We need a better system for medication reconciliation

Medication reconciliation is defined by JCAHO as “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.” The process should be fairly straight forward, but it is actually very difficult and time consuming.

Most consumers don’t do a very good job of keeping track of their medications; much less the medication names, dosages, what they are used for and when they were last taken. It’s not uncommon on admission to the hospital for a patient to say things like “I take a blood pressure pill” or “a pain pill” or “a water pill”. As a pharmacist I can make gross generalizations about these medications, and can narrow the options down with aggressive questioning, but can rarely be sure without seeing the medication for myself.

The Electronic Health Record Incentive Program, a.k.a. Meaningful Use guidelines, calls for medication reconciliation to be used for at least 80 percent of “relevant encounters and transitions of care” (page 95). In addition “the capability to perform medication reconciliation is included in the certification standards for certified EHR technology.” This is easier said than done.

Most medication reconciliation begins in the Emergency Department. It is typically a manual system of information collected by nurses who in turn pass it off to the physician for approval. Unfortunately many physicians don’t take the time to scrutinize the medication list which is often inaccurate or incomplete.

The ideal list of medications currently being taken by a patient wouldn’t be generated by the patient at all. Instead the list would be downloaded from a nationally standardized e-pharmacy. Of course no such thing exists, but that doesn’t mean it shouldn’t.

In theory all medications taken by patients are filled in a pharmacy, whether that is a chain pharmacy, community pharmacy or mail order pharmacy. Modern pharmacies are computerized and connected to the internet so that insurance adjudication can take place. The same data should be transmitted to a centralized e-pharmacy where it would be stored and accessed by hospitals during patient admissions. The list would follow the patient throughout their admission and be finalized on discharge. After all, the medication use profile is never more accurate than at the time of discharge.

In the absence of a centralized e-pharmacy, several vendors offer software applications designed to help hospitals maintain a digital medication reconciliation record. Most of these applications can be integrated into the pharmacy information system, making the process a little easier. The solution is not ideal, but it is better than a manual system with pen and paper.

Some vendors that offer medication reconciliation software are listed below.

RxReconcile
MedsTracker
RcopiaAC
MediRec

Mediware’s ClosedLoop Clinical Systems
HCS Medication Reconciliation

11 thoughts on “We need a better system for medication reconciliation”

  1. I have to agree- we do need something better. Your suggestion would be one start to a more accurate system. Unfortunately knowing the medications the patient may have had filled at a pharmacy does not mean that those are the medications, doses and regimens that the patient is currently taking. I never cease to be amazed at the discrepancies – some generated by new instructions from the MD, some by patient initiative.

  2. I agree that simply having the patients most recent fill doesn’t guarantee accuracy, but it certainly gives us more information than we have now. The database management would require diligent maintenance from everyone involved. Think about how a bank can track your finances down to the penny even though you, and perhaps a spouse, use multiple methods of moving money; ATM, debit card transactions, transfers, checks, automatic deposit, cash deposit, etc. I realize med rec may be a bit more complex, but you get the idea. Gotta’ start somewhere.

    As you reference in your comment, the discrepancies are amazing. I wish I could post some of the stuff we get from the ED when a patient is admitted. I would be embarrassed to sign my name to some of the orders I see. Thanks for the feedback.

  3. I think we can all agree that medication reconciliation, and the health IT industry as a whole, have a long way to go before we reach the ideal end result of this movement. As you mentioned, there is no current centralized e-pharmacy that holds all patient medication history, and even if it did exist, there are other sources for medications including pharmacies not yet connected to the infrastructure, medication samples, OTC medications, and patients who are taking medications prescribed to a friend or family member.

    The important fact is that we can now offer a better way for doctors to treat patients. We can provide information that was unavailable only a short time ago – information that can potentially save a life. Although the systems and the infrastructures they rely upon are not complete, it is still a huge step in the right direction towards the ultimate goal—patient safety. These electronic tools must be an adjunct to an interview with the patient or caregiver if the provider wants the most complete, up-to-date active medication list.

    When choosing a software application it is important to choose a vendor that has this long-term goal in mind. Infrastructures continue to improve, and it is up to forward-thinking vendors to continue to improve their systems by connecting as many communities together as possible.

    Rome wasn’t built in a day – but it was built.

    Disclaimer: I am the Chief Medical Officer at DrFirst

  4. Hi Peter –

    I agree with everything you’re saying here, but I do think we have taken a very cavalier approach to much of the technology in healthcare. You make an excellent point about having previously unavailable information that could potentially save a patients life. The problem is that much of this information is housed in silos, making it unavailable when needed. We have a very disjointed approach to healthcare. Medication samples should be logged. OTC products will always be an issue, but should be tracked by the patients primary care physician. Medications taken off the radar cannot be reconciled without the help of the patient and the physician. This is where the physician knowing their patient becomes important. The biggest development in patient safety may not be technology at all, but rather a solid, trusting relationship between physician and patient. Wouldn’t you agree?

    For an example of how to integrate records, look no further than the banking system. Many people have more than one account at various banks, multiple accounts types (retirement, savings, checking, money market, bonds, credit cards, ATM cards, debit cards, etc), perform thousands of transactions and have multiple users of the same account information in an average family. Yet for the most part, banks manage your money to the penny. In addition your information is available via ATM machines, physically inside the bank, online via computer or smartphone, via text message alerts, and so on. How is it that the banking industry is kicking healthcare’s rear end when the information needed by doctor/nurse/pharmacist is exponentially more important than the individuals account balance. Something to think about.

    I agree that it will take time, but with that said I still think we can do a better job. There is always room for improvement in thinking, development and implementation. Thanks for stopping by and leaving a thought provoking commentary. Perhaps we will run into each other some time. I’d love to sit down and hear more about what your thoughts are.

  5. I agree with you. The banking system is way ahead of eHealthcare but look at the data they’re reconciling–THEY have a standard language (Arabic numberals) and just a few transaction types–far less complex than a medical record. That is why ePrescribing data interchange has been successful – there’s a limited scope to the data, but we still have huge problems with complex sigs (I’ve been heavily involved with the structured/codified sig, and it is awfully hard to code some of those sigs, to say nothing of a simple coding schema for compound drugs). The banking industry also has more buy-in to the advantages of the process as well as less vocal worry about the privacy aspects. That said, CAQH (www.caqh.org) has their CORE project for data interchange among payors and practice management software, and that is based on the banking system. I’ve been out of the look but hear it’s moving along. Like banking, a limited set of data and transaction types, and standardized vocabulary is more easily achievable.

    Thanks for keeping up your blog.

  6. Yep, Peter, you make an excellent point. I believe in standardization and simplification. I’m looking forward to a time when health care information is passed back and forth as easily as a banking transaction. The technology is there, it’s health care itself that seems to be putting up the barriers. I was unaware that CAQH existed; appreciate the link.

    Thanks again for stopping by and adding to the conversation.

  7. Will there be an article on how hospitals deal with reconciling meds that are purchased over-the-counter as well as herbal products? Sometimes patients still (over) medicate themselves with otc and herbal products and do not know that they are causing damage. Also will EHR/EMR’s send warning signals to doctors when certain meds are recorded and the patient is receiving a med that has similar components? Note the comparison of red yeast rice, an OTC/herbal product. Should it be recorded and flagged by an EMR Software if it is being taken with another statin drug?

    http://www.mayoclinic.com/health/red-yeast-rice/NS_patient-redyeast

  8. @Elliott – I didn’t have any plans to post on the reconciliation of OTC meds or herbal products. I like your idea about sending alerts to physicians when certain medication are added to an EHR/EMR. That makes a lot of sense. The problem with OTC meds and herbal products, as it sounds like you may already know, is that many patients don’t report on their use. Many don’t consider herbal products a medication, which you and I know is bologna. Thanks for the idea.

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