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 Defense 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/ViewTrackingRecord .asp?RequestID=20070108 36 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 appointments Entry points into Patient History AfterClinic work team and shared management system Intake Device (APHID) Summary Note • Sponsored by Admission Executive Office and Inpatient hospitalization Health Failure Effects Mode Analysis Patient Safety Committee Transfer Other treating VistA business • Defined work projects services or rules procedure areas by each interface Discharge • Created customized Inpatient to outpatient Electronic Unified Action Profile (eUAP) Patient Education Packet tools with actionable software interfaces Home Health & Nursing Home Nursing homes Home health with with med episodic dispense encounters 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 • Medication discrepancies were Results of chart survey post reduced but not eradicated eUAP-PEP implementation • Most minor errors included inconsequential documentation 7% omissions (e.g. missing topical ointments or failure to list OTC 34% meds on DC summary) No Errors Minor Errors • Less clinically significant Critical Errors variances were identified than 59% 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 including Admission Health Failure data validation concerns Inpatient hospitalization Effects Mode Analysis and time pressures • Opted to experiment with Transfer Other treating VistA business services or rules a consumer-focused procedure areas approach that makes the Discharge patient a steward of Inpatient to Electronic Unified Action Patient Education outpatient Packet healthcare Profile (eUAP) • Less than 50% of Home Health & Nursing Home Nursing homes Home health with with med patients remember episodic encounters dispense capabilities medication related information 45 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 process Strongly Agree was transparent to workflow and Agree improved the medication history Neutral Disagree • Studies being conducted to assess Strongly accuracy, efficacy, and cost Disagree effectiveness Helped Remember Medications • This model meets current security and privacy standards for a healthcare enterprise Strongly Agree Agree 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 Provider ordering 58 admission 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 patient • Capture and consolidate as many data streams as possible 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 • Many strategies are viable to achieve Med recon, but not all of them work to improve patient care Varkey et al, Am J Med Qual, 2006 Poon et al, JAMIA, 2006 Koppel et al, JAMA 2005 85 Bates et al, JAMIA 2003 Questions? 86
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