3. THE PROBLEM
• 1.5 million adverse drug events occur each year in
the United States
• Each preventable adverse drug event added
$8,750 to the cost of a hospital stay
• Potential cost: $3.5 billion annually
• Cost to treat medication errors: $887 million
• Medication errors from medication reconciliation
failures occur:
• 22% at Admission
• 22% at Transfer
• 12% at Discharge
(IOM, 2006; JCAHO, 2008)
4. COMMON MEDICATION ERRORS
Additional Substitutions
Medications 5%
Frequency 5%
Discrepancy
10%
Dose
Discrepancy
21% Omissions
59%
(Mitrzyk, 2009)
10. REFERENCES
• Balint, M., Ball, D. H., & Hare, M. L. (1969). Training medical students in patient-centered medicine. Comprehensive
Psychiatry, 10(4), 249-258. doi: 10.1016/0010-440x(69)90001-7
• Belmont, C., Akpabio, L., Engles, D., O'Hare, E., Russell, B., Richard, R. C., & Waltrip, L. (2010). Medication Reconciliation.
Retrieved from http://www.dell.com/downloads/global/solutions/public/articles/medication-reconciliation-patients-care-
givers.pdf
• California HealthCare Foundation. (2010). Consumers and Health Information Technology: A National Survey. Retrieved from
http://www.chcf.org/publications/2010/04/consumers-and-health-information-technology-a-national-survey
• Christensen, C. M., Grossman, J. H., & Hwang, J. (2009). The Innovator's Prescription: A Disruptive Solution for Health Care.
New York, NY: McGraw-Hill.
• Greenwald, J. L., Halasyamani, L., Greene, J., LaCivita, C., Stucky, E., Benjamin, B., . . . Williams, M. V. (2010). Making Inpatient
Medication Reconciliation Patient Centered, Clinically Relevant and Implementable: A Consensus Statement on Key
Principles and Necessary First Steps. Journal of Hospital Medicine, 5(8), 477-485.
• Institute of Medicine. (2006). Preventing Medication Errors. Retrieved from
http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-
Series/medicationerrorsnew.pdf
• Johansson, F. (2006). Medici effect: What elephants and epidemics can teach us about innovation. Cambridge, MA:
Harvard Business School Press
• Joint Commission on Accreditation of Healthcare Organizations. (2006). Using medication reconciliation to prevent errors.
Joint Commission Journal on Quality and Patient Safety. 32(4), 230-2.
• McGuire, R. (2007). The power of mobility : how your business can compete and win in the next technology revolution.
Hoboken, N.J.: John Wiley & Sons.
• Microsoft. (2012). Microsoft HealthVault. Retrieved from http://www.microsoft.com/global/en-
us/healthvault/renderingAssets/hvClickThru/Personal/hv_final_overview_master_02.pdf
• Mitrzyk, B. M., & Ganatra, S. (2009). Conducting Medication Reconciliation. Retrieved from
http://www.michiganpharmacists.org/education/online/may09_medrec.pdf
• Turvey, C. L., Zulman, D. M., Nazi, K. M., Wakefield, B. J., Woods, S. S., Hogan, T. P., . . . McInnes, K. (2012). Transfer of
Information from Personal Health Records: A Survey of Veterans Using My HealtheVet. Telemedicine and E-Health, 18(2), 109-
114.
Editor's Notes
According to a study reported by Belmont, 51% of all insured Americans (including children) take at least one prescription drug. The same study reported that 75% of older adults take one or more prescription drugs and 25% of older adults take five or more medications on a regular basis. For individuals dealing with multiple chronic conditions, medication management can be a significant issue. In my experience as a caregiver of a cancer patient, the amount of drugs, dosages, and frequencies was staggering and I am a healthcare professional. It was a great source of frustration to have to go to the hospital or to a new consult and have to try to remember or repeat this huge list of medications. I was lucky enough to get the name of the medication right, much less the dose and frequency. A hospitalization is a stressful time and placing an additional burden on the patients or families to recount a list of medications is difficult. I also experience this frustration from the other side as a healthcare worker attempting to get a home medication history or current list of home medications from patients and/or family members. Many times the home med reconciliation had to be delayed until the caregiver could go home and physically look at the medication bottles. Sometimes there would only be one list of medications but very often they were missing data, had misspelled drug names, or some other problem.A study by Rozich and Resar found that unsuccessful medication orders caused work and re-work for healthcare professionals, adding at least 20 minutes to an admission per patient for nurses and over 40 minutes for pharmacists. (end)Successful reconciling processes also reduce work and re-work associated with the management of medication orders. After implementation, nursing time at admission was reduced by more than 20 minutes per patient. The amount of time that pharmacists were involved in discharge was reduced by more than 40 minutes.J.D. Rozich and R.K. Resar, et al. Joint Commission Journal on Quality and Safety. “Standardization as a Mechanism to Improve Safety in Healthcare: Impact of Sliding Scale Insulin Protocol and Reconciliation of Medications Initiatives.” 2004;30(1):5-14
With regards to the financial costs of the problem, the institute of Medicine and The Joint Comission have recognized that medication management is a significant problem. They report that 1.5 million adverse drug events happen each year in the US. They found that one study reported that each preventable adverse drug event added 8,750 dollars to a hospital stay, which could cost a hospital $3.5 billion dollars annually. Another study reported that the total cost to treat medication errors was about $887 million dollars. They also report that medication reconciliation failures happen most frequently at transition points such as admission, transfer, and discharge.
One study found that the most common medication errors were omissions and dose discrepancy. This occurs most often because we rely on Patients and family members as historians. As I stated previously, hospitalizations are very stressful times for patients and family members. Medication management is not easy and it is made even more difficult during stressful situations. Patients are admitted to the hospital and healthcare professionals manage their care during their stay and even we have issues with medication management. 50% of medication errors and 20% of adverse drug events were a result of poor communication of medical information at transition points (admissions, transfer, or discharge)
The Joint Commission has recognized Medication Reconciliation as a National Patient Safety Goal and they, along with the Institute of Medicine, have recommended a few solutions to the problem of medication management in the healthcare setting. They suggest a partnership with patients. We should be encouraging patients to take a more active role in their own medical care. Nurses and doctors come and go but the patient and/or their caregivers are constants in the equation so having them actively participate in their care should reduce the amount of errors that occur. They also recommend that the patient keep careful records. The Joint Commission have a Speak Up program to help reduce medication errors and they have a template for patients to keep a current list of medications in their wallet. As part of partnership, we need to Improve patient-provider communication about medications. Educating patients on their medications and side effects goes a long way and is part of having an active dialogue about their care and their concerns. And finally, Use information technology to help with medication management. Which is where use of mobile technology for this project fits in to the solution.
I collaborated with three categories of individuals in this project. I spoke with patients and caregivers, healthcare professionals, and the information services department director at my hospital. The healthcare professionals I spoke with were a physician, a physician assistant, and nurses, both at my facility and at other facilities. Patients, caregivers and healthcare professionals universally acknowledged that medication management was a source of frustration. The physician brought up many safety issues about medication interactions and the importance of carrying a current list of medications, especially in case of emergencies. The patients and caregivers felt that managing all the information, as well as medications, was a huge task and while they thought it best to keep good, detailed records, they also acknowledged that they didn’t have the time to maintain it and they wished that healthcare providers could help them. My discussion with the director of information services yielded the most technical information about maintenance, data entry, security, platforms and interfacing. Each of the categories of interviewees was chosen because their feedback and experiences are important to discern the breadth and scope of the problem in a real life setting and their expertise and personal experience with medication management is significant to developing a solution which will work for multiple disciplines and systems. All three categories of interviewees yielded information which was important to the project. Initially, I had chosen a different application for this project, but after listening to the feedback from the interviews and concerns about data management, accuracy, and maintenance of the data, I went in search of another application which would present more solutions than problems.
The mobile solution I’m presenting is Microsoft HealthVault. It is an online tool which helps the user manage their personal health record. A personal health record (PHR) is a collection of health-related information that is documented and maintained by the individual it pertains to. As opposed to, an electronic health record (EHR) which is health-related information maintained by health professionals and official agencies. Medications are just a component of the patient’s health record, albeit an important one. HealthVault helps the patient maintain these records in a digital format, which is accessible from any web-based device through their internet browser. There are also a variety of apps which allow the user to access information from HealthVault but, in essence, the information is stored on Microsoft’s HealthVault’s servers. According to a national survey on health information technology, Americans pay more attention and become more engaged in their health and medical care when they have easy access to their health information online. The survey also found that Personal Health Record users cite taking steps to improve their own health, knowing more about their health care, and asking their doctors questions they would not have otherwise asked. InMcGuire’s book entitled the power of mobility, (2007) mobile technology is advancing and changing the way we live, work, and practice and healthcare is no exception. Having online and/or mobile access to important health information gives the patient and also their healthcare provider instant access anywhere there is an internet connection. Microsoft HealthVault has many functions categorized into four areas on their site. The track and manage section allows the user to track their prescriptions and manage their chronic conditions. The user can manually input their health data, but there are also some automatic functions as well. There are devices such as glucometers which have the capability to connect to HealthVault and upload blood glucose readings. HealthVault also can connect to a CVS or Walgreens account for transfer of prescriptions directly into the record. In the organize section, the user can keep track of their health record and also the records of their family members. The user can type in their health data, upload images or records, or have a physician’s office fax records directly into HealthVault. It is also possible to connect with pharmacies, labs, hospitals, and clinics online to get existing information added to HealthVault. The data is also printable into wallet cards or onto sheets of paper from any web-enabled computer for emergency use. In the Get Healthy section, the user can use compatible devices like pedometers and blood pressure monitors to add data into their account. They can also connect with other sites such as the American Diabetic Association and the American Heart Association to find and keep track of food and diet information to maintain a healthy lifestyle. And finally the Apps and Devices section lists all the apps which can be used to connect with HealthVault for data management.
Having a central location for health information is the best way to manage information coming from multiple locations. The patient is the one common factor in their healthcare therefore, for the time being, it makes sense for the information to be kept, maintained, and follow the patient. Microsoft HealthVault is an innovative way to help users manage and converge their health information into a central location. HealthVault will enhance the six-step process of using evidence.1. Firstly, Access: The tool will increase ease of access to healthcare and medical history information after it has been accurately programmed and saved into the user’s account.2. Second,Tailor: Information is organized with easy-to-navigate sections for retrieval of health information on demand. Once access is given,The healthcare provider can easily see what has been done in the past, granted the app is updated, and is able to view previous imaging studies for comparison if they are uploaded to the account as well. Comparison of current state to a previous state is also important when developing a health care treatment plan for the patient. An accurate and in-depth history is one of the first steps in patient-centered medicine, according to Balint. 3. Third,Retrieve: Once information has been programmed and saved, it can be retrieved on demand anywhere there is internet access with an internet-enabled device. The information can also be retrieved and printed on to wallet cards or sheets of paper anywhere there is internet and a printer connected to an internet-enabled device.4. Fourth and fifth, Archive and share Information stored in Microsoft HealthVault server and accessible from any internet-enabled device. The information can also be printed for archiving or sharing. 6. And lastly, Write: Experiences and studies utilizing this type of mobile technology should be shared with others so they can benefit from its use as well. Tools like HealthVault and electronic PHRs are in early stages of use and still under development. Cochrane Systematic Reviews have found many studies written on health technology, however, high quality studies which meet review inclusion criteria have yet to be found. Proactive patients and families would likely enjoy using this mobile app, but physicians, nurses, and other healthcare providers should be aware that this type of technology exists and can be well-integrated into a treatment plan as a helpful tool. Hopefully, in the future, updates can be done wirelessly and seamlessly to prevent data entry errors and promote ease of use and maintenance of health information.
HealthVault is innovative because it is not just a digital health record. Its capability to connect and update automatically across different interfaces, such as with pharmacies, hospitals, labs, pedometers, blood pressure machines, etc. greatly improves its functionality, helps increase accuracy of data entry and maintenance. It is an example of interdisciplinary collaboration and also possibly working at the intersection, according to Johannsen. A solution like Healthvault also helps solve the problem of mutual accommodation of interdependent systems, according to Christensen, with regards to the inability of the current system of electronic health records to interface across systems. Healthcare is complex. Chronic disease management is complex. Navigating the complex healthcare system is important and maintaining a personal health record should help. Imagine how much easier it would be to obtain a list of home medications if it were already compiled and accessible at a moment’s notice. Patients would no longer have to rely on our memories or recall during stressful situations. The patient could just print the information. It would make things easier for patients and healthcare professionals alike. And if a physician calls in a prescription to your local pharmacy, linked to healthVault, the home medication list is automatically updated as the prescription is filled. As with any technology, effective education on its functional capability and utility is important since if the technology is not being used or utilized correctly, it is not reaching its full potential for usefulness. The authors also acknowledge that the personal health records have great potential to improve outcomes and improve continuity of care across providers. (Turvey, )Going back to medication management. since medication reconciliation is a national patient safety goal endorsed by the Joint Comission, its significance in the clinical setting is profound. Benchmarks on medication reconciliation for core measure patients, such as congestive heart failure (CHF), affect hospital reimbursement and non-adherence to medication regimes have been associated with readmissions. Medicare Reimbursements for CHF patients are withheld if there is a readmission within 30 days of prior admission. The importance of PHRs and portability of the information across different sites of care as playing a key role in facilitating and maintaining successful medication reconciliation. They also emphasize the complexity of medication reconciliations, which is exacerbated by the disjointed nature of the American healthcare system. A mobile application which provides an easily transportable PHR, could play a significant role in improving medication reconciliation in the clinical setting.
