Improving efficiencies in medication reconciliation: The McGill Story

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Improving Efficiencies in Medication Reconciliation - The

McGill StoryReview of Challenges and Potential Benefits of

Using IT-Enabled Medication Reconciliation

Robyn Tamblyn, BScN, MSc, PhDProfessor, Department of Medicine and Department of Epidemiology and

Biostatistics, McGill University, Faculty of Medicine

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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.

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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.

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Canadian MedRec Quality Audit month.

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• 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.

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We want to hear from you

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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.

Review of Challenges and Potential Benefits of Using

IT-Enabled Medication Reconciliation

August 2013

BackgroundFailure 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 51. 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.

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

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 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 computerizedmedication reconciliation system

Turchin A, Hamann C, Schnipper JL et al. JAMA 2008

•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 TrialSchnipper J. L et al. JAMA 2009

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

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

Medication reconciliation is a requiredorganizational practice for hospital accreditation

MedRec Accreditation20

13 • 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

RxRx

Rx

RxRx 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 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

Secondary Objectives:

To measure:

Failure to re-prescribe chronic disease medications

Therapy duplications

Time to complete the MedRec process

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

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

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.

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

MOXXIservers

RAMQDatabase

Hospital database

Signed printed prescriptionbrought to community pharmacy

RightRxservers

Accessing RightRx through hospital Electronic Health Record

The MedRec Process

1. Collect and evaluate community medication list

‘Prior to Admission’ tab

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ - Expanded view

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ - Expanded view

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Medication Validation

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Validation of Adherence

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Validation of Adherence

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ - Validation of Adherence

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Adding a medication

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Adding a medication

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ – Adding a medication

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ –Validated list

Prior to admission DischargeAdmission Review/Transfer

‘Prior to Admission’ –Validated list

2. Medication Review

‘Admission Review/Transfer’ tab

Prior to admission DischargeAdmission Review/Transfer

‘Admission Review/Transfer’- In line validation –Continuing a medication

Prior to admission DischargeAdmission Review/Transfer

Prior to admission DischargeAdmission Review/Transfer

‘Admission Review/Transfer’- In line validation –Stopping a medication

‘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/Transfer

‘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 number

Retrieves scrambled physician license number from RAMQ along with medication list

Discharge prescription

Fax changes toprescribing physicians in the community

MOXXIservers

RAMQDatabaseRightRx

servers

Link with College of Physicians file to retrieve physician coordinates PHIRE

DatabaseCMQ file

Pharmacy fax number data flow Patient consent

Retrieves medication and pharmacy coordinates from RAMQ but missing fax number

Discharge prescription

Fax changes tocommunity pharmacies

MOXXIservers

RAMQDatabase

RightRxservers

Link with Order of Pharmacist’s (OPQ) file to retrieve pharmacy fax number

PHIRE DatabaseCMQ file

Match RAMQ pharmacy coordinates with OPQ file

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

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

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

robyn.tamblyn@mcgill.ca

Thank you!

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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.

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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

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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.

www.saferhealthcarenow.ca69

We encourage you to report medication incidents

Practitioner Reporting https://www.ismp-canada.org/err_report.htm

Consumer Reportingwww.safemedicationuse.ca/

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We want to hear from you one more time

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