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www.saferhealthcarenow.ca
Improving Efficiencies in
Medication Reconciliation - The
McGill Story
Review of Challenges and ...
www.saferhealthcarenow.ca
Call Objectives
• Discuss the challenges in improving medication
reconciliation
• Describe what ...
www.saferhealthcarenow.ca
October is Canadian MedRec
Quality Audit month.
The MedRec quality audit month is designed to es...
www.saferhealthcarenow.ca
Canadian MedRec Quality Audit month.
4
• Join us for a national webinar on October 1, 2013 at 12...
www.saferhealthcarenow.ca
We want to hear from you
5
www.saferhealthcarenow.ca
Today’s Speaker
Robyn Tamblyn, BScN, MSc, PhD
Dr. Robyn Tamblyn is a Professor in the Department...
Review of Challenges and
Potential Benefits of Using
IT-Enabled Medication
Reconciliation
August 2013
Background
Failure to reconcile pre-admission medication with medications
prescribed at discharge may contribute to preven...
Challenges in implementing Medication
Reconciliation (MedRec)
1. Collect an accurate and comprehensive community-based
med...
Number of prescribing physicians per patient at the time
of the ED Visit
Tamblyn et al, JAMIA, 2013
Number of pharmacies identified per patient at the time
of the ED visit
Tamblyn et al, JAMIA, 2013
Percentage of patients’ community medications that are
not documented in the hospital chart
Tamblyn et al, JAMIA, 2013
Need to
search for
pharmacy
coordinates
… Google,
Canada 411
Time (in minutes) to complete medication reconciliation
tasks at admission and discharge, per hospital unit
Computers
What has been learned from IT?
• Designed a medication reconciliation application: “The Pre-
Admission Medication List (PAML) Builder” and implemented it...
•Integrated the “PAML builder” to a computerized provider order
entry (CPOE)
• Showed a 28% reduction in unintentional med...
The EMITT Study: Development and Evaluation of a
Medication Information Transfer Tool
Cesta et al, The Annals of Pharmacot...
Reducing Medication Errors and Improving Systems
Reliability Using an Electronic Medication Reconciliation
System
Agrawal,...
Medication reconciliation is a required
organizational practice for hospital
accreditation
MedRec Accreditation
2013
• Organizational Priority
• Implemented in 1
client service area at
admission, discharge
and tra...
Rx
Rx
Rx
Rx
Rx Rx
Assets to enable more efficient MedRec
in Canada
Primary objectives:
To determine if automated transmission of community medications and IT-
enabled MedRec will reduce the...
Secondary Objectives:
To measure:
 Failure to re-prescribe chronic disease medications
 Therapy duplications
 Time to c...
Design:
 Cluster-randomized controlled trial
 Target population: publicly insured admitted adults to target
units at the...
What can I do with RightRx?
1. Collect and evaluate patient’s :
 Community medication list (CML)
 Community pharmacy and...
Where does the information come
from?
 RightRx uses this “real-time” linkage to the
Quebec health insurance agency (Régie...
DATA FLOWS for RightRx
Patient consent
Receives hospital medication list
every 15min, 7/7 days, 6h-22h
Retrieves med list ...
Accessing RightRx through hospital
Electronic Health Record
The MedRec Process
1. Collect and evaluate community
medication list
‘Prior to Admission’ tab
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ - Expanded view
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ - Expanded view
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Medication Validation
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ - Validation of Adherence
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ – Adding a medication
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ –Validated list
Prior to admission Discharge
Admission
Review/Transfer
‘Prior to Admission’ –Validated list
2. Medication Review
‘Admission Review/Transfer’ tab
Prior to admission Discharge
Admission
Review/Transfer
‘Admission Review/Transfer’- In line validation –
Continuing a medication
Prior to admission Discharge
Admission
Review/Tr...
Prior to admission Discharge
Admission
Review/Transfer
‘Admission Review/Transfer’- In line validation –
Stopping a medica...
‘Admission Review/Transfer’- Reason for
Discontinuing
Prior to admission
Admission
Review/Transfer
Ordonnance pharmaceutique Medication Order
‘Admission Review/Transfer’- Finalized order
Tap water enema prn
3. Discharge Prescription
‘Discharge’-tab
Prior to admission
Admission
Review/Transfer
‘Discharge’- In line validation – Continuing a medication
from hospital to home
Prior to admission
Admission
Review/Transf...
‘Discharge’- In line validation – Stopping a medication
from hospital to home
Prior to admission
Admission
Review/Transfer
‘Discharge’- In line validation – Modifying a medication
from hospital to home
Prior to admission
Admission
Review/Transfer
‘Discharge ’- Discharge Prescription
4. Communication with community
providers
‘Pharmacy and Physician coordinates’
Prior to admission
Admission
Review/Transfer
Physician coordinates data flow
Patient consent
Retrieve physician identity from
RAMQ for scrambled physician
license numb...
Pharmacy fax number data flow
Patient consent
Retrieves medication and
pharmacy coordinates from
RAMQ but missing fax numb...
Issues discovered along the way:
1. Social ethical issues:
• Consent-in vs. Opt-out for accessing community drug data
• Th...
3. Professional:
• Roles of physicians and pharmacists in MedRec
• Documentation of pharmacy recommendations for
physician...
4. Technical Issues:
• Lack of standardization of hospital Drug Information
systems (DISs)
• Lack of posology in prescript...
robyn.tamblyn@mcgill.ca
Thank you!
www.saferhealthcarenow.ca
Coming Soon
• Canadian Patient Safety Week is October
28 to November 1, 2013. Register now at
ht...
www.saferhealthcarenow.ca
Coming Soon (Fall 2013)
• Tool kit to help teams move from paper-based
to electronic MedRec syst...
www.saferhealthcarenow.ca
Canadian MedRec Quality Audit month.
68
• Join us for a national webinar on October 1, 2013 at 1...
www.saferhealthcarenow.ca69
We encourage you to report
medication incidents
Practitioner Reporting
https://www.ismp-canada...
www.saferhealthcarenow.ca
We want to hear from you one more time
70
Improving efficiencies in medication reconciliation: The McGill Story
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  1. 1. www.saferhealthcarenow.ca Improving Efficiencies in Medication Reconciliation - The McGill Story Review of Challenges and Potential Benefits of Using IT-Enabled Medication Reconciliation Robyn Tamblyn, BScN, MSc, PhD Professor, Department of Medicine and Department of Epidemiology and Biostatistics, McGill University, Faculty of Medicine
  2. 2. www.saferhealthcarenow.ca Call Objectives • Discuss the challenges in improving medication reconciliation • Describe what has been learned from IT • Describe the assets to enable more efficient IT in medication reconciliation in Canada Identifying challenges in medication reconciliation and assets to enable more efficient medication reconciliation in Canada is a priority.
  3. 3. www.saferhealthcarenow.ca October is Canadian MedRec Quality Audit month. The MedRec quality audit month is designed to establish a national perspective of the quality of admission MedRec in acute and long term care facilities over a one month period. By participating in the national audit, you will be part of a movement to measure the quality of admission MedRec processes which can decrease preventable drug events. 3
  4. 4. www.saferhealthcarenow.ca Canadian MedRec Quality Audit month. 4 • Join us for a national webinar on October 1, 2013 at 12 noon ET to kick-off the Canadian MedRec Quality Audit month. • Register Now to participate in the Canadian MedRec Quality Audit month (October 1 – 30, 2013). Please note: Both registration and participation are complimentary. A tally of audits will be unveiled at Canada’s Virtual Forum on  Wednesday, October 30th , a day dedicated to medication safety  across the continuum.
  5. 5. www.saferhealthcarenow.ca We want to hear from you 5
  6. 6. www.saferhealthcarenow.ca Today’s Speaker Robyn Tamblyn, BScN, MSc, PhD Dr. Robyn Tamblyn is a Professor in the Department of Medicine and the Department of Epidemiology and Biostatistics at McGill University. She is a James McGill Chair, a Medical Scientist at the McGill University Health Center Research Institute, and the Scientific Director of the Clinical and Health Informatics Research Group at McGill University.
  7. 7. Review of Challenges and Potential Benefits of Using IT-Enabled Medication Reconciliation August 2013
  8. 8. Background Failure to reconcile pre-admission medication with medications prescribed at discharge may contribute to preventable ADEs:  19% to 23% of patients will have an ADE within 30 days of hospital discharge1,2  14.3% will be readmitted3  Adverse drug events (ADEs) are preventable in 58% of the cases 4 ADEs are the 6th leading cause of death at a cost over $5.6 million per hospital per year 5 1. Forster AJ, Clark HD, Menard A et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170:345- 349. 2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167. 3. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842-1847. 4. Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274:35- 43. 5. Bates DW Spell N, Cullen DJ et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307-311.
  9. 9. Challenges in implementing Medication Reconciliation (MedRec) 1. Collect an accurate and comprehensive community-based medication list (CML) 2. Conduct medication review on all patients at risk 3. Communicate consistently medication/dose changes at discharge to the community care team
  10. 10. Number of prescribing physicians per patient at the time of the ED Visit Tamblyn et al, JAMIA, 2013
  11. 11. Number of pharmacies identified per patient at the time of the ED visit Tamblyn et al, JAMIA, 2013
  12. 12. Percentage of patients’ community medications that are not documented in the hospital chart Tamblyn et al, JAMIA, 2013
  13. 13. Need to search for pharmacy coordinates … Google, Canada 411
  14. 14. Time (in minutes) to complete medication reconciliation tasks at admission and discharge, per hospital unit
  15. 15. Computers
  16. 16. What has been learned from IT?
  17. 17. • Designed a medication reconciliation application: “The Pre- Admission Medication List (PAML) Builder” and implemented it at two 2 large Partners Healthcare academic hospitals in Boston • Highlighted the need for order entry in addition to medication information Evaluation of an inpatient computerized medication reconciliation system Turchin A, Hamann C, Schnipper JL et al. JAMA 2008
  18. 18. •Integrated the “PAML builder” to a computerized provider order entry (CPOE) • Showed a 28% reduction in unintentional medication discrepancies with potential for harm •Non-integration of the PAML builder with the CPOE system at discharge at hospital 2, showed less of a reduction in potential adverse drug events compared to hospital 1 •Hospital readmission or emergency department visit within 30 days was 4% lower in the intervention group but not significant Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events A Cluster-Randomized Trial Schnipper J. L et al. JAMA 2009
  19. 19. The EMITT Study: Development and Evaluation of a Medication Information Transfer Tool Cesta et al, The Annals of Pharmacotherapy, 2006 •A web based electronic tool designed by the University Health Network in Toronto and integrated with the electronic patient record (EPR) to facilitate the MedRec process • Allows electronic documentation of patient medication history on admission, generation of a discharge medication prescription and a detailed medication information transfer letter •A feasibility pilot of 40 orders involving nine pharmacists suggest that EMITT is a functional and practical tool for transfer of information between health care professionals and may potentially decrease medication discrepancies
  20. 20. Reducing Medication Errors and Improving Systems Reliability Using an Electronic Medication Reconciliation System Agrawal, Abha; Wu, Winfred Y., Joint Commission Journal on Quality and Patient Safety, 2009 •Designed and implemented an electronic Medication Reconciliation “MedRecon” system that integrated with a CPOE system at Kings County Hospital Center in New York City •After implementation, the medication discrepancy rate was 1.4% between community and hospital medications, compared to 20.1% in a pilot sample of 120 encounters before implementation •Demonstrated improved physician compliance from 34% to 84% with “MedRecon” performance when using an interactive reminder alert
  21. 21. Medication reconciliation is a required organizational practice for hospital accreditation
  22. 22. MedRec Accreditation 2013 • Organizational Priority • Implemented in 1 client service area at admission, discharge and transfer • Documented plan to implement throughout the organization 2014 • Strategic Priority • MedRec policy and process at transitions of care • Defined roles and responsibility • Plan to implement and sustain MedRec • Plan is led and sustained by interdisciplinary coordination team • Evidence of staff education
  23. 23. Rx Rx Rx Rx Rx Rx Assets to enable more efficient MedRec in Canada
  24. 24. Primary objectives: To determine if automated transmission of community medications and IT- enabled MedRec will reduce the risk of ADEs, ER visits and hospital readmissions in the 30 days post-discharge by:  reconciliation of community and hospital medications at discharge when facilitated by electronic retrieval of the community list  communication of treatment changes to the community-based prescribing physicians and pharmacists RightRx: Using Novel Canadian Resources to Improve Medication Reconciliation Tamblyn et al, McGill University: CIHR Research in Progress
  25. 25. Secondary Objectives: To measure:  Failure to re-prescribe chronic disease medications  Therapy duplications  Time to complete the MedRec process
  26. 26. Design:  Cluster-randomized controlled trial  Target population: publicly insured admitted adults to target units at the Royal Victoria and Montreal General Hospitals  12-months, 3714 patients
  27. 27. What can I do with RightRx? 1. Collect and evaluate patient’s :  Community medication list (CML)  Community pharmacy and prescribing physician coordinates  In-hospital medication list 2. Conduct medication reconciliation and review  At admission, transfer and discharge 3. Communicate consistently reconciliation decisions at discharge
  28. 28. Where does the information come from?  RightRx uses this “real-time” linkage to the Quebec health insurance agency (Régie de l’assurance maladie du Québec: RAMQ) to retrieve information on community medications and medical services.
  29. 29. DATA FLOWS for RightRx Patient consent Receives hospital medication list every 15min, 7/7 days, 6h-22h Retrieves med list from RAMQ Medication Reconciliation Community list Validation Discharge prescription Automatic transmission of medication changes to community pharmacies/physicians MOXXI servers RAMQ Database Hospital database Signed printed prescription brought to community pharmacy RightRx servers
  30. 30. Accessing RightRx through hospital Electronic Health Record
  31. 31. The MedRec Process
  32. 32. 1. Collect and evaluate community medication list
  33. 33. ‘Prior to Admission’ tab Prior to admission Discharge Admission Review/Transfer
  34. 34. ‘Prior to Admission’ - Expanded view Prior to admission Discharge Admission Review/Transfer
  35. 35. ‘Prior to Admission’ - Expanded view Prior to admission Discharge Admission Review/Transfer
  36. 36. ‘Prior to Admission’ – Medication Validation Prior to admission Discharge Admission Review/Transfer
  37. 37. ‘Prior to Admission’ – Validation of Adherence Prior to admission Discharge Admission Review/Transfer
  38. 38. ‘Prior to Admission’ – Validation of Adherence Prior to admission Discharge Admission Review/Transfer
  39. 39. ‘Prior to Admission’ - Validation of Adherence Prior to admission Discharge Admission Review/Transfer
  40. 40. ‘Prior to Admission’ – Adding a medication Prior to admission Discharge Admission Review/Transfer
  41. 41. ‘Prior to Admission’ – Adding a medication Prior to admission Discharge Admission Review/Transfer
  42. 42. ‘Prior to Admission’ – Adding a medication Prior to admission Discharge Admission Review/Transfer
  43. 43. ‘Prior to Admission’ –Validated list Prior to admission Discharge Admission Review/Transfer
  44. 44. ‘Prior to Admission’ –Validated list
  45. 45. 2. Medication Review
  46. 46. ‘Admission Review/Transfer’ tab Prior to admission Discharge Admission Review/Transfer
  47. 47. ‘Admission Review/Transfer’- In line validation – Continuing a medication Prior to admission Discharge Admission Review/Transfer
  48. 48. Prior to admission Discharge Admission Review/Transfer ‘Admission Review/Transfer’- In line validation – Stopping a medication
  49. 49. ‘Admission Review/Transfer’- Reason for Discontinuing Prior to admission Admission Review/Transfer
  50. 50. Ordonnance pharmaceutique Medication Order ‘Admission Review/Transfer’- Finalized order Tap water enema prn
  51. 51. 3. Discharge Prescription
  52. 52. ‘Discharge’-tab Prior to admission Admission Review/Transfer
  53. 53. ‘Discharge’- In line validation – Continuing a medication from hospital to home Prior to admission Admission Review/Transfer
  54. 54. ‘Discharge’- In line validation – Stopping a medication from hospital to home Prior to admission Admission Review/Transfer
  55. 55. ‘Discharge’- In line validation – Modifying a medication from hospital to home Prior to admission Admission Review/Transfer
  56. 56. ‘Discharge ’- Discharge Prescription
  57. 57. 4. Communication with community providers
  58. 58. ‘Pharmacy and Physician coordinates’ Prior to admission Admission Review/Transfer
  59. 59. Physician coordinates data flow Patient consent Retrieve physician identity from RAMQ for scrambled physician license number Retrieves scrambled physician license number from RAMQ along with medication list Discharge prescription Fax changes to prescribing physicians in the community MOXXI servers RAMQ Database RightRx servers Link with College of Physicians file to retrieve physician coordinates PHIRE Database CMQ file
  60. 60. Pharmacy fax number data flow Patient consent Retrieves medication and pharmacy coordinates from RAMQ but missing fax number Discharge prescription Fax changes to community pharmacies MOXXI servers RAMQ Database RightRx servers Link with Order of Pharmacist’s (OPQ) file to retrieve pharmacy fax number PHIRE Database CMQ file Match RAMQ pharmacy coordinates with OPQ file
  61. 61. Issues discovered along the way: 1. Social ethical issues: • Consent-in vs. Opt-out for accessing community drug data • The incompetent patient • Refusal to consent and consequences for treatment 2. System Issues: • Idiosyncratic process unit by unit, service by service
  62. 62. 3. Professional: • Roles of physicians and pharmacists in MedRec • Documentation of pharmacy recommendations for physician’s orders • Prescribing medications where indication is not known and decision to modify was made by someone else • Expanding role of pharmacy technicians
  63. 63. 4. Technical Issues: • Lack of standardization of hospital Drug Information systems (DISs) • Lack of posology in prescription claims data • Knowledge base and process used to match community and hospital medications • Customized concoctions
  64. 64. robyn.tamblyn@mcgill.ca Thank you!
  65. 65. www.saferhealthcarenow.ca Coming Soon • Canadian Patient Safety Week is October 28 to November 1, 2013. Register now at http://www.patientsafetyinstitute.ca • Visit us at the Zoomer Show in Toronto on October 26 & 27 (Direct Energy Building, Exhibition Place). We are in booth 3225. 66
  66. 66. www.saferhealthcarenow.ca Coming Soon (Fall 2013) • Tool kit to help teams move from paper-based to electronic MedRec system. • PSEP module on Medication Reconciliation • CCEP certified eLearning module on Medication Reconciliation at admission to Acute Care • TechTalk article on the Pharmacy Technician's role in Medication Reconciliation 67
  67. 67. www.saferhealthcarenow.ca Canadian MedRec Quality Audit month. 68 • Join us for a national webinar on October 1, 2013 at 12 noon ET to kick-off the Canadian MedRec Quality Audit month. • Register Now to participate in the Canadian MedRec Quality Audit month (October 1 – 30, 2013). Please note: Both registration and participation are complimentary. A tally of audits will be unveiled at Canada’s Virtual Forum on  Wednesday, October 30th , a day dedicated to medication safety  across the continuum.
  68. 68. www.saferhealthcarenow.ca69 We encourage you to report medication incidents Practitioner Reporting https://www.ismp-canada.org/err_report.htm Consumer Reporting www.safemedicationuse.ca/
  69. 69. www.saferhealthcarenow.ca We want to hear from you one more time 70
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