IHI Expedition Expedition: Improving Medication Safety from the - PowerPoint PPT Presentation

April 9, 2015 These presenters have nothing to disclose IHI Expedition Expedition: Improving Medication Safety from the Patient’s Perspective Session 4: Medication Reconciliation Anne Myrka, RPh, MAT Joelle Baehrend

Today’s Host 2 Akiera Gilbert Project Assistant Institute for Healthcare Improvement

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6 Expedition Director Joelle Baehrend Director Institute for Healthcare Improvement

Today’s Agenda 7 • Welcome & Introductions • Action Period Debrief • Medication Reconciliation – Anne Myrka, RPh, MAT • Action Period Assignment

8 Expedition Sessions Session 1 – Improving Polypharmacy Faculty : Robert Feroli, PharmD and Amanda Brummel, PharmD, BCACP Session 2 – Health Literacy and Medication Safety Faculty : Gail Nielsen, BSHCA, FAHRA Session 3 – Improving Medication Adherence Faculty : William Strull, MD Session 4 – Medication Reconciliation Faculty : Anne Myrka, RPh, MAT Session 5 – Safe Management of Newly Released Anticoagulants and High-Alert Medications Faculty : L. Hayley Burgess, PharmD

Action Period Assignment Report Out Assignment: Have a conversation with a patient at discharge and ask: (1) Do you know what the medication is for? (2) Can you obtain the recommended medication? (3) Do you know about the possible side-effects? Report out: What did you learn? Please chat in any reflections on the exercise.

10 Survey Results - Current State Medication Reconciliation: My hospital has a process to reconcile medications at admission and all transitions of care: • Do not know current status of this practice: 5% • Do not currently have this practice in place: 0% • Have a process that supports this practice: 50% • Process is reliably applied: 15% • Need further clarification on this practice: 30%

11 Faculty Anne Myrka, RPh, MAT Pharmacist IPRO

Medication Reconciliation Anne Myrka, RPh, MAT IPRO April 9, 2015

Objectives  Define medication reconciliation as a component of medication management  Discuss on-going challenges of medication reconciliation  Describe how technology can help improve medication reconciliation  Describe the role of patients/families/caregivers in medication reconciliation 13

Poorly executed med rec. 14

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Medication Management, Medication Reconciliation and On-going Challenges 16

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Medication Management  Medication History  up-to-date listing of all prescription and over-the-counter medications, herbal supplements and vitamins  Medication Reconciliation  comparison of one or more medication lists to new one ● resolve discrepancies ● identify and resolve medication related problems  should occur whenever there is a care transition, or change in medications or diagnosis  Medication Adherence 18

Medication Reconciliation Challenges  In general, the creation and transition of an accurate medication list remains a challenge for every care setting  Systems lack the ability to document rationale for changed medications leaving next provider to “guess” whether changes where intended or unintended 19

Medication Reconciliation Challenges  Lack of standardized process and clear ownership  Communication failures  Coordination gaps  Non-formulary medications and therapeutic interchanges  Lack of standardized medication list “source of truth” document  Failure to identify and resolve medication related problems  Failure to identify multiple existing sources for medication lists 20

Medication Reconciliation Challenges  No one person is accountable for med rec from ED to admission and there are always discrepancies  The best possible medication list is not attempted until discharge so this is when most problems are found and require resolution  Med rec is time consuming, a comprehensive med rec can take 60 minutes or longer  Hospitals using multiple EHR and/or paper based systems are error prone (e.g., EHR in ED is not the same system as the inpatient side, the pharmacy system does not interface with EHR, etc…) 21

Medication Reconciliation: Technological Solutions and Other Interventions 22

Medication Reconciliation Hospital Interventions  Identify an accountable structure and support for med rec throughout the continuum of patient hospital stay from admission to discharge with multiple layers of verification  Use pharmacist & physician champions that can help address problems  Use IT solution where able but don’t wait for “the next update”  Educate staff regarding avoidance of undesirable effects caused by IT  Optimize use of electronic communication capabilities  Avoid using system that is driven by paper or requires transcribing from one system to another 23

Medication Reconciliation Hospital Interventions  Create EHR system fixes for documenting rationale for medical decisions and ensuring such documentation appears on the discharge summary  Create the ability to scan documents that were presented by the patient/family/caregiver into the EHR  Use multiple sources to identify medication lists for reconciliation 24

Background : Transitions between healthcare settings are vulnerable times for patients. Medication discrepancies associated with transitions are particularly problematic. Combining medication history information from various sources may improve the completeness and accuracy of medication information, leading to improved safety outcomes. Objectives: To evaluate the accuracy and completeness of patients’ medication history information at the time of hospital admission from 3 different electronic sources, and to assess the additive value provided by each source. Study Design: Case study of admissions to 2 community hospitals in upstate New York between September 2010 and April 2011. Methods: Medication history information was obtained from the hospital’s electronic health record (EHR), a commercial medication database, and a community wide health information exchange web portal. Information from the sources was compared with the gold standard medication list generated as part of the routine intake medication reconciliation process. Results: We studied 858 patients, who collectively were on 7731 medications. The hospital EHR captured 80% (n = 6152) of medications accurately, the commercial medication database captured 45% (n = 3464) accurately, and the community portal captured 37% (n = 2838) accurately. When all 3 sources of medication information were pooled, medication accuracy increased to 91% (n = 6997). 25 Am J Pharm Benefits. 2014;6(5):217-224

Medication Reconciliation Hospital Interventions  Obtain the most accurate medication history - interviewing tools are available:  Certification for obtaining the best possible medication list: Society of Hospital Medicine MARQUIS toolkit: Self Study guide: http://tools.hospitalmedicine.org/resource_rooms/imp_guides/ MARQUIS/MARQUIS_Certification_Simulation_Case_1_Final.p df  Optimize use of pharmacists 26

Allocation of Scarce Resources  Clinical Pharmacy Services (CPS)  Numerous studies have shown improved economic and health outcomes when CPS is incorporated within collaborative patient care team  CPS should be used for patients who are at high risk due to medications, location or condition  Resolving medication discrepancies is only the tip of the iceberg…pharmacotherapeutic interventions improve patient outcomes even unrelated to ADEs  Challenge: cost of pharmacist is a perceived barrier  ROI calculations can be found in MATCH and MARQUIS toolkits Chisholm-Burns MA,, et al.. Med Care. 2010;48:923-33. Chisholm-Burns MA., et al..Am J Health-Syst Pharm. 2010; 67:1624-34 27

Profiling Patient Risk for Intervention  Elderly  On high risk/high alert medication  ISMP High Alert Medication list  Institute for Healthcare Improvement High Alert drug classes:  Anticoagulants, opioid analgesics, insulin, sedatives  High risk drug classes for nursing home patients:  NSAIDs, digoxin, insulin, antipsychotics, sedatives/hypnotics, anticoagulants  Budnitz, et al, 2011: anticoagulants, antiplatelets, insulin, hypoglycemics, opioids  High risk location/transfer (i.e. nursing home to hospital, ICU to floor)  Health history indicates high risk Boockvar KS, et. al. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009 February ; 18(1): 32 – 36. 28

Medication Reconciliation and Patient/Family/Caregiver Engagement 29