Coordination of medication reconciliation information continues to play a major role in every healthcare setting today
Paul Harvey, the radio commentator, was one of the best. I recall as a boy listening to him speak and getting chills from his powerful delivery of the message he conveyed. One of my favorites was “So God made a farmer.” Public opinion polling shows that the most trusted healthcare professional today is the pharmacist. I want to paraphrase Paul Harvey and provide a compelling example of “Why God made a pharmacist.”
In the middle of the night recently, I took an old friend to the hospital. She was very ill, but her condition was not life-threatening. Following appropriate triage, she had to wait while others in more desperate need of medical attention were seen first. I waited with her across from the Emergency Room (ER) receptionist. For two-plus hours, I saw numerous patients present themselves to the ER carrying bags full of prescription medications. Some would line the medications up on the counter and then explain they had no idea what they were for. Others brought in by rescue/ambulance personnel had plastic bags containing brown prescription bottles with white tops, laid on top of the covering sheet, as they were wheeled into the ER.
Something occurred to me that night about all those bags of prescription bottles. Why were there so many? Why didn’t the patient know what they were for? And, most importantly, who was coordinating all those meds? Can some patients, seen in numerous healthcare settings and by different types of healthcare professionals, get a comprehensive medication review only after they present themselves to an ER with their bag of prescriptions?
The Medication Reconciliation Process (MRP) has been part of a huge quality improvement push from the Joint Commission and other healthcare organizations – as part of the hospital accreditation process. I’m told this push started approximately two years ago when the Joint Commission began changing standards that included the MRP. The Joint Commission National Patient Safety Goal, effective Jan. 1, 2013, offers a straightforward Introduction to Reconciling Medication Information. It states:
“The large number of people receiving healthcare who take multiple medications and the complexity of managing those medications make medication reconciliation an important safety issue. In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies.
The Joint Commission recognizes that organizations face challenges with medication reconciliation. The best medication reconciliation requires a complete understanding of what the patient was prescribed and what medications the patient is actually taking. It can be difficult to obtain a complete list from every patient in an encounter, and accuracy is dependent on the patient’s (or family’s) ability and willingness to provide this information. A good faith effort to collect this information is recognized as meeting the intent of the requirement. As health care evolves with the adoption of more sophisticated systems (such as centralized databases for prescribing and collecting medication information), the effectiveness of these processes will grow.
This National Patient Safety Goal (NPSG) focuses on the risk points of medication reconciliation. The elements of performance in this NPSG are designed to help organizations reduce negative patient outcomes associated with medication discrepancies. Some aspects of the care process that involve the management of medications are addressed in the standards rather than in this goal. These include coordinating information during transitions in care both within and outside of the organization (PC.02.02.01), patient education on safe medication use (PC.02.03.01), and communications with other providers (PC.04.02.01).”
Maybe seamless, real-time electronic medical records that healthcare providers can use to enhance patient safety should be a national policy goal. However, this technology and its adoption are far from reality in many hospitals and other healthcare settings today. The MRP is one of the major problems wrought with potential for error on behalf of patients, doctors, nurses, pharmacists, and other healthcare providers. This process looks at reconciling needed medications from admission, through hospitalization (especially from service/department to service/department), to the point of discharge with prescriptions that the patient carries out the door with them.
There is plenty of literature on these pitfalls, including language issues, poor patient memory, family members giving incorrect information, too much work to enter in electronic medical record systems, lack of hand-off between disciplines, confusion with prescriptions at discharge, no specific or unclear information at discharge, and a patient going to and being seen by multiple doctors or multiple pharmacies. This is a huge problem for healthcare today. Fortunately, healthcare providers along with many others are seeking ways to fix this.
Problems after discharge
Prior to discharge is a good time to start a patient on a prescription in which they can reap long-term benefits. According to an Oct. 23, 2013 article by Paul Barr, in Hospital and Health Networks Daily, about the Oct. 15, 2013 release of “The Dartmouth Atlas of Medicare Prescription Use” (lead author: Jeffrey Munson, M.D., Assistant Professor at Dartmouth Institute for Health Policy and Clinical Practice) “Some heart attack patients may not continue to take a recommended beta-blocker for even the first six months after discharge – three years is the recommendation – without intervention before they leave the hospital and follow-up afterwards.” Coordination of care from hospital physicians to community providers may be one of the biggest problems, especially when multiple physicians become involved.
Similarly, after being discharged, some patients may continue taking risky drugs only short-term in the hospital setting. Proton pump inhibitors, used to treat heartburn, severe indigestion, and ulcers, are a good example of a medicine that many believe the elderly are over utilizing. The Oct. 23, 2013 article in Hospital and Health Networks Daily states “The percentage of patients taking a proton pump inhibitor varied from 15.8 percent in Grand Junction, Colo., to 45.5 percent in Miami, Fla.” What’s going on? Is the food in Miami that much more “picante” than Colorado? The article continues, “Despite the benefits some receive from taking them (the inhibitors), many would be better off on another drug, particularly given that studies are indicating there can be rare but serious side effects.” This class of drugs seems to be problematic, as many experience a recurrence of symptoms after stopping usage. Yet, in some cases people just don’t know or are never told to take a holiday from using the drug.
It’s easy enough to classify this all as a “patient educational issue.” Okay, you got me there. Patient education is certainly part of the solution. However, when patients go from service to service, or from attending to resident to nurse, or from specialist to generalist, it’s understandable when a patient concludes, “I don’t know better so I will continue the medication anyway.” It’s easy to see why the problem persists as patients are bombarded with information while all they’re really interested in is just getting out the hospital door.
Complications to consider
There are other issues that can contribute to the problem. You have to wonder how many patients continue on medications because they have insurance, and, for example, get the medication for a family member or friend, who does not have insurance. What about patients who get drugs on auto refill from pharmacies even though they don’t need them or because treatment changed to include another drug? What about patients going to multiple pharmacies and providing an incomplete list of their medications from only one of the pharmacies they get medication from? Now consider translation issues, as many patients speak little to no English, which may place the burden of their incomplete medication history on well-intentioned, but uninformed, family members. Also consider those patients with disabilities such as poor vision or memory that make the ability to acquire a medication history almost impossible. Last, consider those patients who bring their medication into the hospital in properly labeled vials. However, these vials contain multiple medications that were placed in the same single bottle which will have to be separated by hospital personnel.
As healthcare continues to rapidly evolve for healthcare professionals, organizations and patients alike, the ongoing problems associated with coordination of medication reconciliation information across the continuum of care continues to play a major role in every healthcare setting today. Government mandates for electronic records will help standardize how healthcare systems enter valuable information and will remove the problem of reading illegible handwriting which can lead to medication errors.
Nevertheless, technology without proper communication between the patient and the multiple disciplines caring for them is still the key. This communication piece is even more vital when considering all the medication-related hurdles that a patient faces from the stressful first steps of admission to the sometimes rushed discharge. This becomes even more vital as the patient reenters the community setting where the patient may need to coordinate this medication information, often alone, between the multiple pharmacies and physicians who are caring for them. It’s hard enough to go through this process by yourself, but is the patient expected to know seven years of pharmacy school to insure that all is well with their medications?
So, that late night in the ER, I asked myself, who in healthcare is the real advocate for the patient in terms of ongoing coordination of medications? It finally occurred to me – that’s why God made a pharmacist. To quote Paul Harvey once again, “Good day!”
Note: The author wishes to specifically thank Dr. William Stratis, B.S., Pharm.D., RPh, Director of Pharmacy Services, New York Eye and Ear Infirmary, of the Mount Sinai-Health System, New York, New York, for his guidance and contributions to this article.
Robert Betz, Ph.D., is President of Robert Betz Associates, Inc. (RBA), a federal health policy consulting firm located in the Washington, D.C. area. Additionally, Dr. Betz is an adjunct professor teaching at The George Washington University where he specializes in political science and health policy. For more information about RBA, visit www.robertbetz.com.