Regardless of the difficulties involved, physicians and others say that keeping an accurate, up-to-date record of all over-the counter and prescription medications a patient takes plays an essential role in providing the best possible care. Even the seemingly simple step of sending patients home from the hospital with an easy-to-read, thorough list of prescriptions and other medications to continue at home has a big impact, Snyder argues. "We're going to improve the quality of care because patients will be going home from the worst week of their life with an accurate list of medications that can be used by the next level of care to reduce readmissions," he says.
Fundamentally, medication reconciliation involves managing hand-offs of patients, such as from a primary care physician to a hospital, from the intensive care unit to the nursing unit, or from the hospital back to the primary care doctor. And while information technology can play a huge role in making those handoffs more efficient, equally important is designing good processes in the first place.
"The most important factor for successful medication reconciliation is to have very strong processes in place," stresses Eliot Heller, M.D., chief medical information officer at The Bronx-Lebanon Hospital Center in New York. For example, the hospital has switched the medication reconciliation tasks for patients being transferred within the hospital to the "receiving" clinical team, rather than the "sending" team. That's because glitches arose when a sending team updated the medication records. For example, the medication list could rapidly become out of date if the transfer of an ICU patient to an inpatient bed was delayed for hours.
Another potential glitch comes when a patient arrives at a hospital without a list of their medications, especially in emergencies. Some hospitals are helping address this issue by electronically retrieving lists of prescriptions that physicians previously ordered using electronic networks.
Computerized physician order entry systems, with decision support for ordering medications, can play a big role in medication reconciliation. But some hospitals that lack CPOE are devising clever ways to provide decision support using other available technologies.
A Work in Progress
At Peninsula Regional Medical Center, and many other hospitals like it, automating medication reconciliation is a work in progress. For two years, the 450-bed hospital has been testing new technology from McKesson Corp., San Francisco.
The hospital has a physician portal that doctors use to view home medication lists prepared by nurses when a patient is admitted, explains Snyder, the CMIO. The doctor then uses the portal, linked to decision support embedded in the hospital's CPOE system, to order medications to continue for the inpatient stay. Integrating the portal with the CPOE system proved challenging, but it greatly streamlined the drug ordering process, Snyder says.
An enhanced version of the portal to be implemented this year will clearly group drugs by class, fueled by a drug database from First Databank, San Bruno, Calif.
When a patient is transferred or discharged, physicians review the medication list in the portal, which has been automatically updated with drugs prescribed during their hospital stay. They then select the medications the patient should take at home. The patient gets a printout with the full list of medications plus instructions. A copy of the final medication reconciliation list also gets added to a document management system that stores the hospital's final legal health record.
For now, the hospital faxes the medication list to the patient's primary care physician. But it's considering using McKesson's RelayHealth unit to send a digital file, perhaps automatically loading it into the physician's electronic records system, Snyder says.
As a result of all these efforts, Peninsula Regional Medical Center consolidated as many as five medication lists to one, "eliminating a lot of concerns about handoffs," Snyder says.
The hospital also instructs patients to post their medication lists on their refrigerator using a custom-made hospital magnet. "So when the ambulance team comes in the door, they now always check the refrigerator door," Snyder notes. "We now routinely see these lists come in with patients in the ER rather than a bag of pill bottles."
Automating Each Step
At Bronx-Lebanon Hospital Center, information technology is playing a big role in every step of the medication reconciliation process, although the organization is still working on some missing links. The center's two hospitals made a "big bang" conversion to clinical systems from Eclipsys Corp., Atlanta, in December 2008. This included a medication reconciliation module within a CPOE system.
To ensure that medication reconciliation is completed for all patients entering the hospitals, physicians are locked out of placing orders using CPOE unless the medication reconciliation record is updated within 18 hours of admission, says Heller, the CMIO.
Physicians at the organization's 26 outpatient locations, which serve a heavy volume of Medicaid patients, use an electronic prescription writing system tied to CPOE. So for most patients, the organization already has a fairly detailed electronic list of medications.
When admitting a patient, a physician reviews information in the electronic prescribing application, including any updates on home medications entered by a nurse, to confirm that it's accurate and complete. Then the doctor calls up the reconciliation management module and imports the medication list from the prescription writer. They select which medications the patient should continue to take during their hospital stay by simply moving the drugs from the "home" column to the inpatient column. And they add new drugs to the inpatient list.
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