By Jennifer Lefeber, RN, BSN
“We cannot do everything at once, but we can do something at once.” ~Calvin Coolidge
This advice, coming from the 30th president of the United States, seems especially appropriate for rural and critical access hospitals looking to leverage information technology in their organizations to improve clinical care.
At Myrtue Medical Center (MMC), a 25-bed critical access hospital (CAH) in Harlan, Iowa. the quality improvement team had been contemplating how information technology could help the hospital deliver improved care to its patients. Even though the government’s electronic health records (EHR) incentive program had not yet been unveiled back in 2007, Myrtue’s Quality Improvement Team recognized the value of electronic health records that included advanced functionality such as computerized provider order entry. As a result, strategic planning focused on implementing such a system.
The problem, however, was that EHR adoption was, indeed, a daunting challenge for a small healthcare organization such as Myrtue. The difficulties associated with EHR implementation at small hospitals became even more obvious as the government’s Meaningful Use program was rolled out across the country in 2009. Even with additional help available through programs such as the government’s Regional Extension Centers (RECs), many small hospitals are struggling to put together the financial and human resources necessary to bring EHRs to fruition.
Consider the following: As of September 2012, critical access hospitals were falling behind the pack considerably in terms of EHR adoption. Only 18% of the 1,164 CAHs in the country had attested to Meaningful Use, even though the majority of them were enrolled in a REC program to aid them with EHR adoption. By comparison, 73% of larger hospitals had received EHR incentive program payments according to a data brief from the Office of the National Coordinator for Health IT (ONC Data Brief, 2012). Iowa’s hospitals, however, were implementing systems at a quicker pace than the national average, as 86% of the hospitals that signed up with the REC attested to Stage 1. As of July 31, 2013, 65% of CAHs and small, rural hospitals in Iowa had achieved Meaningful Use. Specifically, 62% (approximately 822 of 1,332) of CAHs and 77% (approximately 293 of 383) of small, rural hospitals (those generally with fewer than 50 staffed beds) had attested to Meaningful Use of EHRs, according to Susan Brown, health IT director at Telligen, the West Des Moines, Iowa-based company that administers Iowa’s REC.
The sweeping organizational change that often accompanies the move to EHRs could prompt small healthcare organizations to become overwhelmed and enter into a period of inertia, a common response that both organizations and people face when confronted with long-term, complicated projects.
At Myrtue, we chose to adhere to Coolidge’s sage advice. Instead of doing everything, we decided to do something to move healthcare information technology adoption forward.
“We knew increased use of technology was going to be mandated in the next three to five years and wanted to prepare for this both financially and in a way that would have an impact on patient safety,” said Kristy Feldman, RNC, nursing supervisor at Myrtue Medical Center. “The current EHR system was meeting needs for clinical assessments and other documentation needs, but there seemed to be something missing. The team knew that the budget would be limited and wanted to be able to make progress and quickly realize a return on our investments and efforts. We wanted to implement something that the entire team (nurses, pharmacists, medical practitioners, and ancillary staff) could utilize.”
Finding a Cause
The first order of business was to identify a specific process that could be improved through use of health information technology (HIT) and that could help the hospital quickly realize patient care and safety benefits in a tangible way.
After evaluating a variety of clinical challenges, hospital leaders decided to focus their attention on medication management—more specifically, the medication reconciliation process. The hospital had just experienced a couple of medication reconciliation-related incidents related to patients’ home medications being held while they were inpatients and not restarted on dismissal. We knew we needed a way to track patients’ medications across the continuum. The quality improvement team also wanted to move the medical practitioners at MMC into a lead role with medication reconciliation.
By zeroing in on just this one challenge, the hospital could make significant quality and patient safety improvements in a defined area.
According to a variety of industry reports, medication management is a problem well worth addressing. For example, the Institute of Medicine’s Preventing Medication Errors (2007) points out that the average hospitalized patient is subject to at least one medication error per day; making such errors the most common patient safety errors (Bates et al., 1997). Perhaps even more disconcerting, more than 40% of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients (Rozich et al., 2004). Of these errors, about 20% are believed to result in harm.
Certainly, these safety concerns prompted the Institute for Healthcare Improvement (IHI) to include medication reconciliation as one of the interventions in the 5 Million Lives Campaign, and the concerns are likely why both the Institute of Medicine and The Joint Commission have identified it as a priority. In fact, medication reconciliation has been incorporated into National Patient Safety Goal #3, “Improving the safety of using medications.” The goal requires that organizations “maintain and communicate accurate medication information” and “compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order to identify and resolve discrepancies” (The Joint Commission, 2014).
When implemented correctly, medication reconciliation can help meet these patient safety goals and reduce errors such as:
- inadvertently omitting a medication during a hospital stay that a patient was taking at home
- failing to ensure that home medications temporarily stopped during a hospital stay are restarted when the patient is transferred or discharged
- duplicating medication orders either because the patient may already be taking the drug or due to confusion between brand and generic versions of a drug or formulary substitutions
- prescribing incorrect dosages (Institute for Healthcare Improvement, 2011)
- not fully realizing interactions and contraindications
- allergy-related errors
Process Is Not So Simple
While medication reconciliation has the potential to significantly reduce errors, frustration ensues when healthcare leaders realize that the process itself falls squarely into the not-as-easy-as-it-looks category.
Consider the following: To ensure that patients are receiving and taking the right medications, healthcare organizations need to ensure that the following five steps are implemented: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient (Barnsteiner, 2008). In addition, medication reconciliation needs to occur at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. The process, however, is complicated by a number of factors.
“The sources of information on medications are scattered in a number of different places,” says Frank Federico, RPh, director of the Institute for Healthcare Improvement. “The physician’s office has records, but they are difficult to keep current, especially if the patient has prescriptions from many specialists. The pharmacy has records, but only for the prescriptions filled there. The hospital medical record may be incomplete, considering that most care is administered in the ambulatory setting. And many patients can’t say what they are taking because they are cognitively impaired or their drug regimen is complex.”
Certainly, many of these complications contributed to the medication reconciliation challenge at Myrtue. The small hospital, however, also struggled with a variety of other circumstances including that many patients at Myrtue simply remembered drugs by visual appearance (blue blood-pressure pill), mistakenly thought their physician memorized what they were taking, or assumed that the list was readily available 24 hours a day. Even more critical was gathering a comprehensive home medication list for emergency room patients. In this fast-paced department, decisions need to be made quickly, and having instant access to a home medication list was a real need.
In addition, because the hospital was still utilizing handwritten orders for all inpatient medication orders, clinicians sometimes had difficulty deciphering the prescriptions at the point of care. In addition, charts sometimes were not updated when clinicians need to reconcile medications. A common admission order when addressing home medications was “continue medications as at home.” This, of course, was not meeting the needs of the patients.
Perhaps most troubling was the fact that clinicians sometimes had to work without being able to immediately consult with a pharmacist. At Myrtue, the hospital pharmacy was open only during business hours during the week and closed on Sundays. Clinicians, therefore, often faced the medication reconciliation process without being able to pull a pharmacist in to consult.
“Not having access to a true source for a medication history was frustrating for all clinicians involved. This was complicated by the fact that access to a pharmacist to collaborate with about interactions and dosing was not available 24 hours a day,” Feldman said.
Seeking the Truth
Myrtue leaders decided that they needed an electronic medication reconciliation solution that would help them gain access to one “source of truth” across the care continuum from the patient’s home, to the outpatient clinics, to the hospital. Leaders, however, wanted to get a system they could not only afford, but one that could meet their unique needs.
The critical access hospital needed a system that could:
- Stand on its own and generate positive results, with the ability to eventually interface with the base EHR.
- Be customized to meet the unique workflow needs of the small hospital.
- Offer strong formulary support, making it possible not only to provide the right medications, but the ones that would be available in the hospital.
- Serve as a conduit for improved communication among the entire healthcare team—not just as a means for physicians to pull together a medication list.
- Engage the entire care team—nurses, pharmacists, respiratory therapists, physical and occupational therapists, dietary staff, and others—at patient admission and discharge.
- Enhance efficiency in the medication reconciliation process, making the task an easier one for all involved.
- Provide the patient with an accurate, clear medication list on discharge in easy-to-understand language. The list should clearly define new, changed, and discontinued medications.
After evaluating several potential medication reconciliation systems, Myrtue selected a web-based system, MedsTracker, that met all of these requirements. Instead of juggling various paper forms to reconcile medications, caregivers now leverage the web-based system to ensure medication accuracy.
Here’s how it works. When the patient is admitted to the emergency department, the nurse reviews the online medication list with the patient, comparing what already is in the system with what the patient says he or she is taking. If the patient is a nursing home patient, the nurse revises the web-based list to match the list received from the nursing home. If the patient is a direct admit from the clinic or another healthcare facility, the physician might then put in orders that are needed immediately for the admission. The nurse on the med-surg unit would then enter the current medication list into the online system within 60 minutes.
Before the physician reconciles the list for admission to the hospital or discharge to home, the nurse marks the list as ready. As such, the physician has the most current list before making any decisions about reconciliation.
Because the solution ensures that the most recent medication information is available, clinicians can leverage the technology to compile a list of the patient’s home medications; reconcile home, current inpatient, and new medications; order reconciled medications; and create a discharge medication list. The end result is an accurate, doctor-reviewed, medication list that includes both home and inpatient medications is available at every point during the patient’s care.
Identifying and installing a user-friendly system was just part of the journey, though. This was going to be a complete change of practice for the medical practitioner who—up to this point—had written each and every order on paper and had not played a lead role in the reconciliation of home medications across the continuum. One of Myrtue’s initial forays into electronic medical reconciliation was assisting doctors and mid-levels in the move from paper to computer reconciliation. As such, the vendor worked closely with Myrtue staff members to get the system up and running successfully. Support was provided to smoothly transition the process from paper to electronic. Training and go-live support made the entire process a success. Staff felt that they had the tools they needed to safely manage the admission and discharge process from the first day of use.
The process was very efficient, collaborative, and professional. The team provided excellent one-on-one assistance to the MMC staff.
The effort paid off when the system was fully implemented in about six weeks in spring 2008, and results started rolling in immediately. Indeed, the web-based system has changed the medication reconciliation process considerably. The medication reconciliation system enables clinicians to compile a list of the patient’s home medications; reconcile home, current inpatient, and new medications; order reconciled medications; and create a discharge medication list. The solution supports medication history, admission, transfer and discharge with safety checks at each step along with a complete audit trail.
Instead of relying on patient input and paper records, clinicians now can compare the online inpatient medication list with the current home medication list at discharge. In fact, the medications are compared in an easy-to-view screen that shows all of the home medications right next to the inpatient medication. As such, every medication is addressed at discharge and checked for drug-drug and allergy alerts, based on evidence-based clinical data that is continually updated.
“The online medication reconciliation solution has simplified and integrated the admission and discharge medication order process. Home and admission medications are easily identified for accurate prescribing,” said Scott Markham, DO, one of the hospital’s physicians.
Indeed, with the system in place, 100% of discharges were fully reconciled at discharge and 100% of admissions’ medication orders to the medical-surgical department were entered electronically. In addition, the hospital quickly documented reduced errors through integrated safety alerts and a reduction in calls to prescribers for clarification and questions about orders. What’s more, the hospital was named one of the nation’s top 100 critical access hospitals in 2013.
With the system now in use for more than five years, Myrtue has:
- Improved medication history complete rates to 100%.
- Improved accuracy of discharge medication reconciliation; 100% of discharges are done electronically in the ED and for inpatients.
- Improved time to completion for discharge medication reconciliation from 3 hours to 10 minutes or less.
- Transformed discharge reconciliation from a long, hand-written, tedious task to one that is completed electronically in a matter of minutes.
- Reduced phone calls to clarify discharge medications.
- Increased patient compliance with discharge medications.
- Increased communication of discharge medications with other healthcare providers by electronically providing clinics, nursing homes, and home health professionals a copy of discharge medications and instructions for use.
- Developed a medication reconciliation process that helped the hospital meet the medication reconciliation requirements of Meaningful Use Stage 1 (attested in 2012) and positioned them in a way that will assist in meeting Stage 2 requirements.
- Enabled the tracking of prescriptions provided to the patient.
- Provided patients with easy-to-read discharge teaching sheets.
“These results prove that smaller hospitals can, in fact, start to experience the benefits of information technology in quick order. By zeroing in on medication reconciliation, Myrtue has been able to have a positive impact on patient care and safety.” said Dewey Howell, MD, vice president of clinical applications at First Databank, South San Francisco, California. “While various information technology applications are apt to result in various care benefits, focusing in on automated medication reconciliation provides the quick win that smaller hospitals need to jumpstart their overall information technology initiatives.”
Myrtue is now building upon this initial healthcare information technology success. For example, the foray into web-based medication reconciliation laid the groundwork for the hospital to implement computerized provider order entry in 2012. Most important, instead of being stuck in idle, the critical access hospital has already realized the promise of information technology with results achieved through web-based medication reconciliation. Myrtue now is ready to broaden the scope of its efforts to address other clinical challenges as it moves toward a complete electronic health records system.
Jennifer Lefeber has been working at Myrtue Medical Center for 18 years. Currently the ER department manager, she also has clinical IT responsibilities throughout the hospital. Lefeber may be contacted at email@example.com.
Bates, D. W., Spell, N., Cullen, D. J., et al. (1997). The costs of adverse drug events in hospitalized patients. JAMA, 277, 307–311.
Barnsteiner, J. H. (2008). Medication reconciliation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Accessed at http://www.ncbi.nlm.nih.gov/books/NBK2648/
Gleason, K. M., Groszek, J. M., Sullivan, C., et al. (2004). Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. American Journal of Health-System Pharmacy, 61, 1689–1695.
Institute for Healthcare Improvement. (2011). Accuracy at every step: The challenge of medication reconciliation. Accessed at: http://www.ihi.org/knowledge/Pages/ImprovementStories/AccuracyatEveryStep.aspx
Institute of Medicine. (2007). Preventing medication errors. P. Aspden, J. A. Wolcott, J. L. Bootman, & L. R. Cronenwett (Eds.). Washington, DC: The National Academies Press. Accessed at http://www.iom.edu/reports/2006/preventing-medication-errors-quality-chasm-series.aspx
The Joint Commission. National Patient Safety Goals Effective January 1, 2014. http://www.jointcommission.org/standards_information/npsgs.aspx
ONC Data Brief. (2012). Progress towards meaningful use among critical access and other small rural hospitals working with regional extension centers. Accessed at: www.healthit.gov/sites/default/files/databrief05_cahandsmallrural.pdf
Rozich, J. D., Howard, R. J., Justeson, J. M., et al. (2004). Patient safety standardization as a mechanism to improve safety in health care. Joint Commission Journal on Quality and Patient Safety, 30(1), 5–14.