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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 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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