Web-based Application for Transfer-Discharge

Medication Reconciliation

Nick Honcharik, Pharm. D.

Regional Pharmacy Manager

WRHA

Case – MedRec at discharge

• Mrs DE, 83 presented to ER with nausea, weakness and a history of “passing out’ at home

• PMH: HTN, Diabetes, AFib• In ER significant lab tests:

– Glucose 2.8• Med Hx: Glyburide 5mg bid, Metformin 500mg

bid, Warfarin 4mg daily, Hydrochlorothiazide 25mg daily, Metoprolol 25mg bid.

• Recent discharge from hospital with similar symptoms.

Case review

• Glyburide discontinued last admission, but patient told to resume home medications on discharge.

• The previous admitting physician had intended to discontinue Glyburide but had not stated this explicitly.

Outcome: The repeat admission could have been

prevented and potential harm avoided.

Transfer / Discharge process

• Many WRHA sites had started and moved toward sustaining admission MedRec

• Eagerness to start transfer/discharge process

• Development of a Pharmacy Information System (Cerner/Centricity) generated medication list for discharge MedRec

Electronic Discharge Form

• Easy to read • Avoids transcription errors• Allows prescriber to select the

medications that should continue (or change, stop) at the next level of care.

• Becomes a valid prescription• Community pharmacies love it!• Copy remains in the chart• Closes the loop of communication

between patient, community pharmacies, primary care physician

Transfer / Discharge process

• Unable to spread electronic discharge form due to inaccessibility of form by non-pharmacy personnel

• Trial of manual discharge MedRec - Failed• Some areas/sites do not want to start admission

process without having the discharge process • Discharge MedRec may promote the importance

of admission MedRec and potentially increase compliance

• Briefing note to senior management - pharmacy resources to print discharge MedRec form

Web based MedRec application

• In cooperation with Manitoba e-Health, developed web-based application

• Provides an electronic discharge form for medication reconciliation

• Populates medication information from pharmacy computer system into Discharge MedRec form

• Access given to designated staff members on the unit for generating the form on demand

FAX COVER SHEET

Confidential Facsimile section to be completed when faxing Rx

Physician certification as per legislation

General instructions to Pharmacist

Demographics print on the form

Scheduled medications checked off as “Continue”,“Change” or “Discontinue”

Quantity DEFAULTS to 30 days. Space available to write in different quantity, along with number of refills.

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Pre-admission medications to be restarted or discontinued are indicated in this section

Changes to current medication (dose/route/frequency) written in this section, along with new medication starts

FOOTER - DISCHARGE Medication Reconciliation/Prescription

Physician prints and signs EACH page along with date/time & licence #

Date and time prescription printed

Total number of pages provided

Pediatric Discharge MedRec Rx

DATA ENTRY function of application

Physician Survey HSC Pilot UnitN = 5

Question Strongly Disagree

Disagree Neutral Agree Strongly Agree

Form easy to access 2 1 1 1

Accurate med list 1 2 2

Easy to use 1 1 1 2

Helpful in the Discharge

process

2 1 2

Saved Time compared

to traditional process3 2

HSC Pilot Unit Discharge AuditJune 21-27, 2010

• 14 charts audited– 79% (11/14) had a discharge MedRec form

• 10/11 with a discharge MedRec had an Admission MedRec

• 10/11 had a “prn” med continue• 8/11 had the last page available

– 5/8 completed “pre-admission” section

HSC Pilot Unit Discharge AuditJune 21-27, 2010

• Done Well• Form was reviewed and signed the same day generated• All decision boxes checked off – i.e. no orders missed

(scheduled or PRN)• Each page was stamped with “COPY”

• Improvement Needed• Ensuring ALL pages are in the chart• Completion of “pre-admission” section• Filling of the form in the orders section of the chart

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MedRec Example

Admission to Discharge

EXAMPLE OF COMPLETED MEDICATION HISTORY

Completed MedRec Discharge Form

PRN medications

are reconciled

Each page is invalidated