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Medication reconciliation done right

September 2009

Published in the September 2009 issue of Today’s Hospitalist

WHEN NOVANT HEALTH decided to tackle medication reconciliation, its physicians wanted to exceed the requirements established by the Joint Commission in 2005.

That year, the commission began requiring hospitals to “accurately and completely reconcile medications across the continuum of care.” But Novant decided to expand on “and improve “the concept of medication reconciliation in two key ways.

First, the health system wanted to make sure its medication lists were accurate, which is difficult given the limited time that nurses and physicians have to research patients’ medication regimens. Second, Novant wanted to continue the reconciliation process beyond patient discharge, an approach that many providers don’t incorporate. [test – legacy server]

To meet both those goals, Novant “which has 10 acute-care hospitals and 373 physician practices in Virginia, North Carolina and South Carolina “had to look beyond its physicians and nurses. It enlisted pharmacists in the struggle to address the thorny issue of medication reconciliation.

A premium on accuracy
One of the problems with designing a sophisticated medication reconciliation process is that there is little guidance in the medical literature or even the Joint Commission requirements. “Medication reconciliation is poorly defined,” says John E. Gardella, MD, a hospitalist and vice president for clinical improvement in Novant Health’s Charlotte Region. “It’s a nebulous process in the sense that best practices are as yet undefined.”

As a result, medication reconciliation processes ” including those that had been put in place at Novant ” were often less than ideal. That left many physicians skeptical about the whole concept of medication reconciliation. “In the opinion of many of our physicians, our medication lists were frequently inaccurate and not worth a damn,” Dr. Gardella says.

After picking up some basic principles at a session held at the Society of Hospital Medicine annual meeting in 2006, Dr. Gardella thought a good starting point would be to test the accuracy of the medication lists that Novant’s nurses were creating. To do that, the health system asked clinical pharmacists to do medication lists for patients who had already been admitted and screened by nurses. When Novant compared those two lists, the discrepancies were eye-opening.

Some problems were minor, such as a missed vitamin or topical agent. “But we were also finding errors that could have caused harm,” Dr. Gardella explains, “with therapies like anticoagulants and insulin.”

To solve these problems, the medication reconciliation team looked at technology-driven solutions that would, for instance, scour commercial pharmacy databases to create a list of patients’ medications. But the Novant team concluded that even those lists needed the attention of a live human being.

Cutting potentially harmful errors
Novant pilot tested a program in June 2008 in which pharmacy techs in the ED interviewed new admissions and compiled pre-admission medication lists. Novant quickly realized that the lists generated by the pharmacy techs were not only more accurate but were drastically reducing the number of potentially harmful errors. By the fall of that year, the pilot program became permanent.

On average, the pharmacy techs see four patients an hour, depending on how many medications the patients are taking. At Presbyterian Hospital in Charlotte, three full-time techs provide 24/7 coverage weekdays. (On weekends, nurses generate the admission med-rec forms.)

Dr. Gardella is quick to emphasize that the nurses were doing a credible job, given their time constraints and conflicting responsibilities. But the pharmacy techs have more time to research the medication history.

“The pharm techs go to all of the data sources, including commercial pharmacies, relatives or primary care physicians,” he says. “That’s something physicians and nurses just don’t have time for.”

Putting pharm techs in charge of creating medication lists, he adds, reduced drug errors that had the potential to cause moderate or serious harm by 89%. In the old model, just over 13% of the errors on the pre-admission medication lists were judged potentially harmful. That figure has dropped to 1.5% for the pharm tech lists.

There have also been instances in which a pharm tech’s history has helped physicians nail down a diagnosis. It was a pharm tech, for example, who discovered that a patient admitted with hypercalcemia and altered mental status was taking a vitamin D preparation her nephrologist had given her and a calcium and vitamin D preparation prescribed by her primary care physician. The tech helped identify the correct diagnosis: vitamin D intoxication.

The initiative has been so successful that Novant is rolling the program out to some smaller hospitals. Dr. Gardella says the program is efficient even for smaller 100-bed hospitals, although not necessarily on a 24/7 basis. Post-discharge surveillance While many hospitals confine their medication reconciliation efforts to the inpatient arena, Novant wanted to add a post-discharge component.

The health system created the Safe Med program to conduct post-discharge medication reconciliation. Safe Med pharmacists call medically complex patients who have been recently discharged and ask if they are having any problems with medications, if they are taking their medications properly or if they have any other issues. When the pharmacists discover a problem, they get in touch with the patient’s PCP, not a hospital physician.

The pharmacists, who are PharmDs with some support staff, focus on patients who are over 65, taking five or more prescription medications, and have a diagnosis like heart failure, diabetes or COPD.

Since they began making patient phone calls in January 2007, the pharmacists have been able to reduce 30- and 60-day readmission rates and bouncebacks to the ED. (See “Post-discharge calls help slash readmissions,” below.) When pharmacists can’t talk to patients, they mail patients generic information about their medications and give them a toll-free phone number they can call with questions.

Building a business case
Dr. Gardella says that although both aspects of Novant’s medication reconciliation initiatives are widely considered a success, it’s difficult to make a solid business case for either. While the Safe Med program has reduced readmissions, for example, it’s hard to attribute exact cost savings.

“It’s difficult to translate these initiatives into a return on investment,” Dr. Gardella says. “We know that the pharm techs are providing more accurate lists, but how many inaccuracies would trickle down to a patient and cause an injury? We don’t know, and there’s no good information in the literature.”

Nevertheless, he says, the program has the support of not only senior Novant leadership but physicians and other providers. “There was a lot of skepticism on the part of the medical staff that this was just going to be an exercise to satisfy the Joint Commission,” he points out. “But by engaging pharmacists, we made med rec a safer process.”

Edward Doyle is Editor of Today’s Hospitalist.