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Medication Reconciliation: Comment on “Hospital-Based Medication Reconciliation Practices”

Medication Reconciliation: Comment on “Hospital-Based Medication Reconciliation Practices” Medication reconciliation, in some form or another, is now standard of care in most hospitals and an expectation of The Joint Commission and Accreditation Canada. In their systematic review of hospital-based medication reconciliation practices, Mueller et al1 offer a useful reminder of the literature supporting this widespread adoption and suggest some future challenges. Similar to many contemporary innovations in practice, medication reconciliation is not a single act or intervention. Instead, it involves a “bundle” of related critical elements applied during the high-risk period of hospitalization. Hospitals are grappling with some essential questions: What strategies for medication reconciliation are most effective? Which patients will benefit most? Is admission or discharge reconciliation most essential? Which health care professionals should lead and contribute?2 This review illustrates that medication reconciliation is not a single intervention but rather takes place at various transitions (ie, admission, transfer, and discharge), involves a range of pharmacy expertise (ie, pharmacy technicians to clinical pharmacists), and may variously include all patients or target patients at high risk for adverse clinical outcomes (eg, adverse drug events and rehospitalizations). The heterogeneity of medication reconciliation interventions makes it difficult to say which actions are necessary or sufficient to a good medication reconciliation process. Of the numerous critical elements of the medication reconciliation process covered in the review, 4 warrant specific mention. Preadmission medication lists are critical; the more accurate and comprehensive the preadmission medication list, the easier the medication reconciliation process becomes. Access to all available medication list sources (eg, the patient, electronic medical records, and pharmacy files) facilitates a high-quality preadmission medication list. Best-possible medication history requires a skilled interviewer. Although the literature does not discriminate on who does it best, it does suggest that additional training in taking a best-possible medication history may be required for any health professional to complete an efficient and comprehensive history.3 Transitions of care are vulnerable moments for medication discrepancies to occur and propagate. Identifying these time points focuses effort. Targeted interventions are probably the most cost-effective. Triaging high-risk patients to interventions is essential to maximizing benefit under the constraints of finite resources. However, such targeting needs to be balanced with the expectation for safe practices that can apply to all patients in any high-reliability organization. Many hospitals have embraced medication reconciliation by adding “check boxes” into the medical record to document that medication reconciliation has taken place. Although such efforts do accomplish compliance with The Joint Commission National Patient Safety Goals, they may fall well short of the enhanced interventions needed to improve care and reduce adverse events. Mueller et al1 bring into focus some of the complexities to consider in achieving effective medical reconciliation. How can reconciliation be integrated from hospital admission through discharge (ie, a focus on admission alone may not be enough without a formal link to discharge and beyond)? How are patients genuinely involved in the process with “patient medication counseling” before discharge and postdischarge follow-up? What are the mechanisms for communication with outpatient providers, including explicit delineation of medication changes since admission? And how are automated electronic health record–based processes used to support interprofessional reconciliation? Overall, the review supports medication reconciliation as an important component of safe and effective hospital care. However, it is hard to imagine how the addition of highly trained experts (pharmacists) targeting their efforts on high-risk patients could fail to exert some form of improvement. Although targeted pharmacist interventions in medication reconciliation and other clinical areas (eg, hypertension, lipids, anticoagulation, infectious diseases, and intensive care units) are universally supported in the literature,4 the exact nature of their incremental contribution to improved patient outcomes is not clear. Most likely, this contribution has more to do with a “comprehensive medication management approach,” which includes medication appropriateness, safety, and efficacy assessments, than with mere “matching of medications.”5 However, we lack an adequate supply of pharmacists and financial resources in our already high-cost health care system to deploy pharmacists to all the care settings in which they are needed. Thus, it is incumbent on us to use the literature to guide our identification of high-leverage areas and of team-based approaches to optimize outcomes. This systematic review also points out specific areas in need of further research or implementation in practice. Triage Applying the same intensity of medication reconciliation to every patient at every transition of care is neither efficient nor cost-effective. Future work should examine how to optimally channel the patients who need the most attention and can get the greatest benefit. A combination of human and information technology solutions will be needed. Organizing teams to allow pharmacists to act as consultants on high-risk patients will maximize resources and help ensure that all team members work at the top of their expertise. Although pharmacy technicians or students trained in taking histories may be effective in identifying high-risk patients, the electronic health record may also be effectively deployed. Data mining6 and other algorithms7 can identify high-risk patients based on medications, drug-drug/drug-disease interactions, past health care use, and other characteristics. Triage that can add value without increasing costs will be a true innovation. Process improvement Implementing medication reconciliation in inpatient care is complex and not a one-time effort but rather an ongoing process including local needs assessment, flow mapping of existing processes, and establishment of appropriate metrics of success. In most cases, this process must be performed using existing resources of staff and salary. Some hospitals have effective process improvement systems in place to facilitate implementation, whereas others need help. “Mentored implementation,” during which individuals from one setting (eg, a specific care unit or another hospital) experienced with medication reconciliation serve as mentors to another site, offers one model for successful change. Better measurement Real-time and automated collection of medication discrepancies, adverse drug events, and pharmacist interventions will allow for ongoing measurement and improvement. Pharmacy data and associated clinical outcomes should become part of standard hospital epidemiology practices in much the same way as infection control is integrated into information systems and quality improvement. Systematic reviews such as that by Mueller et al1 allow us to pause and look back at what we know and at the same time guide how we should move forward. The literature supports medication reconciliation, most likely as a bundled intervention of critical elements. As we move forward, we need to better understand how we implement these critical elements to promote high-quality, high-efficiency health care. Back to top Article Information Correspondence: Dr Kaboli, Department of Internal Medicine, Iowa City VA Medical Center, University of Iowa, Hwy 6 W 152, Iowa City, IA 52246 (peter.kaboli@va.gov). Published Online: June 25, 2012. doi:10.1001/archinternmed.2012.2667 Financial Disclosure: None reported. References 1. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review [published online June 25, 2012]. Arch Intern Med2012;172 (14):1057-1069Google Scholar 2. Fernandes O, Shojania KG. Medication reconciliation in the hospital: what, why, where, when, who and how? Healthc Q. 2012;15:42-49Google Scholar 3. High 5s: action on patient safety getting started kit: assuring medication accuracy at transitions in care: medication reconciliation. http://www.high5s.org/pub/Manual/TrainingMaterials/Medication_Reconciliation_Getting_Started_Kit.pdf. Accessed October 22, 2011 4. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955-96416682568PubMedGoogle ScholarCrossref 5. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894-90019433702PubMedGoogle ScholarCrossref 6. Glasgow JM, Kaboli PJ. Detecting adverse drug events through data mining. Am J Health Syst Pharm. 2010;67(4):317-32020133538PubMedGoogle ScholarCrossref 7. Lund BC, Steinman MA, Chrischilles EA, Kaboli PJ. Beers criteria as a proxy for inappropriate prescribing of other medications among older adults. Ann Pharmacother. 2011;45(11):1363-137021972251PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Medication Reconciliation: Comment on “Hospital-Based Medication Reconciliation Practices”

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.2667
Publisher site
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Abstract

Medication reconciliation, in some form or another, is now standard of care in most hospitals and an expectation of The Joint Commission and Accreditation Canada. In their systematic review of hospital-based medication reconciliation practices, Mueller et al1 offer a useful reminder of the literature supporting this widespread adoption and suggest some future challenges. Similar to many contemporary innovations in practice, medication reconciliation is not a single act or intervention. Instead, it involves a “bundle” of related critical elements applied during the high-risk period of hospitalization. Hospitals are grappling with some essential questions: What strategies for medication reconciliation are most effective? Which patients will benefit most? Is admission or discharge reconciliation most essential? Which health care professionals should lead and contribute?2 This review illustrates that medication reconciliation is not a single intervention but rather takes place at various transitions (ie, admission, transfer, and discharge), involves a range of pharmacy expertise (ie, pharmacy technicians to clinical pharmacists), and may variously include all patients or target patients at high risk for adverse clinical outcomes (eg, adverse drug events and rehospitalizations). The heterogeneity of medication reconciliation interventions makes it difficult to say which actions are necessary or sufficient to a good medication reconciliation process. Of the numerous critical elements of the medication reconciliation process covered in the review, 4 warrant specific mention. Preadmission medication lists are critical; the more accurate and comprehensive the preadmission medication list, the easier the medication reconciliation process becomes. Access to all available medication list sources (eg, the patient, electronic medical records, and pharmacy files) facilitates a high-quality preadmission medication list. Best-possible medication history requires a skilled interviewer. Although the literature does not discriminate on who does it best, it does suggest that additional training in taking a best-possible medication history may be required for any health professional to complete an efficient and comprehensive history.3 Transitions of care are vulnerable moments for medication discrepancies to occur and propagate. Identifying these time points focuses effort. Targeted interventions are probably the most cost-effective. Triaging high-risk patients to interventions is essential to maximizing benefit under the constraints of finite resources. However, such targeting needs to be balanced with the expectation for safe practices that can apply to all patients in any high-reliability organization. Many hospitals have embraced medication reconciliation by adding “check boxes” into the medical record to document that medication reconciliation has taken place. Although such efforts do accomplish compliance with The Joint Commission National Patient Safety Goals, they may fall well short of the enhanced interventions needed to improve care and reduce adverse events. Mueller et al1 bring into focus some of the complexities to consider in achieving effective medical reconciliation. How can reconciliation be integrated from hospital admission through discharge (ie, a focus on admission alone may not be enough without a formal link to discharge and beyond)? How are patients genuinely involved in the process with “patient medication counseling” before discharge and postdischarge follow-up? What are the mechanisms for communication with outpatient providers, including explicit delineation of medication changes since admission? And how are automated electronic health record–based processes used to support interprofessional reconciliation? Overall, the review supports medication reconciliation as an important component of safe and effective hospital care. However, it is hard to imagine how the addition of highly trained experts (pharmacists) targeting their efforts on high-risk patients could fail to exert some form of improvement. Although targeted pharmacist interventions in medication reconciliation and other clinical areas (eg, hypertension, lipids, anticoagulation, infectious diseases, and intensive care units) are universally supported in the literature,4 the exact nature of their incremental contribution to improved patient outcomes is not clear. Most likely, this contribution has more to do with a “comprehensive medication management approach,” which includes medication appropriateness, safety, and efficacy assessments, than with mere “matching of medications.”5 However, we lack an adequate supply of pharmacists and financial resources in our already high-cost health care system to deploy pharmacists to all the care settings in which they are needed. Thus, it is incumbent on us to use the literature to guide our identification of high-leverage areas and of team-based approaches to optimize outcomes. This systematic review also points out specific areas in need of further research or implementation in practice. Triage Applying the same intensity of medication reconciliation to every patient at every transition of care is neither efficient nor cost-effective. Future work should examine how to optimally channel the patients who need the most attention and can get the greatest benefit. A combination of human and information technology solutions will be needed. Organizing teams to allow pharmacists to act as consultants on high-risk patients will maximize resources and help ensure that all team members work at the top of their expertise. Although pharmacy technicians or students trained in taking histories may be effective in identifying high-risk patients, the electronic health record may also be effectively deployed. Data mining6 and other algorithms7 can identify high-risk patients based on medications, drug-drug/drug-disease interactions, past health care use, and other characteristics. Triage that can add value without increasing costs will be a true innovation. Process improvement Implementing medication reconciliation in inpatient care is complex and not a one-time effort but rather an ongoing process including local needs assessment, flow mapping of existing processes, and establishment of appropriate metrics of success. In most cases, this process must be performed using existing resources of staff and salary. Some hospitals have effective process improvement systems in place to facilitate implementation, whereas others need help. “Mentored implementation,” during which individuals from one setting (eg, a specific care unit or another hospital) experienced with medication reconciliation serve as mentors to another site, offers one model for successful change. Better measurement Real-time and automated collection of medication discrepancies, adverse drug events, and pharmacist interventions will allow for ongoing measurement and improvement. Pharmacy data and associated clinical outcomes should become part of standard hospital epidemiology practices in much the same way as infection control is integrated into information systems and quality improvement. Systematic reviews such as that by Mueller et al1 allow us to pause and look back at what we know and at the same time guide how we should move forward. The literature supports medication reconciliation, most likely as a bundled intervention of critical elements. As we move forward, we need to better understand how we implement these critical elements to promote high-quality, high-efficiency health care. Back to top Article Information Correspondence: Dr Kaboli, Department of Internal Medicine, Iowa City VA Medical Center, University of Iowa, Hwy 6 W 152, Iowa City, IA 52246 (peter.kaboli@va.gov). Published Online: June 25, 2012. doi:10.1001/archinternmed.2012.2667 Financial Disclosure: None reported. References 1. Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review [published online June 25, 2012]. Arch Intern Med2012;172 (14):1057-1069Google Scholar 2. Fernandes O, Shojania KG. Medication reconciliation in the hospital: what, why, where, when, who and how? Healthc Q. 2012;15:42-49Google Scholar 3. High 5s: action on patient safety getting started kit: assuring medication accuracy at transitions in care: medication reconciliation. http://www.high5s.org/pub/Manual/TrainingMaterials/Medication_Reconciliation_Getting_Started_Kit.pdf. Accessed October 22, 2011 4. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955-96416682568PubMedGoogle ScholarCrossref 5. Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894-90019433702PubMedGoogle ScholarCrossref 6. Glasgow JM, Kaboli PJ. Detecting adverse drug events through data mining. Am J Health Syst Pharm. 2010;67(4):317-32020133538PubMedGoogle ScholarCrossref 7. Lund BC, Steinman MA, Chrischilles EA, Kaboli PJ. Beers criteria as a proxy for inappropriate prescribing of other medications among older adults. Ann Pharmacother. 2011;45(11):1363-137021972251PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 23, 2012

Keywords: medication reconciliation

References