Electronic Medication Reconciliation - Improving patient safety through e-medicine admission and discharge management
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This document discusses implementing electronic medication reconciliation (eMR) to improve patient safety during transitions of care. eMR embeds the medication reconciliation process within electronic systems used at admission, transfer, and discharge. Pilot programs at two District Health Boards saw improvements like fewer medication errors and increased accuracy and completeness of medication information. Challenges included engaging doctors and changes to workflows. Ongoing efforts are needed for regional clinical information sharing and electronic prescribing across care settings.
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Electronic Medication Reconciliation - Improving patient safety through e-medicine admission and discharge management
- 1. eMR - Electronic Medication Reconciliation Improving patient safety through e-medicine admission and discharge management
- 2. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey Patient
- 3. Admission Transfer 1 Transfer 2 Discharge
- 4. Admission Transfer 1 Transfer 2 Discharge
- 5. Admission Transfer 1 Transfer 2 Discharge
- 6. GP Pharmacy Outpatient Clinic
- 7. GP? Pharmacy? Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic? The Patient Journey Patient?
- 12. Paper MR - defining the process
- 14. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey eMR Patient
- 15. Admission Transfer 1 Transfer 2 Discharge Medication History Form (MHF) – Building the medication list
- 17. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Interim
- 18. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Interim
- 19. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – Completed
- 20. Admission Transfer 1 Transfer 2 Discharge Medication Reconciliation Form (MRF) – 2 nd cycle of eMR
- 21. Admission Transfer 1 Transfer 2 Discharge Electronic Discharge Summary (EDS) Medications - Interim
- 22. Admission Transfer 1 Transfer 2 Discharge Electronic Discharge Summary (EDS) Medications – Completed
- 23. Admission Transfer 1 Transfer 2 Discharge Electronic ‘Yellow Card’ – Generated from MRF or EDS
- 24. GP Pharmacy Outpatient Clinic
- 25. GP Pharmacy Admission Transfer 1 Transfer 2 Discharge Primary Care Secondary Care Outpatient Clinic The Patient Journey eMR Patient
Editor's Notes
- 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