212 Medication Reconciliation _The Good_ The Bad_ and The Ugly by lanyuehua

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									VeHU 212 - Medication Reconciliation
 (The Good, The Bad, and The Ugly)

      Jennifer M. Blanchard, PharmD,
                   BCPS
        Blake Lesselroth, MD, MBI
          Rob Silverman, PharmD
        John W. Triplett, RPh, PhD
                  Objectives

• Background data on medication errors
• Review IHI 100,000 Lives Campaign
• Review Joint Commission Safety Goal
  8
• Define medication reconciliation
• Technology and its limitations
• Regional software development
• Lessons learned
• Solution strategies and future
  interventions                          2
           Frequency of Medication Errors

• Incomplete histories can undermine our ability to
  deliver comprehensive care
• Inaccuracies in medication documentation lead to
  prescribing errors, clinical harm, and measurable
  adverse outcomes
• Medication errors are the most common type of
  healthcare error
• The Institute of Medicine reports that a hospitalized
  patient can expect on average to be subjected to
  more than one medication error each day.
• Preventable hospital-based ADEs add an estimated
  $8,700 (2006 dollars) to the cost of a hospital stay.
            » Institute of Medicine, Preventing Medication Errors
            » Pronovost et al., J of Crit Care, 2003
            » Forster et al., Ann Int Med, 2003                     3
                        When Errors Occur

• Transition points and interfaces in care are common
  areas where clinical errors occur
• When patients are moved from one care setting to
  another or from one provider to another, they are
  particularly vulnerable to medication errors
• Joint Commission International Center for Patient
  Safety reports that communication of medical
  information at transition points of care have been
  cited as a major cause of medication errors.
• It has been estimated that 46% of medication errors
  occur during a patient’s admission to or discharge
  from a clinical unit and/or hospital.

            » Rozich et al. Jt Comm J Qual Patient Saf, 2004
            » Vira et al. Qual Saf Health Care, 2006           4
               100,000 Lives Campaign


• Institute for Healthcare Improvement
  announced the 100,000 Lives Campaign in
  December of 2004, a national initiative to
  involve thousands of US hospitals in an
  effort to prevent 100,000 needless inpatient
  deaths through improvements in care.
  – IOM estimates as many as 98,000 people die
    each year in US Hospitals due to medical injuries.

           » Institute for Healthcare Improvement



                                                     5
                    Campaign cont.

• The core of the campaign involved
  participating hospitals committing to make
  changes that have been proven to prevent
  death. These changes included the
  following:
  – Deploy Rapid Response Teams
  – Deliver Reliable, Evidence-Based Care for Acute
    Myocardial Infarction
  – Prevent Adverse Drug Events
  – Prevent Central Line Infections
  – Prevent Surgical Site infections
  – Prevent Ventilator-Associated Pneumonia
                                                  6
                 Campaign cont.

• The prevention of adverse drug events
  (ADE’s) involved the implementation of
  a Medication Reconciliation system for
  inpatients. Reconciliation must occur
  not only at admission or discharge, but
  also during any transition point in care
  (Example: transfer from MICU to the
  floor).


                                         7
                          Campaign cont.

• Poor communication of medical information and
  information gaps at transition points-in-care may
  account for up to 50 percent of all medication errors
• Errors of omission and information gaps in the
  medication history may account for up to 20 percent
  of adverse drug events in the hospital
• Several studies have shown that the implementation
  of simple standardized reconciliation forms can
  have a five-fold reduction in errors
• Each time a patient moves from one setting to
  another, clinicians should review previous
  medication orders alongside new orders and plans
  for care, and reconcile any differences
            » Institute for Healthcare Improvement
                                                      8
                       Campaign cont.

• Institute for Healthcare Improvement has
  progressed from 100,000 Lives Campaign to
  the 5,000,000 Lives Campaign, which
  officially started December of 2006.
• 5,000,000 Lives Campaign challenges
  participating hospitals to adopt 12 changes
  in care that save lives and reduce patient
  injuries
• One of the changes advocated was
  medication reconciliation across the
  continuum of care to prevent adverse drug
  events
          » Institute for Healthcare Improvement
                                                   9
           The Joint Commission Safety
                       Goal
• The Joint Commission in keeping with
  the times and all the attention being
  focused on the prevention of
  medication errors, officially added
  Medication Reconciliation to the
  patient safety goals in 2005.
• It remained on the list in 2006 and is
  included in the 2007 and 2008 lists.
     ( It’s not going to go away!).

                                           10
        Joint Commission Safety Goal 8

• Accurately and completely reconcile
  medications across the continuum of
  care.
  – 8A Implement a process for obtaining and
    documenting a complete list of the
    patients current medications upon the
    patient’s admission to the organization and
    with the involvement of the patient. This
    process includes a comparison of the
    medications the organization provides to
    those on the list.

          » Joint Commission International Center for Patient Safety   11
           Joint Commission Safety Goal 8
                       cont.

– 8B A complete list of the patients
  medications is communicated to the next
  provider of service when it refers or
  transfers a patient to another setting,
  service, practitioner or level of care
  within or outside the organization. The
  complete list of medications is also
  provided to the patient on discharge from
  the facility.

       »   Joint Commission International Center for Patient Safety



                                                                      12
          Medication Reconciliation - Steps

• Engage the patient
• Assemble a medication and allergy history
• Compare against any recorded lists
• Compare medications with new orders
  anticipated in next care context
• Reconcile discrepancies
• Update changes throughout episodes of care
• Document the reconciled list and distribute
  to patient and/or caregiver

                                            13
     Medication Reconciliation - Definitions


• What is a medication?
  – Prescription medications, sample
    medications, and over-the-counter agents
  – Vitamins, herbals, and neutraceuticals
  – Vaccines, diagnostic and contrast agents,
    radioactive medications
  – Parenteral nutrition, blood derivatives, IV
    solutions
  – Any product designated by the FDA as a
    drug
          Joint Commission International Center for Patient Safety
                                                                     14
     Medication Reconciliation - Definitions


• When must reconciliation occur?
  – Whenever a patient moves to another
    setting, service, practitioner or level of
    care within or outside the organization
  – Any time medication orders will be written
    or medications will be used in a treatment
    plan
  – Any time the affect of a medication or the
    presence of a medication sensitivity may
    impact a treatment plan
                                               15
        Medication Reconciliation - Definitions


• Where should reconciliation occur?
  –   Inpatient
  –   Outpatient
  –   Urgent care
  –   Episodic ambulatory care
  –   Imaging, procedural, and ancillary settings
  –   Home based encounters



                                                  16
                        The Role of Technology

• Complex medication lists impede clinic throughput
  and increase likelihood of cognitive errors
• Electronic record systems can accurately aggregate
  fragmented or distributed medication lists
• Information technology can be used to create
  independent and redundant error checking systems
• Automation can support reconciliation by providing
  a structured and uniform approach to data
  management and workflow processes


       Rogers et al, Jt Comm Qual Safe, 2006
       Cornish et al, Arch Int Med, 2005

                                                       17
           Current Technology Limitations
               within the VA System

• Comparable to other mature electronic
  health record systems
• Fragmentation of data across multiple views
• Episodic orientation may confound
  representation of a continuum of care
• May not embed well within existent
  processes of care
• Significant cognitive overhead associated
  with electronic health record interfaces

                                              18
        Regional Software Development

• In light of the technological difficulties
  with the current software previously
  highlighted, many facilities have taken
  it upon themselves to develop regional
  software in order to implement new
  Medication Reconciliation process
  consistent with JCAHO safety goal #8



                                           19
             Regional Software cont.

• 4 facilities solution strategies will be
  highlighted.
  – Cincinnati VA Medical Center
  – Hines VA Hospital
  – Portland VA Medical Center
  – Miami VA Healthcare System
  Strategies range in complexity and degree
    of technical support needed to implement
    and maintain.

                                               20
         Cincinnati VA
Medication Reconciliation Tools

  Jennifer M. Blanchard, PharmD, BCPS
               Cincinnati VAMC

• Outpatient Medication Reconciliation
  process involves the use of Class III
  software that was originally developed
  at the Tucson, AZ VA by Donald
  Watkins.
• Creates a patient friendly large print
  medication calendar that can be used
  for Medication Reconciliation.


                                       22
             Cincinnati VAMC cont.

• Class III software was modified locally
  to include the following for Medication
  Reconciliation purposes:
  – Active medications that had been placed
    on hold by either Providers or Pharmacy
  – Recently expired medications (90 days)
  – Non-VA Medications




                                              23
25
26
                  Cincinnati VAMC cont.

• Calendars are printed at the time the patient checks
  in for an outpatient appointment.
• Patients are instructed to review calendar and note
  any discrepancies
• Calendar is to be reviewed with the Healthcare
  provider during course of visit
• Provider is expected to document any changes on
  both the paper copy and electronically (CPRS)
• Patient leaves with an updated Medication Calendar
  (medication list) at the end of the appointment
   – Hand annotated changes considered acceptable




                                                     27
      Hines VA Hospital
Medication Reconciliation Tools

     Robert Silverman, PharmD
          “Complete and Accurate”…

• In slide #12, Jennifer references the
  requirement for a complete and
  accurate list of medications
• How complete can we get with VistA?
  – Locally dispensed Outpatient
    Prescriptions
  – Inpatient orders
  – Non-VA medications documented at your
    facility
  *NEW* : REMOTE medications from other
    VA stations and the Department of     29
            Remote Data Interoperability (RDI)

• Remote Data Interoperability (RDI) allows VA
  providers and pharmacists at one facility to interact
  with patient data from other facilities.

• RDI retrieves outpatient medication and drug allergy
  data from the Health Data Repository (HDR) and
  does order checks against that data. Existing order
  checking functionality is used for this process.

• CHDR uses RDI to do medication and drug allergy
  order checks against Department of Defense data in
  the HDR. This data is displayed to all CPRS users
  but is only for patients marked as ADC at any
  VAMC that shares care with a DoD medical facility.

                                                      30
          New Medication Reconciliation
           Tools using RDI Components

• TIU Data Object “Remote Active
  Medications”

• Health Summary “Medication
  Reconciliation Profile + Remote”




                                          31
Remote Active Medications
    TIU Data Object




                            32
Medication Reconciliation Profile
           +Remote




                                33
            Potential Future Tools

• Remote Allergies TIU Data Object
• Addition of Pending/Held medications
  to other available Med Rec tools
  – “Med-Chart”




                                         34
               New Service Request

• Interim Solution
  – Distribute the Hines Class III Medication
    Reconciliation Tools as Class I
  – IDMC has accepted this issue and
    prioritized it as mandated work for FY08
  – Funding not yet approved
• Long Term Solution
  – Will be incorporated as one of the
    enhancements of CPRS v29

                                                35
                    References

• What is RDI?
  http://vaww1.va.gov/netsix-ric-
  cprs/docs/RDI.doc
• VistA University RDI Training
  Materials
  http://vaww.vistau.med.va.gov/VistaU/
  rdi/
• New Service Request for Medication
  Reconciliation (Interim Solution)
 http://vista.med.va.gov/pas/ViewTrackingRe
                                           36
 cord.asp?RequestID=20070108
 Portland VA Medical Center
Medication Reconciliation Tools

     Blake Lesselroth, MD, MBI
               Portland VA - Strategic Plan

                          Enterprise Continuum of Care

• Assembled a
  multidisciplinary PI                       Episodic                              Automated




                             Clinic
  work team
                                           appointments      Entry points into   Patient History      AfterClinic
                                            and shared           system          Intake Device      Summary Note
                                           management                               (APHID)




• Sponsored by




                             Admission
  Executive Office and                                          Inpatient
                                                              hospitalization
                                                                                 Health Failure
                                                                                 Effects Mode
                                                                                   Analysis

  Patient Safety
  Committee
                             Transfer
                                                              Other treating
                                                                                 VistA business

• Defined work
                                                               services or
                                                                                      rules
                                                             procedure areas



  projects by each
  interface
                             Discharge




                                                                                   Electronic
                                                               Inpatient to                        Patient Education
                                                                                 Unified Action
                                                                outpatient                              Packet
                                                                                 Profile (eUAP)

• Created customized
  tools with actionable
                          Home Health &
                          Nursing Home




                                                             Nursing homes
  software interfaces                     Home health with
                                             episodic
                                            encounters
                                                               with med
                                                               dispense
                                                              capabilities



                                                                                                                       38
Select ‘Med Recon’ View




                          39
40
Select ‘Discharge Med Review’ View




                                     41
Patient Education Handout




                            42
            Discharge - Unified Action Profile

• Aggregate distributed information by assembling
  medication couplets associated with ordering and
  dispensing information
• Reduce cognitive overhead by creating actionable
  tools within CPRS that approximate traditional
  clinical activities and support reconciliation
  decisions
• Enforces a process-standardization step in the
  discharge cascade
• Automate creation of an auditable ‘snapshot’ of the
  medication dispense list to consolidate supply chain
  activities and reduce duplicative work

                                                     43
                     Preliminary Outcome Data

•   Compared medication lists to
    plans outlined during staff
    rounds
                                       Results of chart survey post
•   Medication discrepancies were       eUAP-PEP implementation
    reduced but not eradicated
•   Most minor errors included                  7%
    inconsequential documentation
    omissions (e.g. missing topical                  34%
    ointments or failure to list OTC                           No Errors
    meds on DC summary)                                        Minor Errors
                                                               Critical Errors
•   Less clinically significant           59%
    variances were identified than
    anticipated based on prior
    studies (7% vs 18-20%)
•   There were no documented
    cases of clinical harm

                                                                          44
               Portland VA - APHID
• Challenged by the          Enterprise Continuum of Care

  dynamic nature of the
  ambulatory clinic                             Episodic                              Automated




                                Clinic
                                              appointments      Entry points into   Patient History      AfterClinic
                                               and shared           system          Intake Device      Summary Note
                                              management                               (APHID)

• Unique business needs
  and constraints




                                Admission
  including data
                                                                                    Health Failure
                                                                   Inpatient
                                                                                    Effects Mode
                                                                 hospitalization
                                                                                      Analysis


  validation concerns and
  time pressures

                                Transfer
                                                                 Other treating
                                                                                    VistA business
                                                                  services or
                                                                                         rules

• Opted to experiment                                           procedure areas




  with a consumer-              Discharge


  focused approach that                                           Inpatient to
                                                                                      Electronic
                                                                                    Unified Action
                                                                                                      Patient Education
                                                                   outpatient                              Packet

  makes the patient a                                                               Profile (eUAP)




  steward of healthcare
                             Home Health &
                             Nursing Home




                                                                Nursing homes
                                             Home health with

• Less than 50% of
                                                                  with med
                                                episodic
                                                                  dispense
                                               encounters
                                                                 capabilities


  patients remember
  medication related                                                                                                      45
  information               Kramer et al, Am J Health-Syst Pharm, 2007
               Ambulatory Care - APHID

• Electronic kiosk
  accessed by veteran
  prior to clinic
  appointment

• Security ensured by
  allowing access only via
  Veterans Identification
  Card

• Deliver a structured and
  automated history form

• Distribute data to
  members of health care
  team for action                        46
The Interface - Login




                        47
Check-In




           48
Patient Allergies




                    49
Medication Reconciliation




                            50
Non-VA Medications




                     51
                   Data Utilization –
                Convenient and Efficient

• Information gathered
  at kiosk can be
  printed or retrieved
  using Patient Data
  Objects
• Universal access to
  information at any
  point during the
  workflow
• Medication reviews
  may be used for med
  recon documentation
  or patient education
                                           52
                 AfterClinic Summary

• Uses TIU
  package to
  generate a
  concluding
  document
• Designed for
  patient
  consumption
• May be used by
  any member of
  care team
                                       53
                              APHID Data
                                          Device Was Easy to Use

• Approximately 85% of patients are
  capable of using the kiosk
                                                                   Agree

• Most patients take an average of 7                               Disagree
                                                                   Neutral

  minutes but it is important to allow
  up to 25 minutes for check-in          Comfortable With Technology

• Most providers reported the                                  Strongly Agree


  process was transparent to                                   Agree

  workflow and improved the                                    Neutral

  medication history                                           Disagree

                                                               Strongly
• Studies being conducted to assess                            Disagree

  accuracy, efficacy, and cost           Helped Remember Medications
  effectiveness
• This model meets current security
  and privacy standards for a                                  Strongly Agree
                                                               Agree

  healthcare enterprise                                        Neutral




                                                                                54
                            Portland VA Med Recon
                             Additional Information




http://vaww.portland.med.va.gov/Departments/CIO/CA/index.asp?tab=3#documentation


                                                                          55
Miami VA Healthcare System


     John Triplett, RPh, PhD
                                                                                                                                                                  Compare identified lists to create an
 Points of Medication Reconciliation                                                                                                                              accurate medication list, document
 Outpatient and admission providers can maintain patient medication list current by utilizing Medication Reconciliation Worksheet.                                  discrepancies in progress note
 Inpatient providers can utilize the CPRS Medication Reconciliation Tool to create an accurate & current
 medication list.
   Admission
   (entry into


                         Outpatient
    system)

                                                       Inpatient
                       (Observation &                                              Geriatrics /                Residential
                                                 (A&D or ward / unit                                                                      Home Care                    Home          Admission
                         Ambulatory                                              Extended Care                 Programs
                                                   if direct admit)                                                                                                   Meds / OP        order
                          Surgery)                                                                                                                                      Meds           Meds
   organization)




                                                     Other treating
     Transfer




                                                                                                                                                                        Current       Transfer /
      (within




                                                      Service or                                              Operative /                                                Active       Delayed
                                                                                   Diagnostic
                                                    Specialty (Other                                           Invasive                                               (Inpatient)       Order
                                                                                   Procedures                                                                           Med list        Meds
                                                   level of care OR,                                       Procedure Areas
                                                       PAR, etc)



                                                                                                                                                                        Current
        Discharge




                                                                                                                                                                         Active      Discharge
                                                                                                                                                                      (Inpatient)      Meds
                                      Inpatient to                Inpatient to              From Residential
                                                                                                                       Miami VA to other                                 Meds
                                       Outpatient                  Geriatrics /             program to follow-
                                                                                                                         organization
                                   (including Home               Extended Care                 up program                                                                     Active
                                         Care)                                                                                                                               Outpatient
                                                                                                                                                                               Meds
        Outpatient




                                                   Ambulatory Care                                            Operative /                                                     Active
                                                                                   Diagnostic
                                                     (Outpatient                                               Invasive                                                      Outpatient
                                                                                   Procedures                                                                                  Meds
                                                       clinics)                                            Procedure Areas



A brief patent encounter involving situations which pose minimal risk for medication duplication, omission or interaction such as the use of topical fluoride in dentistry, local infiltration
anesthesia for dental work or suturing lacerations, enteric barium for imaging and do not involve discharge prescription of medications, or any other changes in medications that the
patient has been taking reconciliation, in this context, simply means checking the patient information (current medications and history of allergies and past sensitivities) to make an
                                                                                                                                                                                          57
informed decision about the use of these medications.
     Ambulatory & Preadmission Process

Clerk generates
form

Patient/Caregiver
completes form
   VA Medications
   Non-VA
   medications
   Allergies
Medication List
Updated by:
   PC Provider in
   clinic
                                         58
   Provider ordering
              Admission to Inpatient


Admitting clerk assures that patient or
care giver has completed the Ambulatory
worksheet.

Provider writing admission orders is
responsible for medication reconciliation.

The CPRS based Medication
Reconciliation tool MUST be utilized for
all admissions.                              59
              Admission to Inpatient

IMPORTANT POINTS:
Non-VA medications MUST be ordered
prior to initiating the CPRS tool.
Medications new to the patient at the time
of admission MUST be ordered prior to
initiating the CPRS tool.
The Medication Reconciliation tool is
initiated through the Notes tab.
                                             60
Medication Reconciliation Tool: Admission




                                            61
Medication Reconciliation Tool: Admission




                                            62
Medication Reconciliation Tool: Admission




                                             Click on the
                                            medication(s)
                                             you wish to
                                             continue or
                                             discontinue.
                                            The program
                                            will create an
                                            order that you
                                             will need to
                                              sign later




                                                   63
Medication Reconciliation Tool: Admission




                                        If rationale is not
                                      given *reminder box
                                            will pop-up




                                                        64
Medication Reconciliation Tool: Admission




                                        Program linked to
                                         CPRS Note Title

                                         Note will list all
                                       current medications
                                       and medications not
                                       continued along with
                                             rationale




                                            Click Finish




                                                       65
                    Medication Reconciliation Tool: Admission




If the outpatient
order does not                                                  A “now dose”
have a                                                          can be ordered
recognized                                                      if necessary
standard
schedule, one
must be
selected.




                                                                        66
Medication Reconciliation Tool: Admission




                                            67
68
                Other Transition Points


Reconciliation MUST also occur at the
following inpatient transition points:

Upon Transfer (when new orders are required by
policy, i.e. change in level of care). Compare
current inpatient orders with new inpatient
orders.

At Discharge The new Home Medications list
MUST be compared with the pre-admission Home
list, AND with the current inpatient medications. 69
70
Medication Reconciliation Transfer




                                     71
Medication Reconciliation Transfer




                                     72
Provider discharge piece




                           73
Provider discharge




                     74
             Pharmacist discharge

• -launched by an icon on the desktop
• -CPRS sign in




                                        75
Pharmacist discharge




                       76
Pharmacist discharge




                       77
Pharmacist discharge




                       78
Pharmacist discharge




                       79
Pharmacist discharge




                       80
Pharmacist discharge




                       81
Pharmacist discharge




                       82
          Monitoring Implementation of the
                      Process



• Use of Tool Not Mandatory

• Done by Note Titles

• VistA Report Developed
  – 89% of Admissions, 60% of Transfers,
    93% of Provider Discharges and 85% of
    Pharmacist Discharges.

                                            83
                      Lessons learned
• Retrieve and aggregate medication lists into like
  couplets to improve efficiency, and reduce cognitive
  errors
• Try to embed ‘actionable’ order capabilities to
  facilitate user adoption and influence point-of-care
  behavior
• Study workflow carefully and recognize provincial
  and environmental constraints. Know the failure
  modes.
• Capitalize upon the current health record
  architecture and medication error checking
  functionality
• Make every member of the team a steward in
  medication reconciliation activities – including the   84
                      Lessons Learned cont.

• Use multi-media to it’s full potential – pictures,
  paper, reports, and dialogs
• User buy-in is critical to success. Identify several
  clinical champions to catalyze change
• Process improvements should deliver a tangible
  return-on-investment (like automatic
  documentation)
• Expect criticism. Any effort that re-engineers a
  process will represent a compromise between
  stakeholders
• Regular data collection and enthusiastic feedback is
  essential to drive continuous quality improvement
                                        Med recon,
• Many strategies are viable to achieve Varkey et al, Am J Med Qual, 2006
                                        Koppel et care
  but not all of them work to improve patiental, JAMA 2005 85
                                        Poon et al, JAMIA, 2006

                                                    Bates et al, JAMIA 2003
Questions?




             86

								
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