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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)

Published in: Health & Medicine, Business
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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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