintentional discrepanciesRate of potential harm (%) x 100

# of patients in the sample

# of no discrepancies + # of documented intentional discrepanciesMedication Reconciliation Success Index x 100

# of patients in the sample

Total # of resolved Type 2 errors + Total # of resolved Type 3 errorsMean # of Discrepancies Resolved

# of patients in the sample

Metrics

Measurement Tips for collecting metrics:

• Plot data over time—much information about a system and how to improve it can be obtained by plotting data over time and then observing trends and other patterns.

♦ Tracking a few key measures over time is the single most powerful tool a team can use and will help them to see the effects of the changes that are being made.

♦ This is probably best done by running charts to track the measures over time. (There are several methods to do this.)

• Seek usefulness, not perfection—measurement is not the goal, rather improvement. Measurement should be integrated into the daily routine, and both qualitative and quantitative data should be used.

• Goals should be set, and then tracked for successful implementation.

In Conclusion

• If Mrs. Folle’s medications had been

reconciled at each point of care…

– Dr. House:

• counseled her against the use of Grapefruit seed.

– Dr. Carter

• Prescribed Clozaril vs. Mellaril

– Dr. Freud

• Switched to a low-risk medication due to MetS

Key Elements to take away

• These lessons are applicable to any practice setting (that is,

inpatient and outpatient) & any type of medical record

system (that is, electronic, paper-based or both).

• There is no electronic substitution for a thorough medication

interview with patients and/or their caregivers to obtain and

verify current medication regimens.

• Until healthcare information technology with advanced

clinical decision support becomes advanced medication

reconciliation will remain a ―manual‖ process.

Take away lessons (cont.)

• Medication reconciliation should be weaved into the culture

and practices for safe medication management.

• Medication reconciliation should be an integral part of

handoffs and communication during transitions in care.

http://www.medrec.nmh.org/nmh/medrec/designingtheprocess.htm

What are others doing?

• Medication Reconciliation – www.medscheck.ca (a Canadian Pilot Project)

• $1000 administration fee paid to Pharmacists

• $50 per annual visit (30 minutes)

• $25 per follow up visit

• For example, in Pictou County, N.S., Canada, community pharmacists, healthcare facility pharmacists, nursing staff and preadmission clinic personnel joined forces to create an innovative program where community pharmacists provide medication history information which the nurse in the preadmission clinic discusses and verifies with the patient.

References (Partial List)

1. “PSYCKES Medicaid”. New York State Office of Mental Health.

https://psyckesmedicaid.omh.state.ny.us/Common/Overview.aspx. Accessed: 4/30/09.

3. Hert, M., Schreurs, V., Vancampfort D., Van Winkel, R. “Metabolic syndrome in people with schizophrenia: a review. World

Psychiatry. 2/2009. http://www.ncbi.nlm.nih.gov/pubmed/19293950. Accessed 5/13/09.

4. Safer Healthcare Now! (May 2007) Getting Started Kit: Medication Reconciliation Prevention of Adverse Drug Events, How-to

Guide V2.0

6. Northwestern Memorial Hospital, “The Application of FMEA to a Medication Reconciliation Process”

http://www.nmh.org/nmh/pdf/Defining%20the%20problem%20-%20FMEA%20Med%20Rec.ppt, retrieved May 16, 2009

7. Varkey, P. & Cunningham & J. Bisping, S. (May 2007) “Improving Medication Reconciliation in the Outpatient Setting” The

Joint Commission Journal on Quality and Patient Safety Volume 33 Number 5 p286

9. Breydo, E. et al. “Identification of Inactive Medications in Narrative Medical Text.” AMIA 2008 Symposium Proceedings.

Clinical Informatics Research and Development, Partners HealthCare, Boston, MA, Brigham and Women’s Hospital, Boston,

MA & Harvard Medical School, Boston, M. 16 May 2009

http://www.pubmedcentral.nih.gov.ezproxy.galter.northwestern.edu/articlerender.fcgi?artid=2655977&tool=pmcentrez&rendert

ype=abstract>

12. Hasan, S., and Et al. "AMIA 2008 Symposium Proceedings: Towards a Collaborative Filtering Approach to Medication

Reconciliation." 2008. The Heinz School, Carnegie Mellon University, Pittsburgh, Pa. 16 May 2009

<http://www.pubmedcentral.nih.gov.ezproxy.galter.northwestern.edu/articlerender.fcgi?tool=pubmed&pubmedid=18998834>.

14. Joint Commission Resources, Co-published with the American Society of Health-System Pharmacists (ASHP). "Medication

Reconciliation Handbook." Handbook on Medication Reconciliation. 2006. Joint Commission Resources - Co-published with

the American Society of Health-System Pharmacists (ASHP). 16 May 2009 <http://www.jcrinc.com/>.

18. Schenkel, S. The Unexpected Challenges of Accurate Medication Reconciliation, Annals of Emergency Medicine, Volume 52,

Issue 5, November 2008, Pages 493-495, ISSN 0196-0644, DOI: 10.1016/j.annemergmed.2008.07.026.

<http://www.sciencedirect.com/science/article/B6WB0-4TB0TXX-2/2/0e24b48ac923d3233c495e5de98a6fe2>.

Thank You

Questions