Medication Reconciliation

1. Leslie Ochs PharmD, PhD, MSPH Assistant Professor UNE College of Pharmacy April 27, 2014 Medication Reconciliation

2. Objectives • Describe the importance of medication reconciliation for patient safety • Identify opportunities, barriers and challenges in performing successful medication reconciliation • Identify strategies for effective medication reconciliation • Describe the importance of your role in effective medication reconciliation

3. Test Your Knowledge • What is the purpose of medication reconciliation? • To ensure sure patient’s medications meet current treatment guidelines • To decrease patient medication costs • To reduce medication errors • To decrease the number of medications a patient is currently taking

4. What is Medication Reconciliation? “The process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care” Best suited for inpatient services TJC - Issue 35, January 25, 2006

5. What is Medication Reconciliation? “Reconciliation is a process of identifying the most accurate list of all medications a patient is taking – including name, dosage, frequency and route – and using this list to provide correct medications for patients anywhere within the health care system.” Best suited for outpatient services Institute for Healthcare Improvement – 2007 http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx

6. What is Medication Reconciliation? • Process of reconciling a patient’s medication list at transitions of care • Ensures patient’s medications accurate on admission to a hospital or nursing home, at inpatient transfers, on D/C and in community or outpatient setting • Helps to reduce errors • Omissions, duplications, incorrect doses and DDI • Improves communication TJC - Issue 35, January 25, 2006

7. Mandates for Medication Reconciliation Joint Commission on Accreditation of Health Care Organizations Institute for Healthcare Improvement • 2009 - National Patient Safety Goal 8 • “Reconcile medications across the continuum of care” • Ambulatory care • Emergency and urgent care • Home care • Inpatient services • Long‐term care • 100,000 Lives Campaign • Designed to improve care and avoid mortality • Medication reconciliation – key component Pharmacist’s Letter 2010; Course No. 303

8. Importance of Medication Reconciliation • Difficulties in process • No clear roles or responsibilities • Duplicate in patient’s medical charts • Documentation in different places • May or may not be in agreement • Difference in collecting information • Consider OTC “to be medications”? • Patient’s medical condition

9. Test Your Knowledge • What percentage of patients have unintended discrepancies on admission to healthcare facilities? • 30% • 25% • 67% • 59%

10. Why is it necessary to do medication reconciliation? • Adverse Drug Events (ADEs) happen frequently • 5‐40% of hospitalized patients • 12‐17% of patients after discharge • Transitions increase discrepancies and the risk for ADEs • 70% of patients on admission have discrepancies • 1/3 of these are potentially harmful ADEs • Unintended discrepancies • 67% on admission • 11‐59% harmful Mueller et al. Arch Intern Med 2012;172:1057 Kwan et al. Ann Intern Med 2013;158:397

11. Types of Transitions

12. How does medication information flow in these transitions? • Electronic information • Written information • Patient reporting • Team discussion • Nursing handoff

13. Issues in Communication • Between MD • Direct Interaction – Hospital MD & PC MD – 3-20% • D/C summary at follow-up appt • 1st – 12-34% • 4 week – 51-77% • Impact in care in 25% • Community Pharmacy Information • Use more than one pharmacy – not complete • Poor communication between pharmacies • Insurance for some medication, cash for others • Get medical information from patient or family • Long Term Care • MD and pharmacist not on site • Assisted living may nit have medication review by pharmacist • Discharge Instructions • Poor instructions between settings • Community Pharmacist is out of the loop Snowet al. J HospMed 2009;4:364 Hume et al. Pharmacotherapy 2012;32:e326

14. Care Coordination at Discharge • Pharmacist not involved in home services • Limit information sharing with home care b/misinterpret HIPPA • Discharge visits may be overwhelming • Often not one entity that takes responsibility for coordinating care. Improved with: • Patient-centered medical home • Accountable care organizations Hume et al. Pharmacotherapy 2012;32:e328

15. Patients at Risk for Transition Problems • Older • Cognitive impairment • End of life • Low health literacy • More than 5 medications/day • Disabilities • Low income • Homeless • New admission to long-term care Hume et al. Pharmacotherapy 2012;32:e328

16. Is there evidence that medication reconciliation programs work? • Evidence to support pharmacist’s involvement • 36% of patients had medication errors on admission – 85% originated from medication list • Strategies to reduce medication errors at transitions include pharmacist medication review at D/C • Medication review and consultation in various settings • Reductions in MD visits, ED visits, hospital days and cost Schnipperet al. Arch Intern Med 2006;166:565 Doyle E. September 2009

17. Hospital-Based Medication Reconciliation – Systematic Review Mueller et al. Arch Intern Med 2012;172:1057 26 studies • Provider • 15 Pharmacist • 6 Information technology • 5 Other providers • Comparison • Usual care • Discrepancies • Intentional & Unintentional

18. Unintentional Discrepancies 2 Randomized Controlled Studies • Study #1 • 178 pts in Boston teaching hospital • Intervention ‐ Med rec, counseling with RPh, F/U telephone within 5 days • Control - RN discharge counseling, RPH reviewed meds without formal med rec • Results • 1% Intervention group had pADE • 11% Control group had pADE(p=0.01) • Total ADEs - No difference • Study #2 • 14 teams; 2 teaching hospitals in Boston • 320 pts • Intervention – Web based electronic med application – “Preadmission Medication List (PML) Builder” used to facilitate med rec process • Control– Resident took med history, RPH check order, MD wrote D/C orders, RN educated on meds • Results Schnipperet al. Arch Intern Med 2006;166:565 Schnipper et al. Arch Intern Med 2009;169:771

19. Test Your Knowledge • Which of he following are examples of the most common medication errors discovered by reconciling medications? • Wrong dose • Wrong patient • Omission of medications • Extra dose

20. Medication Reconciliation as a Patient Safety Strategy • Most common errors • Improper dose or quantity • Omissions • Prescribing errors • Less common errors • Wrong dose • Extra dose • Wrong patient • Mislabeling • Wrong administration technique • Wrong dosage form TJC - Issue 35, January 25, 2006

21. Medication Reconciliation as a Patient Safety Strategy • Continuation of a medication when patient no longer needs • Omission of outpatient medications on admission into the hospital • Fail to restart a medication at D/C when medication was temporarily discontinued during hospital stay

22. Medication Reconciliation Process • Verification • Collection of the medication history • Clarification • Ensure that medications and doses are appropriate • Reconciliation • Documentation of changes in the orders Institute for Healthcare Improvement – 2007 http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx

23. Prior to Medication Reconciliation • Starts prior to the visit • Review list for duplicate therapies • Beta-blockers, HTN medications • Remove discontinued therapies • Old antibiotic prescriptions • Remind patient to bring in medications or their list • Prescription bottles best/medication list Obtain list of medications actually filled from the pharmacy or Health Info Net

24. Medication Reconciliation Process at Every Visit • Ask all patients to provide a current list of medications, including OTC and herbals • Review medication with patient • Reconcile and document patient’s medication list and EMR medication list • Check new medications for interactions/conflicts with updated EMR medication list • Provide patient with a paper copy of an updated, reconciled medication list • Identify who is responsible to resolve discrepancies and duplications

25. What Medication Information Should be Collected? • Medications on the “home medication list” • Prescription medications • Sample medications • Vitamins • Nutraceuticals • Over-the-counter (OTC) drugs • Respiratory therapy-related medications

26. What information should the medication list Include? • Drug name • Dose • Route • Strength • Frequency • Indication • Last dose • Who is providing the information • Who is collecting the information

27. Sources for Medication • Prescriptions • Over the counter medications and supplements • Family members and friends • Samples • Internet prescriptions • Prescription assistance programs

28. Test Your Knowledge • Which of the following are TRUE in regards to information that should be collected about a patient’s medications? • Only include prescription and OTC products on the medication list • Only include those medications that the patient takes orally • Herbal and nutritional supplement information is unimportant because these products do not interact with other medications • The most comprehensive and accurate list is important for medication reconciliation (Rx, OTC, Vitamins, Vaccines, etc.)

29. Medication History – Critical to Have a Complete List • Herbals • Nutritional and dietary supplements • Vitamins • OTC medications • Prescription medications • Respiratory therapy medications • Inhalers and nebulization treatments • IV solutions and medications • Vaccines • Radioactive medications • Diagnostic and contrast agents Pharmacist’s Letter 2010; Course No. 303

30. Following Medication Reconciliation Process • Determine who should be aware of the changes to the medication list • Ensure sharing discontinued medications • Failure to communicate with pharmacies leaves prescriptions active on patient profiles that can be filled by patients Don’t forget to share the updated medication list

31. What if you don’t have enough time for medication reconciliation? • Multiple chronic disease (>3) • Multiple medications (>10) • High risk medications • Heart medications • Opioids • Immunosuppressants • Blood sugar medications • Medications with Narrow Therapeutic Index • Anticoagulants • Psychiatric medications • Seizure medications

32. Barriers to Medication Reconciliation • No standardized process • Difficult to obtain accurate medication history • Multiple providers involved in patient’s care • MD office is is not aware of patient’s prescriptions ASHP-APHA Medication Management in Care Transitions Best Practices 2013

33. Challenges to Medication Reconciliation • Understand the importance • Obtaining complete and accurate information • Engage everyone in the process • Health care providers, patients and caregivers • Create an expectation of the patient that they receive a current medication list • Develop patient responsibility to carry the list • Time to reconcile medications • Resources need to complete reconciled list ASHP-APHA Medication Management in Care Transitions Best Practices 2013

34. Strategies for Medication Reconciliation • Review the workflow process and see how medication reconciliation can best be incorporated within the facility • Clearly define responsibilities • Remind patients to bring medication bottles • List printed at check-in, patient to review while waiting for their appointment • Quality audits and feedback on performance/program

35. What features do successful medication reconciliation programs share? • Multidisciplinary Team • Transitions involve many people - must involve a variety of providers • Providers must communicate and collaborate well ‐ avoid turf issues and silo approach • Institutional Support • CQI central to process - helps document positive outcomes • Dynamic Pharmacy Team • Changing Roles • Reassessment of job responsibility • Support for pharmacist in expanded role • Pharmacy extenders can be very useful - pharmacy interns, residents, technicians • Training for pharmacy team • Reconciliation, prior authorization, documentation, communication, and data management • Competencies & protocols to ensure high standards • Schools have focused on this in APPEs ASHP-APHA Medication Management in Care Transitions Best Practices 2013 Mueller et al. Arch Intern Med 2012:1067

36. What features do successful medication reconciliation programs share? Data to Justify Program Share Information Well • Metrics to show Return on Investment (ROI) • Types of metrics • Readmit • ED visits • Med Rec problems • Disease specific metrics • Patient satisfaction • Always plan goals and data collection before program • Efficient transfer of information • Approaches for transferring information: • EMR • Prior authorization • E-prescribing • Contacting provider/prescriber • Billing options ASHP-APHA Medication Management in Care Transitions Best Practices 2013

37. What does a “best practice” medication reconciliation program look like? • Best possible medication history (BPMH) • Structured interview to identify all prescribed and OTC medicationsAND • Verify the results with at least 1 other reliable source of information • Medication vials • Patient medication lists • Community pharmacy record • Clinic record • Medication reconciliation • BPMHANDCorrect discrepancies Kwan et al. Ann Intern Med 2013;158:397

38. What steps should be followed in creating a medication reconciliation program? • Make a standard form or guide to help carry out the process • Make sure the approach facilitates getting a complete list of • medications/treatments • Dose, route, frequency, immunizations, allergies, herbals, etc • Put med list where it is easy to find • Determine a timeframe for completion • Assign responsible person at all transitions (e.g., admit, discharge) • Give patient a discharge med list • Suggest patient carry discharge list and update • Start with a small sample to pilot the process • Provide education to all health care providers participating in medication reconciliation • Give feedback on program to providers Pharmacist’s Letter 2010; Course No. 303

39. Community Pharmacist Role • Important component of medication reconciliation • Communication with pharmacy to obtain accurate medication history on admission • Importantto reducing medication errors • Communication with patients after discharge • Counsel medications • Remind to stop taking unnecessary pre-admission regimens • Answer questions • Medication record • Update information Pharmacist’s Letter 2010; Course No. 303

40. Community Pharmacist Role • Educate patients and family members to serve as advocates • Patients understand the complexities of the medication process and the role they play in medication management • Allows patients to keep better track of medications they are taking • Have patients bring their medications to every healthcare encounter • Educate and empower patients to be responsible for their medication list Pharmacist’s Letter 2010; Course No. 303

41. Medication Reconciliation Resources • The Institute for Healthcare Improvement (www.ihi.org) • Case studies, literature review, resources, frequently asked questions • The Massachusetts Coalition for the Prevention of Medical Errors (www.macoalition.org ) • Safe practices, sample processes, toolkit, reference list • The Joint Commission (www.jointcommission.org ) • Information on compliance with standards, frequently asked questions, flow chart • The American Society of Health‐System Pharmacists (www.ashp.org) • “how to guide, reference list, “clearing house information” • The Agency for Healthcare Research and Quality (www.ahrq.gov) • Toolkit

42. Medication Form Example

43. Questions?

44. Post Question 1 • All of the following are outcomes of an effective medication reconciliation process except: • Promote overall continuity of patient care • Increase in medication errors • Support safe medication use by patients • Encourage providers and health systems to collaborate

45. Post Question 2 • The important steps of an effective medication reconciliation as suggested by the Institute of Healthcare Improvement (IHI) include: • Verification • Clarification • Reconciliation • All of the above

46. Post Question 3 • What information should a community pharmacist share when contacted by other healthcare providers to help update a patient’s medication list? • Drug name, dose, route and strength • Medication frequency • Last refill or date received • Healthcare provider who is collecting medication information • All of the above

47. References • http://www.ihi.org/knowledge/Pages/Tools/MedicationReconciliationReview.aspx • Joint Commission on Accreditation of Health Care Organizations Sentinel Event Alert. Using medication reconciliation to prevent errors. Issue, January 25, 2006. www.jointcommisson.org/sentinel_event_alert_issue_35_using_medication_reconciliation(AccessedApril 15, 2014). • Improving Patient Safety: medication reconciliation basics. Pharmacist’s Letter 2010; Course No. 303 • MuellerSK, Sponster KC, Kripalaniet al. Hospital-basedmedicationreconciliationpractices: systematicreview. Arch Intern Med 2012;172:1057 • Kwan JL, Lo L, Sampson M et al. Medicationreconciliation during transitionsofcare as a patientsafetystrategy: a systematicreview. Ann Intern Med 2013;158:397 • SnowV, Beck D, Budnitz et al. Transitions of CareConsensus policy statement. J HospMed 2009;4:364 • Hume AL, Kirwin JL, Bieber HL et al. Improvingcaretransitions: currentpractice and futureopportunities for pharmacists. Pharmacotherapy2012;32:e326 • Doyle E. Medicationreconciliationdoneright. September 2009. www.todayshospitalist.com/index.php?b=articles_read&cnt=871 (AccessedApril 15, 2014). • Schnipper JL, KirwinJL, Cotungoet al. Role of pharmacist counseling in preventing adverse events after hospitalization. Arch Intern Med 2006;166:565 • Schnipper JL, Hamann C, Ndumele CD et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events. Arch Intern Med 2009;169:771 • ASHP-APHA Medication Management in Care Transitions Best Practices 2013