Despite progress, medication reconciliation remains a bitter pill. Un-intended changes in medications occur in one-third of all patients transferred between hospital departments, and in 14 percent of patients at hospital discharge, according to the Agency for Healthcare Research and Quality.
Most medication inconsistencies could be avoided if reconciliation were performed at patient admission, transfer and discharge. Hospital information systems are helping some wired hospitals rdo this across the care continuum despite the lack of a universal solution.
When patients are admitted to Nemaha County Hospital, Auburn, Neb., the patient's current medication list is obtained from the patient or referring physician's network. A nurse or pharmacist reviews the list and determines whether any vitamins, herbal remedies or over-the-counter medications also are being taken. The medication list then is added to the hospital medical-record system.
When a patient is transferred, a medication-administration record is provided to the receiving facility in electronic or paper format. If the patient is discharged to home, a nurse or physician assistant reviews the medication list with the patient, who gets it in electronic or paper form to present to subsequent caregivers. "One hundred percent of patients are reconciled at discharge or transfer," says Kermit Moore, chief operating office/chief nursing officer.
Moore says Nemaha's goal is to create a culture of acceptance so patients remember to provide discharge medication lists at their next care encounter. "It's also important to establish communication flow with other providers to increase their awareness of the medication reconciliation process," he says.
At Aurora Health Care in Wisconsin, medication reconciliation functionality is being added to the electronic health record. "Programs in our EHR provide automated support for creating medication lists and medication reconciliation," says Kathy Leonhardt, M.D., vice president of patient experience and patient safety. The medication list is the same for outpatient and inpatient settings, so Aurora's physicians see the same list in their clinic as at the hospital.
"In the future, as other systems get up-to-speed via the HITECH Act, we'll be able to share this information with other providers electronically," says Philip Loftus, Aurora's CIO.
Some historical medication-purchase information already is being collected and shared at places like Yale–New Haven Hospital, where a commercial network connects community pharmacies to the hospital via insurance carriers. "All of the medications a patient received through local CVS or Walgreens pharmacies provide us historical medication data if the patient used their health insurance to obtain the medication," says Majorie Lazarre, Yale pharmacy manager.
Even though data from patients who use cash or insurance plans outside the network cannot be obtained, the system has made headway. Lazarre says about 70 percent of the local population will have some data within the medication database, which saves time during hospital admittance interviews. "An interview that once took an hour now takes 15 minutes, because we have that preliminary data to build from—we're confirming and validating rather than starting from scratch," Lazarre says.
Medication reconciliation was designated a 2005 National Patient Safety Goal by the Joint Commission, which recommended that organizations accurately and completely reconcile medications across the continuum of care. In 2009, however, the commission announced it would no longer score medication reconciliation during on-site accreditation surveys, because of difficulties with implementation strategies. Then, in December 2010, the commission announced a new version of the NPSG (08.01.01), to be effective July 1 of this year. According to the commission, the new streamlined version focuses on critical-risk points in the medication reconciliation process.
The Institute for Safe Medication Practices still is disappointed in the current status of medication reconciliation. "It's not what we expected for a process that on the surface seems so simple," says Stu Levine, an ISMP informatics specialist.
Levine believes both the problem and the solution lie in the EHR. "Until we have total electronic sharing of a patient's medication and health record via devices like smart cards, medication reconciliation information will not be accurate," he says.
Douglas Page is a freelance writer in Pine Mountain, Calif.