Medication Reconciliation: The Inpatient Hospitalist Perspective

1. Medication Reconciliation:The Inpatient Hospitalist Perspective Peter Kaboli, MD, MS Iowa City VAMC CRIISP (Center for Research in the Implementation of Innovative Strategies in Practice) University of Iowa, Iowa City, IA AHRQ-Washington, D.C. September 27, 2007

2. JCAHO Definition of Med 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.

3. Is Med Reconciliation New? • Absolutely not. • JCAHO & IOM put it into the spotlight. • Transitions of care have always been a problem. • EMRs help, but don’t fix problem (VA). • Fragmented care is the norm, even as far back as 1872.

4. Beethoven's Doctor Accidentally Poisoned Him, Pathologist Claims Wednesday, August 29, 2007 VIENNA, AUSTRIA —  DID SOMEONE KILL BEETHOVEN? A VIENNESE PATHOLOGIST CLAIMS THE COMPOSER'S PHYSICIAN DID — INADVERTENTLY OVERDOSING HIM WITH LEAD IN A CASE OF A CURE THAT WENT WRONG. OTHER RESEARCHERS ARE NOT CONVINCED, BUT THERE IS NO CONTROVERSY ABOUT ONE FACT: THE MASTER HAD BEEN A VERY SICK MAN YEARS BEFORE HIS DEATH IN 1827.

5. Are Computerized Med Lists Accurate? • 493 older veterans on >5 medications • Pharmacist “brown bag” interview • Mean of 12.4regularly scheduled meds • range 5-49 • 8.0 Rx, 2.9 OTC, 1.5 vitamins/herbals • Kaboli, et al. Assessing the Accuracy of Computerized Medication Histories, AJMC. 2004;10;872-877

6. Agreement Definitions • % of Patients with Perfect Agreement between the interview and computer • Omissions: meds not on computer profile, but being taken by the patient • Commissions: meds on the computer profile, but not being taken by the patient

7. Findings • Only 5.3% of patients had perfect agreement • Omissions: • 1.3 medications per patient • 25% of all medications omitted • Commissions: • 1.3 medications per patient • 12.6% of all medications not being taken • 23% of Allergies and 64% of ADEs missing • Impossible to have 100% accuracy all the time

8. Top 5 Omissions 34% of omissions were prescription drugs

9. Top 5 Commissions 66% of commissions were prescription drugs

10. Other findings from our VA outpatient clinical pharmacist/physician intervention: • Health literacy was associated with medication knowledge, but NOT with taking meds correctly or ADEs at 6 and 12 months. • Outpatient pharmacist/physician evaluation can improve medication appropriateness, but hard to show improved clinical outcomes (ADEs). • Patients are just as likely to NOT be taking a recommended medication as they are to be taken extra medications (polypharmacy).

11. Implementing Med ReconciliationKaboli, et al. Clinical Pharmacists and Inpatient Medical Care: A Systematic Review. Arch Int Med, 166, May 8, 2006 • Clinical Pharmacists • 11 RCTs of Admission and/or Discharge Med Reconciliation • ↓ Preventable ADEs • ↓ Time to input allergy information • ↓ Readmission • ↑ Medication knowledge • ↑ Medication appropriateness • ↑ Compliance • Why wouldn’t a clinical pharmacist help? • Unfortunately not cheap or available 24-7

12. Clinical Pharmacist InterventionSchnipper, et al. Role of Pharmacist Counseling in Preventing ADEs After Hospitalization. Arch Int Med, 166, Mar 13, 2006. • Discharge counseling with 3-5 day follow-up phone call (N=178). • 30 day Preventable ADE rate 11% vs. 1%, but not all ADES • Half of patients had discrepancies from pre-admit to discharge • Did not improve medication adherence or ED/hospital re-admission

13. Inpatient Clinical Pharmacists: Roles • Careful review of med lists, including contacting local pharmacy if necessary • Rounding with team, especially in ICU • Make recommendations to inpatient team at admit and/or discharge • Ensure patients get medications • 3-5 day follow-up phone calls • Are they “better” than physicians or nurses?

14. What works for you? • Clinical pharmacists • Hospitalists • Residents • Nurses • Pharmacy students • Pharmacy techs

15. Summary Keys for Success • Pharmacist and Physician champions • Electronic or paper format • Team accountability • Involvement of patient/family • Health literacy and social support • Discharge counseling • Communication to primary care or SNF and outpatient pharmacy • Follow-up phone call