Published in the November 2012 issue of Today’s Hospitalist
WHILE JUST ABOUT EVERYONE AGREES medication reconciliation is the right thing to do to protect patients, hospitals feel under the gun to show how med rec can pay for itself. Now, a handful of studies “and several real-world examples “are giving hospitals reason to be cautiously optimistic that med-rec programs can not only support themselves financially, but may even deliver a return on investment.
Novant Health in North Carolina is a good example. By revamping its med-rec system for its two largest hospitals (one with 921 beds, the other with 607), the system was able to garner significant net annual savings, according to Francie Carney, RPH, head pharmacist at Presbyterian Hospital Huntersville, a 75-bed Novant facility.
But Novant saw that stellar return only after it tried several iterations of medical reconciliation. According to data from those two largest facilities, nurses originally given the task created accurate medication lists only 20% of the time. Data collected from Presbyterian Hospital Huntersville found that hospitalists were able to bring that level up to only 50%.
“We got frustrated with how wrong it was,” explains Ms. Carney, a member of Novant’s original corporate med-rec team.
The system went back to square one, returning nurses to clinical care and using pharmacy techs, now called “medication reconciliation assistants,” around the clock in the ED instead. That’s when the system hit the jackpot: The audited accuracy of the techs, Ms. Carney says, often reaches near 100% and, as a bonus, the system now saves more than $830,000 a year.
Saving time and money
Med rec has been getting hospitals’ attention ever since the Joint Commission made it mandatory in 2006. But as pressure mounts from meaningful use rules and new readmission penalties, med rec is becoming a more significant player in the big league of cost savings.
“Hospitals can expect an absolute 2% reduction in readmission rates if they do medication reconciliation well,” says Jeffrey L. Schnipper, MD, MPH, a hospitalist at Boston’s Brigham and Women’s Hospital. Dr. Schnipper has studied the clinical effectiveness of med-rec programs.
“That may not sound like a lot, but a reduction from an 18% rate to a 16% rate could mean a difference of millions of dollars in Medicare penalties.” At the Novant facilities where pharm techs collect medication histories, the percentage of medication lists that were defective dropped from 80% to less than 10%.
That’s helped the system slash the number of adverse drug events by 75% for a typical year (based on 2007 volumes) from 543 to 136. The system estimates that each averted drug event would have cost about $4,000, for a total savings of $1.6 million. Factor in staff costs of about $800,000, and the system is able to keep the rest.
At Presbyterian Hospital Huntersville alone, the number of adverse drug events fell from 33.6 per year to 8.4, Ms. Carney says, saving more than $100,000 before salary costs were considered.
She notes that the hospitals’ overall return on investment is even higher when you factor in the 15 minutes per admission that doctors no longer have to spend because they can now trust the med-rec information they receive.
Great in theory
Other hospitals are taking different paths to cost savings through medication reconciliation. Researchers at Baltimore’s Johns Hopkins Hospital, for example, make a strong case for investing in an even more expensive nurse-pharmacist team.
In a study, registered nurses at the hospital completed initial inpatient medication lists and compared them to physician-generated histories. The nurses then looked for discrepancies and consulted with a pharmacist if they weren’t sure if a discrepancy was intentional. They then repeated the process on discharge.
The program, which was described in the May-June Journal of Hospital Medicine, showed that 40% of the 563 patients in the study had at least one unintended discrepancy on admission or discharge. Researchers found that 72% of those discrepancies had the potential to harm patients, and they concluded that the program would save the hospital money.
A previous study had estimated that only 0.9% of all discrepancies actually cause harm; assuming that rate, 4.8 of the 531 discrepancies found in the Johns Hopkins study would cause actual harm. Because researchers estimated that each harmful event would cost the system more than $9,300, they concluded that the intervention would avert $44,607 in costs, for a price tag of $17,915.
Lead author Leonard S. Feldman, MD, assistant professor of internal medicine and pediatrics at Johns Hopkins Hospital, says that the study makes a compelling case. But he admits that more data are needed.
“It’s theoretical because we don’t know how many harms would have really happened or been caught later,” says Dr. Feldman.
Challenges in values and data
Proving a negative is the crux of the problem when it comes to demonstrating the value of medical reconciliation initiatives, says Sunil Kripalani, MD, MSc, chief of hospital medicine at Vanderbilt University in Nashville.
“A hospital that invests in better med rec and improved medication safety may not see the benefits if it keeps the person at home after discharge and if there is no adverse drug event,” says Dr. Kripalani. “The hospital may not get a reward for that.”
Hospitals face another challenge in trying to assign a financial value to med-rec efforts: They sorely lack solid data on best practices. A systematic review in the July 23 Archives of Internal Medicine found that out of more than two dozen studies on medication reconciliation, only 10 were randomized controlled trials and only one looked at data from more than one site.
Dr. Schnipper, one of the authors of that review, says that inconsistent data make it hard to say what components of medication reconciliation yield the best ROI. “Some interventions show an impact, some don’t,” he notes. “The studies are too heterogeneous to know why some are more successful than others.”
Hospital and patient variables
And sometimes even the best-laid med-rec plans have a limited impact. A study in the July 3, 2012, Annals of Internal Medicine, for example, found that among 851 patients from Vanderbilt and Brigham and Women’s Hospitals, 50.8% had one or more medication-related problems within 30 days of discharge. But adding a pharmacist, as well as low-literacy aids and post-discharge calls, to the med-rec process did not significantly reduce adverse drug events once patients left the hospital.
Dr. Kripalani, lead author of that study, thinks the negative results stem from the fact that both hospitals studied already had a high standard of care at baseline, including widespread use of pharmacists on the wards. The hospitals also had relatively few study participants with low health literacy.
He suspects that pharmacist-led med rec might have a bigger impact in a hospital that doesn’t already have a robust med-rec program and has more patients with low health literacy. Dr. Kripalani notes, however, that the intervention did increase patients’ confidence with managing their own medications, and it reduced medication discrepancies at the Vanderbilt site.
He also points out that Vanderbilt has since increased its use of pharmacists to perform med rec and to counsel more complicated general internal medicine and cardiology patients.
Emerging models and dollars
While hospitals may struggle to prove the financial return that med-rec programs are delivering, the reality is those programs are here to stay. “In the past, med rec wasn’t paid for,” says Hasan F. Shabbir, MD, chief quality officer at Emory Johns Creek Hospital in Johns Creek, Ga. “But in the new paradigm of shared savings and bundled payments, this will be a cost-effective endeavor.”
ACOs or organizations already functioning like ACOs may wring the most ROI out of medication reconciliation, according to Hans Jeppesen, MD, chief of the hospitalist service at Cambridge Health Alliance in Cambridge, Mass. “ACOs get a certain number of dollars for taking care of patients,” Dr. Jeppesen notes. “There are potential ways to save money: Find ways to simplify the medication list, change medications to less expensive forms such as generics, and reduce the number of adverse events.”
And while data on the cost effectiveness of medication reconciliation remain a little scarce, there’s no shortage of anecdotal evidence pointing to the value of these programs.
Take the patient who came to a Novant ED with what everyone thought was a neurological issue. After the pharmacy tech interviewed the patient, he found that medication compliance issues were to blame for her confused state. That helped avert test orders, an admission, and patient and family anxiety. Even without an agreed-upon dollar figure, it was clearly a strong ROI for both the hospital and the patient.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
Whose job is it anyway?
WHEN IT COMES TO CALCULATING the return on investment of medication reconciliation programs, a big factor is the cost of the staff involved. But determining exactly who should be responsible for med rec varies from hospital to hospital.
One school of thought holds that med rec calls for dedicated staff. If everyone is responsible for medication reconciliation, the thinking goes, nobody really views it as a core mission.
“It becomes an ill-defined team approach where we’re all vaguely responsible, and no one person or role is accountable,” explains Tony Yen, MD, a hospitalist and CMIO at Evergreen Hospital Medical Center in Kirkland, Wash.
At Evergreen, capturing and entering home medications for med rec used to be shared between the ED and floor nurse. But that process, which wasn’t followed consistently, seldom captured all home medications within 24 hours of admission.
Instead, Dr. Yen says, a pharmacy tech now enters patient medications while patients are evaluated in the ED, with a pharmacist confirming the data. The new process is documenting more than 70% of home medications and providing a list that can be electronically reconciled by the admitting physician within two hours of hospital admission through the ED. To provide 24/7 coverage, Evergreen now employs four pharmacy techs to capture medication information in the ED and for elective surgery patients.
“The cost of employing four pharmacy techs,” says Dr. Yen, “is certainly less than the potential cost of delayed or inappropriate care if a patient’s usual medications are not well defined within hours of admission.”
Emory Johns Creek Hospital in Johns Creek, Ga. is taking a different approach, using inpatient nurses to obtain the medication history. For high-risk patients, pharmacy technicians or nurse medication-history specialists are called in for help with med rec. Physicians there also receive med-rec training so they can step in as needed. The hospital has been helped in those efforts by participating in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), a six-site study funded by AHRQ and led by the Society of Hospital Medicine.
Hans Jeppesen, MD, chief of the hospitalist service at Cambridge Health Alliance in Cambridge, Mass., says the system is still trying to determine the best staffing approach to med rec. At a previous job, however, he says that a dedicated med-rec team consisting of a pharmacist and pharm tech were considered, but ultimately deemed too expensive.
Using only pharmacy techs is an affordable option “but they likely require additional training especially if they come from a retail background, says Francie Carney, RPH, head pharmacist at Presbyterian Hospital Huntersville, a Novant facility in Huntersville, N.C. Ideal candidates, she points out, need to be registered with the board of pharmacy, be certified through the pharmacy certification tech board and have two years of experience.
Johns Hopkins Hospital in Baltimore, meanwhile, wants to investigate involving pharmacy students in the med-rec process as a low-cost option, says Leonard S. Feldman, MD, an assistant professor of internal medicine and pediatrics there.
At the same time, some hospitals find that dedicated staff aren’t the way to go, particularly if staff can’t be employed 24/7. At the 208-bed Doylestown Hospital in Doylestown, Pa., hospitalist and informatician Mary Ellen Pelletier, MD, says the hospital used to rely on dedicated nurses for medication reconciliation. But “our med rec nurses were not on weekends or overnight,” Dr. Pelletier points out. “So to focus on quality and 24/7 care, we decided to switch gears.”
The hospital is two months into a pilot whereby patients’ primary nurses do med rec. While it was tough at first to give the nurses one more thing to do, “we have been capturing the list 80% of the time so far and are encouraged,” says Dr. Pelletier. “The doctors are responsible for reconciling the new med list going out the door, and the primary nurse on the floor reviews the meds with the patient at discharge.”