Electronic Medication Reconciliation - Improving patient safety through e-medicine admission and discharge management

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Aaron Jackson
Middlemore Hospital
(3/11/10, Illott, 3.00)

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  • Give brief definition of Med Rec Key players CMDHB QIU/Pharmacy, WDHB, hA, Orion Healt and SMMP as the sponsor
  • Start with a pt story, not a dramatic case with terrible errors and pt harm… Patient story - 72 yrs old, multiple recent hospital admissions, struggling at home Problems - Cardiovascular – (Unstable BP, heart failure, AF), Diabetes (Type 2), Decreased mobility and falls, Osteoporosis Recent medication changes following a visit to the GP…...
  • Collapsed Sunday night, suspected MT (NSTEMI) Med History prior EDS, multiple sources used inconsistently Pt takes 10 of 13 meds prescribed by GP, 4 intermittently (scared of warfarin, frusemide toilet all night, BP meds feel tired, dizzy 5 times overdose of Cilazapril (5mg rather than 0.5mg) Recharted atorvastatin – Stopped in prior admission muscle pain, GP restarted (continued script) 13 prescribed meds Cardiovascular (4) Diabetes (1) Diuretic (1) Lipids (1) Bones (2) Pain (3) Antibiotic (skin infection) (1)
  • CCU Medical ward 3 charts in 4 days, multiple changes Admission meds stopped, changed, withheld. New meds started, when? By whom? Some will continue on discharge, others may not Reasons for changes not documented, discussed on the ward round. Pharmacists ask questions, communicate via pager, sticky notes the med charts, entries on the clinical notes (never read). Only major issues escalated, minor ones often missed (often significant for the patient – bowel meds, eye drops, inhalers..)
  • Free text vs coded selection – poorly managed. Difficult to do the right thing CDs printed not triplicate scripts (no pain relief on discharge – Pt suffers)
  • The infamous ‘50 character limit’ debarcle RSD standard, certain fields truncated at 50 characters, admission med list transposed with discharge med lists EDS optimization collaborative with WDHB - Improve quality of information as care is transferred 1 0 to 2 0 Purpose Irrelevant info, inaccurate info, need for an executive summary (what is the purpose of the EDS?) Focus and recommendations – improve quality, content and format EDS appears scrambled, but when introduced GPs loved it!
  • Omissions or inaccuracies perpetuated during the hospital stay and longer if not identified and corrected, error replicated on readmission Summarize each boxes issues: Patient confused GP confused – error transfer, what meds are they/should they be taking now. Reluctance to change hosp clinicians meds…Just want to know what in, what home, what changed and why WWWW Pharmacist confused – prior meds no longer prescribed? Doses changes, new meds which the patient doesn’t seem to know about Outpatient clinic 6 weeks later – what has happened since patient discharged, look to the discharge EDS for info… We are failing our most at risk patients Key Issues: Admission Access to medication records after-hours The art of taking an accurate medication history being lost? Omissions or inaccuracies perpetuated during the hospital stay and longer if not identified and corrected Transfer Discharge RMO time, cut and paste, shortcuts EDS - major bottle neck for discharging pts, time pressure Transfer of care to the GP EDS key interface with primary care Quality of the EDS Incomplete scripts, unable to dispense critical medications
  • Extent of problem – why invest so much time, energy and resource?
  • ADE - harm $ - LOS, 9.1 million for CMDHB Errors occurred across care boundary's
  • A Primary Care perspective – Not just a secondary care issue Reinforces earlier slide of GP issues WWWW
  • How can we reduce our error rate? MR – The 3 CCC’s. Playing detective….. Pharmacists essentially takes a more accurate med history, ‘the little round blue ones with a cross…..throw brand names at the patients to job their memory
  • Forms stored at the bedside with the chart Define discrepancy – unintended/unintended difference Pink zones, non med information 2006, 50% of wards, 30% admissions, 86% reduction in errors (unreconciled discrepancies) Becoming part of the culture, business as usual
  • Drs undervalue process, too busy, need to create an incentive, please reconcile…Additional rather than core business GP questions formed the basis of our problem statement, engaged Orion to design the solution
  • CMDHB & WDHB collaborative, supported by hA and Orion (Vendor) Development SMT template types for key stages of the MR process, stored in CDV P1 (hybrid) – Mar this year Pilot ATR, Burns, Plastics (CMDHB), ATR (WDHB) P2 go-live Dec (Orion reps in the room)
  • All clinicians / pharmacists can initiate process flexible Import medication sources, Intro TestSafe Nov Build a list, keep, discard – take to bedside, talk to patient Duplicates identifies, must recent data displays Save and reconcile …., print, stored in CDV, copy in clinical notes, future reference (current and subsequent admissions) All users can create MHF
  • Supportive information – not just medication list Most useful – Dr alert, Pharmacy details Can printed, filed in notes
  • Reconciliation within 24hrs… Med prior to admission + meds started after admission Compare with current Medchart - Same or different Differences – intended/unintended Intended - If documented in notes/discussed on the round, Updated with reason 3 discrepancies requiring followup Phase 1 - hybrid
  • Mandatory reasons stopped/changed/new, forcing functions – do the right thing Captopril intended - stopped Alendronate unintended – Omission/Error, confirm chart updated Simvastatin – intended – changed, presented with only simvastatin formulations
  • Stored on CDV, printed as a reference, stored with the chart
  • Transfer Medical Ward to AT& R – business process stipulates when (high risk handoffs ICU/CCU ward. Ward to rehab…) Information flows, track changes over time Alendronate listed as preadmission med Changes to meds identifiable
  • Information flows Validation, confirmation steps. Pharmacists involved in preparing info for Drs, Engage Drs, incentive, pre-prepare EDS prior to discharge, save time, inprove accuracy
  • PDF functionality (EDS optimization) – pdf + structured data (slightly different GP view) Change status, traffic light, new - Intro drug search, generic + brand, coloured by subsidy, 3 characters part name form, ‘sim 10’ Cant cut and paste Succinct summary WWWW EDS bottleneck, No MR, no MR table Push vs pull
  • EDS focus in a complete list of meds on discharge, not just scripts Can not automate YC generation, patient centric, ultimate aim to improve safety – store on the fridge Bolded brand names + synonyms How many and when to take Whats it for What SE to look our for Change status, new changed, unchanged and stopped – read with EDS Print PILS
  • Change status prints on scripts Extremely positive feedback from community pharmacist. Dispensing hospital scripts blind for years
  • Improving the quality of medication information as care is transferred Checkpoints to validate med info at key handoffs The MR Cycle, FP, chronic disease, complex medication regimens, frequent changes to meds GPs can now reconcile their records
  • Familiar tools for our clinicians, training/implementation P1 aligned with paper based process/Pink Form. Leverage existing process, incremental change P2 Testsafe import, electronic reconciliation, improve workflow efficiency, reduced duplication, validation steps, YC, Fully auditable via UI, track changes over time (outward looking to primary care) ALSO performance KPIs, process outcomes measures
  • Improved multidisciplinary acceptance, engagement, still some way to go Pharmacists more involved in the discharge documents SMMP audit – process measures, MR rates, discrepancy rates ADE – outcome measures
  • Resource. Need to prioritise Bedside capture. Need for wireless devices. P2 print MHF imported meds take to bedside Engaging Drs – pull for pharmacist support. P2 no MR, No MR table
  • Electronic Medication Reconciliation - Improving patient safety through e-medicine admission and discharge management

    1. 1. eMR - Electronic Medication Reconciliation Improving patient safety through e-medicine admission and discharge management
    2. 2. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey Patient
    3. 3. Admission Transfer 1 Transfer 2 Discharge
    4. 4. Admission Transfer 1 Transfer 2 Discharge
    5. 5. Admission Transfer 1 Transfer 2 Discharge
    6. 6. GP Pharmacy Outpatient Clinic
    7. 7. GP? Pharmacy? Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic? The Patient Journey Patient?
    8. 8. Overview <ul><li>What is the extent of the problem? </li></ul><ul><li>What changes can we make to achieve our aims? </li></ul><ul><li>Medication Reconciliation (MR) defined </li></ul><ul><li>Paper-based MR. Defining the MR process </li></ul><ul><li>eMR - Embedding MR processes within our IT systems </li></ul><ul><li>eMR Pilot - Phase 1 & 2 </li></ul><ul><li>How will we know if we have made an improvement? </li></ul><ul><li>Challenges and lessons learnt </li></ul><ul><li>Looking ahead </li></ul>
    9. 9. What is the extent of the problem? <ul><li>Aim: A substantial reduction in medication errors and adverse drug events (ADEs) </li></ul><ul><li>Adverse events in NZ - Peter Davis study (2001) </li></ul><ul><ul><li>13% of hospitalised patients suffer adverse drug events, which are highly preventable </li></ul></ul><ul><ul><li>Cost ~$13,000 per adverse drug event </li></ul></ul><ul><ul><li>NZ healthcare system – 4500 preventable ADEs per annum, or $58 million per annum….. </li></ul></ul><ul><li>Poor communication of medication information at transition points is responsible for more 50% of all medication errors, and 20% of all ADEs.... </li></ul><ul><ul><li>Errors of omission </li></ul></ul><ul><ul><li>Errors of commission </li></ul></ul><ul><ul><li>Transcription error </li></ul></ul><ul><li>Counties Manukau DHB </li></ul><ul><ul><li>ADE rate is ~20% (IHI Trigger Tool) Or 1:5 patients are harmed by our medication processes </li></ul></ul><ul><ul><li>MR baseline audits (2006) - 2.7 admission medication errors per patient </li></ul></ul><ul><li>Waitemata DHB </li></ul><ul><ul><li>EDS documents with at least 1 error - General Medicine 43%, AT&R 25% </li></ul></ul><ul><li>Threatens confidence in our healthcare system.... </li></ul>
    10. 10. What is the extent of the problem? <ul><li>Online GP questionnaire (Harbour PHO) </li></ul><ul><li>Concerns </li></ul><ul><ul><li>Inaccurate information </li></ul></ul><ul><ul><li>Irrelevant information </li></ul></ul><ul><ul><li>Poor formatting </li></ul></ul><ul><ul><li>Insufficient information relating to follow-up requirements </li></ul></ul><ul><li>Recommendations. Improve: </li></ul><ul><ul><li>Content </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Relevance </li></ul></ul><ul><li>David Hopcroft, Jill Calveley ‘What primary care wants from hospital electronic discharge summaries’ New Zealand Family Physician Journal, Volume 35 Number 2, April 2008 </li></ul>
    11. 11. What changes can we make to achieve our aims? <ul><li>Medication Reconciliation defined (SMMP): </li></ul><ul><li>“ The process to collect, compare, and communicate the most accurate list of all medicines that a patient is taking, together with details of any allergies and/or adverse drug reactions (ADRs) with the goal of providing correct medicines for a given time period at all transition points” </li></ul><ul><li>Pharmacist led MR is one of the most effective strategies in reducing medication errors and adverse drug events </li></ul><ul><li>Pharmacists typically identify: </li></ul><ul><ul><li>More medications for patients, more medication doses, dosage schedules, significantly more discrepancies…. </li></ul></ul><ul><li>Paper-based MR on admission (2006) – ‘Think Pink’ </li></ul><ul><ul><li>Pharmacist led initiative – Aim ‘to half medication errors’ </li></ul></ul><ul><ul><li>Formal process – Supporting forms, policy and procedures </li></ul></ul><ul><ul><li>Defined roles & responsibilities </li></ul></ul><ul><ul><li>Check points in the patients journey to confirm current medication list & validate recent changes in therapy </li></ul></ul><ul><li>MR is about talking to patients about the medications they are taking. Not just what is prescribed or has been recently dispensed </li></ul>
    12. 12. Paper MR - defining the process
    13. 13. Paper to electronic - Transitioning <ul><li>Limitations of paper-based MR: </li></ul><ul><ul><li>Focused on admission only, difficult to track changes over time </li></ul></ul><ul><ul><li>High quality medication information documented did not flow on discharge </li></ul></ul><ul><ul><li>Few incentives for juniors Drs to engage in the process </li></ul></ul><ul><ul><li>Resource intensive </li></ul></ul><ul><li>Our objective: </li></ul><ul><ul><li>To improve the quality of medication information communicated between secondary and primary care to improve patient safety </li></ul></ul><ul><li>How do we answer the following questions for GPs & their patients? </li></ul><ul><ul><li>What medications did the patient come in on? </li></ul></ul><ul><ul><li>What medications did they go home on? </li></ul></ul><ul><ul><li>What changed? </li></ul></ul><ul><ul><li>And Why? </li></ul></ul><ul><li>The need to embed MR processes within our EDS software was identified to facilitate MR on discharge and promote the safe transfer of care. </li></ul>
    14. 14. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey eMR Patient
    15. 15. Admission Transfer 1 Transfer 2 Discharge Medication History Form (MHF) – Building the medication list
    16. 16. <ul><li>Customisable sections: </li></ul><ul><li>Dr Alert </li></ul><ul><li>Allergies & ADRs </li></ul><ul><li>Information sources </li></ul><ul><li>OTC medications </li></ul><ul><li>Regular Pharmacy details </li></ul><ul><li>Responsibility for medications </li></ul><ul><li>Compliance issues </li></ul><ul><li>Language difficulty </li></ul><ul><li>Additional information </li></ul>Admission Transfer 1 Transfer 2 Discharge Medication History Form (MHF) – Completed
    17. 17. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Interim
    18. 18. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Interim
    19. 19. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Completed
    20. 20. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – 2 nd cycle of eMR
    21. 21. Admission Transfer 1 Transfer 2 Discharge Electronic Discharge Summary (EDS) Medications - Interim
    22. 22. Admission Transfer 1 Transfer 2 Discharge Electronic Discharge Summary (EDS) Medications – Completed
    23. 23. Admission Transfer 1 Transfer 2 Discharge Electronic ‘Yellow Card’ – Generated from MRF or EDS
    24. 24. GP Pharmacy Outpatient Clinic
    25. 25. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey eMR Patient
    26. 26. Solution overview
    27. 27. Implementation & results so far <ul><li>Counties Manukau DHB: </li></ul><ul><li>Phase 1 went live March 2010 (Phase 2 scheduled for December 2010) </li></ul><ul><li>Pilot areas: AT&R (3), National Burn Centre & Plastics (approx.150 beds) </li></ul><ul><li>850 eMR EDS documents completed to date </li></ul><ul><li>Over 2000 MHF documents completed </li></ul><ul><li>Results: </li></ul><ul><ul><li>Baseline audits underway (SMMP Measuring and Reporting Framework) </li></ul></ul><ul><ul><li>Institute for Health Care Improvement (IHI) ADE trigger tool audit </li></ul></ul><ul><ul><li>Qualitative online surveys </li></ul></ul><ul><li>Waitemata DHB: </li></ul><ul><li>Phase 1 went live May 2010 (Phase 2 scheduled for February 2010) </li></ul><ul><li>Pilot areas - AT&R wards (120 beds) </li></ul><ul><li>Results: </li></ul><ul><ul><li>Pre eMR (234 patients), 6.7% items had errors, 35% patients had an incorrect EDS </li></ul></ul><ul><ul><li>Post eMR (225 patients), 1.73% items had errors, 7.5% patients had incorrect EDS </li></ul></ul><ul><li>Informal feedback from junior doctors and pharmacists at both DHB’s has been extremely positive </li></ul>
    28. 28. Challenges <ul><li>Resource. High quality information takes time to produce. </li></ul><ul><li>Process issues: </li></ul><ul><ul><li>Document medication history on paper at the bedside, then transcribe into an electronic form in the office….. </li></ul></ul><ul><ul><li>Long admissions (AT&R) – Collating all medication changes at the point of discharge </li></ul></ul><ul><li>Engaging the junior doctors </li></ul><ul><ul><li>“ The EDS takes too long to complete…” </li></ul></ul><ul><ul><li>“ I cant ‘free text’ medication names anymore…..” </li></ul></ul><ul><ul><li>“ The pharmacist hasn’t done their bit…..” </li></ul></ul><ul><ul><li>Training </li></ul></ul><ul><li>Implementation issues: </li></ul><ul><ul><li>Service based SMT templates/functionality, ward based pharmacists </li></ul></ul><ul><ul><li>Lost MR forms! </li></ul></ul><ul><li>The need for regional alignment </li></ul><ul><li>Ownership and acceptance. MR is not a ‘pharmacy’ problem </li></ul>
    29. 29. Lessons learnt <ul><li>eMR solves many problems, and creates new ones </li></ul><ul><li>Medication selection error </li></ul><ul><li>Information quality </li></ul><ul><li>Access to the outputs of eMR for community pharmacists </li></ul><ul><li>Resource </li></ul><ul><ul><li>Reinforce a multi-disciplinary approach to MR </li></ul></ul><ul><ul><li>Prioritise your at risk patients </li></ul></ul><ul><li>Focus on the problem, measure and report </li></ul><ul><li>Incremental change </li></ul>
    30. 30. Summary <ul><li>eMR is a relatively low cost solution to a complex problem </li></ul><ul><li>Improves the accuracy, currency and completeness of medication information as patient’s transition between care settings </li></ul><ul><li>We are already seeing benefit </li></ul><ul><li>Provides a platform for the future development of e-medication management solutions </li></ul><ul><li>Looking ahead </li></ul><ul><li>Regional repositories of clinical information </li></ul><ul><li>Inpatient ePrescribing </li></ul><ul><li>Community ePrescribing </li></ul><ul><li>Shared Care across care boundaries </li></ul><ul><li>But….. </li></ul><ul><li>We will still need to sit down with patients and ask them what medications they are actually taking….. </li></ul>
    31. 31. Questions? <ul><li>Acknowledgements: </li></ul><ul><ul><li>David Ryan (Waitemata DHB) </li></ul></ul><ul><ul><li>Mary Seddon (Counties Manukau DHB) </li></ul></ul><ul><ul><li>John Scott (Waitemata DHB) </li></ul></ul><ul><ul><li>Stuart McKinnon (Health Alliance) </li></ul></ul><ul><ul><li>Russell Neal (Health Alliance) </li></ul></ul><ul><ul><li>Orion Health team </li></ul></ul><ul><ul><li>Safe Medicines Management Programme team </li></ul></ul>

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