Published in the January 2007 issue of Today’s Hospitalist.
When the Cambridge Health Alliance (CHA) turned its attention to medication reconciliation, officials there knew they had their work cut out for them, largely because the system has three hospitals with three very different ways of doing things. But they never imagined that ironing out those differences would actually lead to a simpler reconciliation process-and a much more useful reconciliation form.
CHA, an academic public health care system with three acute care hospitals just outside of Boston, started the process by focusing on a way to reconcile medications on admission. The first step was undoing a previous effort that had met with mixed results and getting physicians and nurses to buy into an entirely new system.
In 2004, the health care system developed a worksheet in which nurses wrote the names and doses of home medications for newly-admitted patients on the left side of the sheet; on the right, physicians were supposed to check off which medications were to be continued. While the worksheet was simple enough, physicians often failed to fill out their side of the form, which meant that medications were not consistently being reconciled.
Melissa Bartick, MD, MS, a hospitalist and member of CHA’s medication reconciliation task force, proposed creating a combination reconciliation and order form similar to the one used at other medical organizations. A nurse would fill in a column on the left with a patient’s home medications. The physician would use a right-hand column to circle whether a medication was to be continued or discontinued.
Once the physician signed the form, it could double as an order form. "That would eliminate the number of times a medication is rewritten," Dr. Bartick says. "Less copying means less work for everyone and fewer chances for errors."
Less work or more confusion?
But the revised form hit a snag as soon as Dr. Bartick began training doctors to use it in the different hospitals.
The biggest problem revolved around differences in how orders are generated at the three campuses. Another concern was that the housestaff at one hospital didn’t want to add one more paper-based order form to the dozen or so pre-made order forms they were already using for diagnoses such as chest pain, pressure ulcers, diabetes and infections.
In addition to swimming in paperwork, housestaff noted that many of the other sets included medication orders, which could lead them to duplicate orders for the same medication.
"The housestaff were concerned that this was going to add another piece of paper and more confusion," says Dr. Bartick, who is also an instructor of medicine at Harvard Medical School.
Input and buy-in
Fortunately, one intern suggested a solution: Create a form that displays the medications used pre-admission on the left side and new medications prescribed in the hospital on the right side. In the middle, give physicians checkboxes to indicate whether pre-admission medications should be continued or not. Other housestaff also suggested putting a list of the different order sets at the bottom, Dr. Bartick points out, "where we could check off the sets we would use."
If a physician was replacing a home medication with a new therapy, other clinicians would be able to see that simply by reading the form from left to right. If aspirin taken at home was to be replaced with warfarin, for instance, that would be reflected on the form. The admitting doctor (housestaff or otherwise) would also check off on the order set box at the bottom. All the order sets were revised to include boxes saying "see medication reconciliation sheet" to avoid duplicating an order for the same medication.
Initially, says Dr. Bartick, she was disappointed to hear that she’d have to start over almost from scratch. "But it ended up being a much stronger form and we got their buy-in," she explains. "The key was in getting input."
In September 2005, the new pilot form was rolled out in selected units at the three hospitals. "We needed something that would work across all the different units, that would meet everybody’s needs and ways of doing things," Dr. Bartick says. "It’s been a challenge."
Getting moonlighters on board
Another problem the task force had to solve: how to get internists who moonlight as hospitalists at night at two of the campuses up to speed on the new forms.
"We had to figure out how to train them if we never saw them," Dr. Bartick says. One solution was to put posters in the call room where physicians sleep and keep their coats. The posters let physicians know that the forms were coming and what they needed to do to complete them. Emergency department staff also worked with moonlighting hospitalists during patient handoffs to help them fill out the forms.
"We used examples with fake patients, like Homer Simpson and Santa Claus, to draw interest to the posters," she says. "That also made the training more fun."
And because the moonlighters are employed by a subcontractor, the hospital contacted that company to alert the physicians by mail about the new forms.
"They got the picture," says Dr. Bartick. "Some of them have gotten it more quickly than others, but it’s gone fairly smoothly."
What was the biggest lesson learned from designing something to fit so many diverse groups?
"You really need to make it as self-explanatory as possible," says Dr. Bartick. "The more you have different groups of people using a product, the simpler it has to be." What you don’t need is a form that requires detailed instructions or training. "That’s going to make it a lot harder for people to use it correctly."
Overall, the use of the combination forms has improved medication reconciliation. Between June and August of 2005, 80% of medication reconciliation histories were completed across all three campuses. During the same period in 2006, that figure rose to 96%, largely because of the new sheet.
The exercise also taught many useful lessons about changing hospital processes.
"It’s very challenging to get all your users and stakeholders and include them on your team," she notes. "Just keep things as simple and as self-explanatory as you can."
Janice Simmons is a freelance health care writer based in Alexandria, Va.