Successful Interfacing with VA MedRecon Technology

1. Successful Interfacing with VA MedRecon Technology A Roundtable Discussion VeHU 160

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3. 3 Why MedRecon? Prevent Adverse Drug Events Coordinate Care Address Adherence Promote Shared Decision Making Cost Avoidance Foundation of Patient Centered Care

4. 4 VA Medication Reconciliation Initiative“Our mission is to support safe, effective, and patient centered medication reconciliation across the VHA system”

5. 5 MedRecon Initiative Products

6. 6 MedRecon Initiative Products

7. 7 The VA MedRecon Definition:Drawn from The VA MedRecon EPRP, Joint Commission & Current Literature MedRecon is a process to ensure maintenance of accurate, safe, effective, and above all patient centered medication information, by

8. 8 The VA MedRecon Definition: Obtaining medication information from Patient, caregiver, and/family. Comparing this to the medication information available on the electronic medical record including current medications, non VA medications, and medications given at other VA facilities (remote data) for the purpose of identifying and addressing discrepancies. Assembling and documenting the updated medication information. Communicating with and providing education to Patient, caregiver, and/or family regarding this information. Communicating this medication information with the appropriate members of the VA and non VA healthcare team.

9. 9 Minimum MedRecon Documentation Requirements Patient provided medication information obtained at the episode of care must be represented in the electronic medical record (EMR) Comparison of this to the medication information available on the EMR* Final updated medication list highlights the added, changed, and discontinued medications Discharge instructions=discharge medication information in the EMR *This documentation shall include active medications, recently expired medications, non VA medications*, and medications given at other VA facilities (remote medications) highlighting the discrepancies identified *This documentation shall include active medications, recently expired medications, non VA medications*, and medications given at other VA facilities (remote medications) highlighting the discrepancies identified

10. 10 Didactics Break Outs: MedRecon 102, Documentation, Metrics, Provider & Patient Education JC Town Meeting 200+ virtual and live participants-Every VISN, & key program offices Clinical Application Coordinators Educators Nurses Patient Safety and Quality Officers Pharmacists Providers Researchers

11. 11 Common Themes: “It is hard to do!” Requires rethinking the “monologue” Involves reliance on a team Tools need to reflect the patient and healthcare team workflow and allow for iteration Pharmacists, Providers, Nurses, Caseworkers, Social Workers, Front Desk Staff, Patient Safety & Quality Staff, Medical Records, and Clinical Applications Coordinators all are intrinsic to making MedRecon work in your facility. Pharmacists, Providers, Nurses, Caseworkers, Social Workers, Front Desk Staff, Patient Safety & Quality Staff, Medical Records, and Clinical Applications Coordinators all are intrinsic to making MedRecon work in your facility.

12. 12 My List (Bob S.) Furosemide 40 2 pills in the morning, 3 if my ankles are up, take in the afternoon if going to church Simvastatin 40 ½ pill in the morning, take it at bedtime on bridge nights Metoprolol 25 1 pill in morning one at night, skip Friday night if OK with wife Can’t take Sertraline (dizzy) –still down Take Ambien 10 rarely for sleep- once a month Full of context, amendments, adverse drug reactions and potential for ADEs, this list is Bob’s list—how we all interpret our treatment plans, personally, taking into account: Shared Decision Making Adherence Choice Literacy/Numeracy/AccessFull of context, amendments, adverse drug reactions and potential for ADEs, this list is Bob’s list—how we all interpret our treatment plans, personally, taking into account: Shared Decision Making Adherence Choice Literacy/Numeracy/Access

13. 13 At present, these are the issues: Many resources are unknown to local MedRecon Teams It is difficult to obtain and document patient data Maintaining an accurate medication list means amending orders Remote data is a problem Non VA list must be updated Communication with the Non VA Provider requires ROI, storing demographics, and having a method of data transfer

14. 14 MedRecon Holy Grail Patient Data has a place in the chart Bidirectional Communication Customized care plan One stop shopping “snap shot” dashboard The Patient The Organization Order Communicate Software works for you to assemble, calculate, alert, retrieves & store medication information Disease Model Patient Centered Care Connects to the non VA environs Imbedded monitoring

15. Innovations on the Horizon:There are many! Kiosk IMM MHV PRE Greenfields Phoenix And your local innovative processes! 15

16. 16 What can you do to help (now)? Take an active role on your VISN or Facility MedRecon Team Multi-discipline Active Leadership Support Measure if your changes represent improvement Encourage documented communication between the patient and the healthcare team Use existing tools Start small

17. 17 Thanks! Medication Reconciliation Will fundamentally change how we practice medicine by systemizing the management of the medical treatment plan, placing checks and balances at every interface, and instituting an ongoing dialogue with the patient and his/her healthcare team.

18. Projects, Solutions, and Updates

19. 19 Objectives of this Presentation Update attendees on the wide number of projects that all have some relevance to Medication Reconciliation Describe specific VistA projects that are in progress or planned Discuss the prioritization of related changes that will improve the experience of Medication Reconciliation

20. 20 Projects Related to MedRecon Enhancements to the Class I VistA MedRecon Reports Phoenix Medication Form Active Prescriptions Awaiting Patient Request To Be Dispensed VHA Innovation Project – D/C Remote Meds Integrated Medication Manager

21. 21 Enhancements to the Class I VistA MedRecon Reports PSO*7*316 and GMTS*2.7*92 Under SQA Review Addresses Tool #2 (Medication Worksheet) Primarily corrects standards issues and problems with the original June 2008 release PSO*7*314 and GMTS*2.7*94 To address Tool #1 (Medication Reconciliation) PSO*7*foo and GMTS*2.7*bar At this time, these patches have not yet been assigned numbers

22. 22 Phoenix Medication Form Class III New Service Request http://vista.med.va.gov/nsrd/Tab_GeneralInfoView.asp?RequestID=20071110 Could be considered “Tool #5” as part of VistA reporting options for MedRecon purposes Status update presented to OHI IT Patient Safety for review March 29, 2010 May 2010 – under revision to include remote medication data in the report

23. 23 Active Prescriptions Awaiting Patient Request To Be Dispensed Re-entry of a 2003 New Service Request http://vista.med.va.gov/nsrd/Tab_GeneralInfoView.asp?RequestID=20090509 Identified as one of the top two corollary needs for MedRecon at the Sept 2009 conference in Ann Arbor There is a Round 2 Innovation entry selected to address the same business need as well

24. 24 VHA Innovation Projects D/C of Remote Medications http://wiki.v08.med.va.gov/groups/cdpmva/ http://wiki.orlando.med.va.gov/fmi/iwp/cgi?-db=GreenField&-loadframes (Entry #168) http://vaww.infoshare.va.gov/sites/chio/HMIS/VHAInnovationProgram/greenfieldwikisites/Wiki%20Pages/Home.aspx (Top Level Web Site) Other Innovations Round 2 https://vha.ideascale.com/

25. 25 Integrated Medication Manager New user interface for managing medications, observations, goals and interventions http://vista.med.va.gov/nsrd/Tab_GeneralInfoView.asp?RequestID=20080116 Additional “child” NSRs to address a second phase of development Active work on Business Requirements Document and Use Cases

26. 26 Clinical Reminder Order Checks Coming with CPRS version 28 Clinical Reminder Terms and Clinical Reminder Definitions will be able to generate Order Check Text for selected Orderable Items VERY POWERFUL! Use with caution to prevent system overload while trying to solve all the world’s problems VistA Outpatient Pharmacy patch PSO*7*344 will make additional Rx data available to reminders in support of this enhancement Test version 2 is at test sites as of May 2010

27. Medication Reconciliation Monitor The Why and The How

28. 28 Introduction A study of the Institute of Medicine from 1997 and released in 1999, confirm that from 33.6 admissions to hospitals in the US there was a 2.9% to 3.7% of occurrence of adverse events. From all annual deaths 98,000 were due to medical errors. Medical errors carry a high financial cost. The Institute Of Medicine report estimates that medical errors cost the Nation approximately $37.6 billion each year; about $17 billion of those costs are associated with preventable errors. The IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct.

29. 29 Introduction 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.* *(From :”The Good, the Bad and the Ugly” VeHU 2007-Class 212 Medication Reconciliation)

30. 30 Background Medication Reconciliation was established as a goal during 2005, for full implementation by January 2006. VACHS Patient Safety Group developed a policy, strategies, tools and educated their staff On 2008, a HFMEA was appointed to improve the process NPSG #8 in 2009 added required documentation Several modifications were done to the existing Clinical Reminders to facilitate documentation

31. 31 Manual Record review

32. 32 Manual Record review

33. 33 Medication Reconciliation MonitorThe Why After last revision on January 8, 2010 DUSHOM recommendations were to include in their Monitors and Guidelines for FY 10 Medication Reconciliation: Medication Reconciliation (MedRecon) (NEW) In addition to addressing the Joint Commission National Patient Safety Goal (JCNPSG) the MedRecon Performance Monitor addresses a recent OIG recommendation that MedRecon be monitored by every VAMC facility.  It is also imperative that the VA establish a system wide MedRecon Monitor to support continuous quality improvement, develop meaningful documentation and monitoring tools, and assess compliance at multiple levels of the enterprise. The MedRecon Monitor will make a difference in the delivery of care at VA facilities by measuring the terminal step in MedRecon which requires that a current medication list be given to each patient upon discharge from a hospital admission.

34. 34 Medication Reconciliation MonitorThe Why The monitor has its own objectives: The objectives of this monitor are designed to assess Medication Reconciliation in VAMC Facilities at the point of discharge by asking two MedRecon related questions at the time of the post discharge phone call. The facilities need to have a “post discharge telephone contact “ (PDTC) call note to document this new information.

35. 35 Post Discharge Call

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38. 38 VA Caribbean Health Care Systemefforts on MedRec documentation San Juan have two Clinical Reminders to document Outpatient and Inpatient MedRec Marketing has been very difficult, since still need some adjustments in terms of check the new meds orders in the “orders” tab, and not having the close printer necessary to hand-out the current list to each patient at the time of the visit in the outpatient setting.

39. 39 Documentation as OP Clinical Reminder

40. 40 Admission Documentation

41. 41 Health Summary-Med Recon

42. 42 Clinical Reminder Satisfied

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44. Improving Compliance of Inpatient Med Reconciliation Deborah Baruch-Bienen, MD, FACP Acting Chief, Medicine Service, STVHCS AMD Associate Professor of Medicine, UTHSCSA Bioethics Consultant 2010

45. 45 Introduction For hospitalized patients med rec is required On admission On discharge (copy to patient) In addition, when a patient changes services, the accepting team must not only review current inpatient meds, but review the original outpatient med rec from that admission

46. 46 Our Institution’s History Documentation for medicine reconciliation was poor, resulting in an RFI from the Joint Commission (TJC) after their June 2008 visit.

47. 47 Process Improvement We identified the following obstacles to instituting Admission and Transfer Med Rec: Lack of education residents/staff Lack of standardization for med rec documentation in templates Lack of standardization for note titles used and an abundance of unnecessary note titles in CPRS

48. 48 Templating for Med Rec Templating med rec for increased TJC compliance requires the following; Standardization of note titles & templates Inactivation of Unnecessary note titles Ease of use for providers The following describes templates for both inpatient physician notes Project aimed at ALL ward services: Medicine, surgery, psych, SCI, KD, research, ECTC, & KTCC

49. 49 Fixing CPRS Documents From late Aug through Nov 2008, all physician inpatient notes were reviewed by a physician and CAC Ensured all services had needed templated notes: History and Physical admission note Transfer Accept Note Daily Progress note At the same time, we inactivated ALL UNNESSARY NOTE TITLES

50. 50 Fixing CPRS Documents Key to success: template notes with REQUIRED radio boxes reconciliation statements to choose from. Two slightly different fields were inserted into the template for the inpatient admission (H&P) & for transfer accept notes. This FORCED the doctor to pick a med rec statement.

51. 51 Admission Med Rec All inpatient services given customized templated note title mandatory for all admissions The outpatient med list automatically templates in, however, providers are expected to modify based on information given to them by last med rec, patient, care givers, or other sources Providers then must choose from a list of statements that explain HOW they reconciled the medicine list

52. 52 Med Rec Mandatory Field

53. 53 Transfer Accept Med Rec

54. 54 Transfer Accept Med Rec

55. 55 Data Collection During Summer 08, templated notes existed, however, fields not mandatory, education still variable, and doctors had other note titles to choose from that bypassed the templated med rec.

56. 56 Results Daily audits performed 16 Sept – 22 Oct, 31 Oct – 3 Nov 100% audits Admission & Transfer Accept notes. Able to drill down for causes of fall outs resulting in improved templates & service specific education Consistent improvement with daily 100% audits seen Numbers not weighted

57. 57 Sustainable Success

58. 58 Conclusion By examining the real time process of inpatient medicine reconciliation documentation, including reasons for fall outs, and as a result of dedicated time & staff for process improvement, we have been able to improve and sustain compliance with Med Rec for inpatients from an unacceptable performance to BLUE scores for the TJC measures for success!

59. Medication Reconciliation: West Palm Beach VA Medical Center Nann Chavalitanonda, Pharm.D., BCPS Clinical Pharmacist-Internal Medicine

60. 60 Medication Reconciliation Outpatient Medication Reconciliation is performed at EVERY visit with a provider, using a clinical reminder An outpatient medication list is printed for the patient to review and update prior to his/her appointment Inpatient Medication Reconciliation is completed by providers, floor clinical pharmacists, and nurses using a clinical reminder

61. 61 Medication Reconciliation

62. 62 Medication Reconciliation

63. 63 Outpatient Medication Reconciliation Check Compliance for Outpatient Med Reconciliation can be done through a routine created by IRM and pharmacy Evaluates compliance with the provider completing the med reconciliation reminder Evaluates the input of 2 health factors HF1=Medication Reconciliation Performed HF2=Visit Not related to Med Reconciliation

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69. 69 Outpatient Medication Reconciliation Check After the Med Recon routine has been run, the date can be sorted and reviewed at the service level. Data may be sorted by clinic location and then evaluated by date. If the date of the appt and the date of the HF entry are on the same day, the provider is compliant with medication reconciliation. Information can be reviewed on a case by case basis for specific provider issues

70. 70 Transfer Note/Handoff Communication Progress note is utilized by a provider whenever a patient changes level of care (transitions from ICU to acute care ward, etc) Condition of the patient upon transfer, the provider they are transferring care to, and pertinent medical issues of the patient. Provider will enter a list of medications the patient should be transferred/continued.

71. 71 Transfer Note/Handoff Communication

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73. 73 Med Reconciliation Performance Monitor The current post-discharge process requires a post-discharge phone call be placed to the patient within 48 hours of discharge from an inpatient hospital stay. Were you provided a copy of your updated medication list upon discharge? Do you know where to get more information?

74. 74 Post D/C Phone Call Tools CPRS template was created for the discharge nurse to document phone call using a specific progress note title and health factor. These allow us to build tools to track performance data.

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77. 77 Post D/C Phone Call Tools Clinical Reminder Report created to obtain compliance data for IPEC monitors. Combination of reminders, location list, patient’s list, health factors, progress note title and reports template are used. Extract exact number of patients who should be contacted Exclude wards such as NH Allows reasons why patient could not be contacted

78. 78 Post D/C Phone Call Tools Location list created excluding wards Inpatient wards excluding non-discharge wards Reminder to obtain total amount of discharges (denominator) Reminder to obtain post-discharge compliance. Pt contacted and responded “yes” (numerator) Patient list created which are used in the reminder reports as the patient sample to determine compliance

79. Portland Patient Safety Center of Inquiry Blake Lesselroth, MD, MS

80. 80 Portland Strategic Overview

81. 81 APHID Solution Point of service patient-facing software Developed by Portland VA Medical Center (PVAMC) in partnership with the VHA National Center for Patient Safety (NCPS) Efficient way to engage patient Leverages consumer multimedia technology

82. 82 APHID Solution Supports administrative transactions including clinic check-in Compiles all active, remote, non-VA, discontinued, and expired medications into composite list Completes medication and allergy history using pictures and web buttons

83. 83 Hospital Admission Med Recon Hospital Admission Med Recon (HAMR) program based on APHID model Accessed using CPRS “Tools” menu on mobile computer Staff members generates CPRS data objects and notes Several workflow models piloted (nurses and residents) Currently testing in surgical holding

84. 84 Patient Centered Medical Home Portland VA Medical Center one of six funded Patient Centered Medical Home Demonstration Labs Grant funding to develop, implement, and evaluate model of care for fragile CHF cohort Goal is to establish Cards-PC “care platforms” equipped and supported with IT tools

85. 85 Home Health Med Recon APHID technology using home-based nursing care model Anticipate nurses using mobile technology including laptop computers New software capabilities to address unique task and setting Focus upon medically fragile heart failure population

86. 86 Organizational Change Engage stakeholders and clinical champions to incentivize staff Carefully consider context, built environment, and patient consumer Employ User Centered Design strategies and provide infrastructure to support goals

87. 87 DISCUSSION