If you’ve ever worked with geriatric patients, you know how unlikely it is that they’ll be able to tell you exactly which medications they are taking or what the dose is. Yet, too often, this verbal history is all we have to go on at the time of a hospital admission – or, if we’re lucky, the patient might present us with a plastic bag full of pill bottles to sort through. And just to clarify, the confusion isn’t limited to the elderly.
Upon admission, patients commonly receive new medications or have adjustments made to existing prescriptions. According to an AHRQ study, unintended medication discrepancies occur in nearly one-third of all admissions and 14 percent of all discharges.
When hospitalists don’t have access to complete medication lists, transitions of care may result in incorrect dosages, omissions, or duplicate therapies. The term “medication reconciliation” refers to the process of avoiding these discrepancies, by reviewing the patient’s complete medication regimen at every transition of care – admission, transfer, and discharge – and comparing it to the regimen being prescribed at each new care setting.
Medication reconciliation has always been problematic, however. As noted above, it can be difficult to piece together a list of current medications, or to evaluate the accuracy of the data it contains. If we’re getting information from primary care providers, pharmacy records, and patient interviews, which set of data is correct? How do we know the patient is actually refilling and taking each medication as prescribed?
Comparing and reconciling the lists after a transition of care can also present problems. What happens when two providers have prescribed different doses of the same medication, or two different medications that perform nearly the same function? Who makes the clinical judgment call on what the final medication regimen should be?
Clearly, the inherent difficulties in the reconciliation process can jeopardize patient safety. It’s no wonder that Meaningful Use guidelines call for an automated process to more accurately and efficiently address medication reconciliation. Nurses and case managers may think of Meaningful Use as a technology initiative – yet, some of the goals of Meaningful Use actually tie into the mission to improve care through enhanced patient engagement and better discharge planning.
Stage Two of Meaningful Use guidelines state that participating hospitals must electronically perform medication reconciliation for 65 percent of patients making a transition of care. It is hoped that an automated process will address this crucial step more accurately and efficiently than comparing the pre- and post-discharge medication lists by hand. Software designed for this purpose integrates with pharmacy systems and computerized provider order entry (CPOE) systems to help ensure that no medications or dosage changes have been missed.
Guidelines for Meaningful use also state that technology vendors cannot obtain certification for their EMR technologies without including the functionality to electronically compare two or more medication lists, so the IT industry is committed to developing these technologies. Ideally, the EMR will integrate with pharmacy systems and computerized provider order entry (CPOE) systems to provide a seamless reconciliation workflow once the pre-admission list has been compiled. In some fully integrated EMR systems, hospitalists making medication changes are required to document the reasons for those changes, which can provide clarity to the primary care provider who receives the discharge summary – and help avoid discrepancies.
Still, the automated process shares one key weakness with the manual process: it depends entirely upon the accuracy of the pre-admission medication list. Perhaps this situation will improve gradually, as the industry works to engage patients in their own care. Engaged consumers of health care are more likely to manage their own data and be able to communicate with providers. Nurses should be knowledgeable about tools that support this, and able to counsel patients in their use. Personal health records are a good start. So are mobile apps that are designed to help consumers track their own health information.
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