By Megan Maddox, PharmD, BCPS, CDE
Editor’s note: This is an excerpt from the HCPro book Medication Reconciliation: Practical Strategies and Tools for Compliance. Learn more at https://hcmarketplace.com/medication-reconciliation-practical-strategies-tools-for-compliance.
With the widespread implementation of the electronic medical record (EMR) and the ability to trigger that reconciliation gets completed at various stages of a patient’s healthcare encounter, the focus of medication reconciliation has now turned to how to collect the most accurate and updated medication list on our patients on admission or during clinic visits. In addition, organizations are focusing on opportunities to ensure patients are being discharged with the medication list the provider intended. What has been identified over the past decade by healthcare organizations working on med rec is a patient’s medication list is ever changing and the reality is the medication list needs to be reviewed and updated at each healthcare encounter. To do this well, it typically requires dedicated resources that focus solely on collecting medication histories. The issue that healthcare organizations struggle with now is where to get the resources to develop a med rec team that is dedicated to collecting patient medication histories. Bottom line: You need to be creative!
Up until lately, when it was truly identified how inaccurate medication lists are in the EMR, the responsibility of collecting medication histories largely fell on the admitting nurse as one of a dozen tasks that need to be completed in the first couple hours of that patient’s admission. We know nurses can collect an accurate medication list—but the reality is that for the admitting nurse, collecting the medication list, while important, has become a task on a very long to-do list that makes it hard to be a priority when everything on that list is important. What many organizations are realizing is to provide the safest care possible to their patients, it is imperative to have an accurate and up-to-date medication list upon admission so they are strategically looking at what resources are available to do this work and where they can get the biggest return on investment with those resources.
Medication Reconciliation Team Models
Focus on high-volume entry points
When deciding on where to place med rec resources, start by looking at where most of your admissions come from. For many hospitals, admissions largely come from planned surgical procedures or the Emergency Department, so these are prime areas in which to consider having a med rec team collect medication histories. At Sanford Medical Center in Sioux Falls, South Dakota, the initial focus for our med rec team was planned surgical patients who were going to be admitted, because this accounted for a big portion of our daily admissions. Next, we needed to determine how we were going to staff this team and decided to use an interdisciplinary approach that included a specific group of preop nurses and staff pharmacists on the team. This ended up being a great combination because there was one nurse and one pharmacist on the team every day, so both professions were able to work closely together and ask each other questions. The nurses relied heavily on consulting the pharmacists when a medication history didn’t make sense; likewise, the pharmacists utilized the nurses’ preop knowledge of all that goes into getting a patient ready for the operating room when trying to collect medication histories on these patients before they are headed up to surgery. In 2015, this dedicated med rec team of nurses and pharmacists interviewed more than 6,000 patients in our pre-surgical area and on average found more than four discrepancies on every patient’s EMR medication list.
Focus on high-risk patient entry points
Another option to consider for med rec team placement is looking at admission points for higher-risk patients. At Sanford Medical Center in Sioux Falls, once we had established the med rec team in the preop admission unit, we expanded to collecting medication histories in our pre-admission area for cardiac catheterization lab (CCL) patients—knowing these patients typically had long medication lists, complex disease states, and were likely taking high-risk medications. Initially, this area was staffed only by pharmacists who were on the med rec team, but the number of patients being admitted through that area continued to increase, so we followed the same model we had over in the preop area and recruited specific CCL pre-admission nurses to join the med rec team. The team in the CCL pre-admission unit saw more than 5,600 patients in 2015 and on average, found four discrepancies on every patient’s EMR medication list.
Another high-risk area to focus on and a likely high-volume admitting area as well is the Emergency Department. This can be a more challenging population to ensure an accurate medication history is completed because the patients can go anywhere and may or may not enter the hospital through a venue that lends itself to being staffed with a member of the med rec team. There are different approaches to getting this set of patients’ medication history collected. One option is to assign med rec team members who are responsible for collecting medication histories on direct admits and these team members carry spectra link phones so they can be notified by the nurse who is receiving the direct admit. Another option is to utilize your EMR and give med rec team members a patient list that identifies newly admitted patients who still require their medication lists to be collected and updated.
Utilizing the EMR and designated criteria to stratify which patients need med rec
As noted earlier, many organizations have frontline nursing staff collecting medication histories on admission to the best of their ability and thus, it is completed in a timely manner. Then when able, a med rec team member or pharmacist re-interviews the patient to ensure the medication list is up to date and accurately reflects what the patient is taking, and, if there are any changes, contacts the provider who reviewed and ordered the home medications. To ensure the high-risk patients are seen by the med rec team or pharmacists as soon as possible, healthcare organizations are utilizing their EMR to help stratify and determine who the high priority patients are and the order in which med rec should be completed on patients based on predetermined factors.
Sanford Medical Center in Fargo, North Dakota, is utilizing its EMR to prioritize patients that need pharmacist-completed medication histories with the following factors outlined.
The med rec scoring list assigns a score, allowing you to prioritize your work. The highest possible score is a “4”:
- 1 point if the patient has >/= 10 home medications on their list
- 1 point if the patient’s med list is marked something other than complete
- 1 point if the patient is on a high-risk/low therapeutic index medication (immuno-suppressants, insulin, anticoagulation, etc.)
- 1 point if the patient resides in a nursing home
Pharmacy technician or pharmacy intern collect medication histories
Many healthcare organizations are thinking outside the box and paving new roads regarding who can be part of the med rec team and collect medication histories. Because resources are limited and organizations want to be cost effective, many have started to employ pharmacy technicians and pharmacy interns as part of their med rec team. Both of these are excellent options so long as this is allowed by the Board of Pharmacy in your state and appropriate pharmacist oversight is in place. Pharmacy technicians are very knowledgeable on names of medications and what strengths they come in, which can be very helpful when interviewing patients.
In addition, they can make phone calls to other resources such as community pharmacies, physician offices, nursing facilities, home health nurses, and others to clarify any questions regarding medications to ensure the list is as accurate as possible. A recent study involving pharmacy technicians, working under pharmacist supervision, found that they completed admission med rec on 1,797 patient encounters and identified 1,748 discrepancies with the most common discrepancy type being omission of medications (Sen, S., Siemianowski, L., Murphy, M., & McAllister, S. C., 2014). Involving pharmacy interns on the med rec team is an excellent opportunity to ensure your patients’ medication lists are up to date and, in addition, helps these future pharmacists sharpen their medication history taking skills and the ability to utilize their clinical knowledge to ask questions to the supervising pharmacist when something on the medication list doesn’t make sense.
Characteristics of good med rec team members
If your organization has chosen a med rec design that involves a designated team collecting medication histories, the following characteristics can be beneficial when selecting those team members: detail-oriented, excellent communication skills, team player, problem solver, good at time management, strong investigator. Many times, these individuals have to call numerous pharmacies, physician offices, nursing homes, etc., to answer questions or spend time digging into the patient’s chart to find answers. Getting the right people on the team is important because the impact on patient safety is significant.
Admission vs. discharge
Another common question that comes up when discussing med rec is: Where is the best place to put your resources—on admission or on discharge? This is a really challenging question—and the best answer is both—but this typically is not realistic.
Sen, S., Siemianowski, L., Murphy, M., & McAllister, S.C. (2014). Implementation of pharmacy technician-centered medication reconciliation program at an urban teaching medical center. American Journal of Health-System Pharmacy 71:51–6.