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
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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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