According to Anne Myrka, a drug safety pharmacist at IPRO (the CMS-designated Quality Improvement Organization for New York State), “If you want to do medication reconciliation correctly, you have to start with a medication management process.” (IPRO leads the Medicare-funded Atlantic Quality Innovation Network, or AQIN, which heads up quality improvement activities in New York, South Carolina, and the District of Columbia.) Ms. Myrka is also faculty for the IHI Expedition on Improving Medication Safety from the Patient’s Perspective. In this interview with IHI Content Development Manager Jo Ann Endo, Ms. Myrka recommends tools and strategies to help with this perennially challenging process.
Why do you think medication reconciliation continues to be a struggle for many health care providers?
I think most institutions fail to perceive medication reconciliation as part of a larger medication management system. Instead, they often think of it as just a checklist they need to complete for which everybody is responsible and no one does it well, rather than having clear accountability, responsibilities, and roles delineated. They also fail to take into account that certain aspects of medication reconciliation really need a credentialed person to do them. By credentialed I mean a trained person. For example, getting the best possible medication list by doing a patient or caregiver interview should be a process that is taught explicitly and evaluated so that the staff person [conducting the interview] understands how to do it appropriately.
Another area that requires an intervention is pharmacotherapeutic intervention. Pharmacotherapeutic interventions involve the identification and resolution of medication-related problems, including assessment of adherence to evidence-based guidelines and clinical appropriateness of therapy. We could get the best possible medication list, but just getting the list is the tip of the iceberg. You really need a pharmacotherapeutic evaluation done by a pharmacist to ensure that the therapy is appropriate. We don’t want to forward a list with inappropriate medications on to the next provider.
What are the keys to successful medication reconciliation?
The key to successful medication reconciliation is seeing it as part of a larger medication management system with clear executive leadership owning that system, a robust quality improvement process integrated [into that system], and staff education. Also, getting the best possible medication list from multiple sources, understanding how the patient takes their medication, and having the best possible patient or caregiver interview regarding medication history.
Another area is pharmacotherapeutic interventions when appropriate and targeting the correct population for those interventions, such as the elderly or patients that are returning or going to, or coming from, a skilled nursing facility. Certain populations and drug categories should have explicit attention paid to them from admission through intra-facility transfers and to discharge. Some of those medications would include anticoagulants, opioids, and hypoglycemics among others. Antibiotics can be problematic. Other narrow therapeutic range drugs can be problematic.
How does improving the medication reconciliation process help reduce unnecessary hospital readmissions?
Studies show that improving medication reconciliation processes can reduce readmissions. In one particular randomized controlled study, they found a 16 percent reduction in readmissions when a pharmacist performed med rec on those targeted high-risk populations or drug categories and performed a pharmacotherapeutic intervention. High-risk populations would be the elderly or skilled nursing facility residents. High-risk drugs would be opioids, anticoagulants, or hypoglycemics.
Is there a business case for improving the medication reconciliation process?
Yes, there is. Resolving discrepancies through the medication reconciliation process can reduce adverse drug events [ADEs] and readmissions due to ADEs. There are estimates that each ADE readmission costs anywhere between $5,000 and $10,000 per event. If you were a hospital that had, say, 15,000 discharges a year and you prevented 1 percent of adverse drug event readmissions that would translate to 150 patients. At anywhere between $5,000 and $10,000 per event, [that amounts to an estimated] $750,000 to $1.5 million in cost savings. You could very appropriately use those savings in the pharmacy department to train staff, credentialing them to do appropriate patient histories and reinvesting in the culture of the hospital for medication safety.
There are two resources I can recommend to help institutions understand how to do their own return on investment calculations: the MARQUIS Implementation Manual developed by the Society of Hospital Medicine, and the Medications at Transitions and Clinical Handoffs (MATCH) Toolkit. Both are medication reconciliation toolkits developed with AHRQ grant support.
Would you describe the new tool you recently helped to develop, aimed at reducing anticoagulant-related adverse drug events?
The IPRO drug safety team developed the Anticoagulation Discharge Communication (AC-DC) Audit Tool as part of our work to reduce readmissions due to adverse drug events in care transitions communities (including hospitals, nursing homes, home health care agencies, and community-based organizations). The tool came out of a pilot project that ran from January 2014 to July 2014 in which volunteer care transitions communities evaluated their internal anticoagulation-related communication practices upon patient discharge to the next provider.
The tool contains audit criteria questions drawn from a range of evidence-based resources. It includes questions like, “Is there an indication for use?”, and if the drug is used for short-term therapy (say, for example, warfarin post-surgery), “Is there a stop and end date?”
The hospital and the nursing homes in the pilot project demonstrated statistically significant improvement. We’re now going to apply this process to the rest of our care transitions communities for the rest of the scope of work and also expand to other high-risk drugs like opioids and hypoglycemics and possibly antibiotics.
This tool is essentially to improve communication. Would you talk about communication as an overarching medication reconciliation issue?
We want clear, concise communication that not only provides information but can lead the next provider to the correct clinical steps to avoid adverse events. We don’t want a 50-page booklet, right? We aim to standardize this communication process in all of our care settings within our care transitions communities.
Another important part of communication is patient and family engagement. For example, when the patient enters the hospital ED and they have a paper artifact like their medication list or their Medical Orders for Life-Sustaining Therapy (MOLST), what happens to that piece of paper? Do you have a process for entering it into the medical record so a clinician can act upon the information in a timely manner? If not, you’re not listening to the patient and the patient has something important to say. Once you have a comprehensive medication management system and you have staff trained in the medication reconciliation process, then the process will move more smoothly. Organizations can solve these problems, but you need intensive effort and executive-level leadership to remove barriers and improve processes.
In some cases, there is disagreement about who should ultimately be responsible for medication reconciliation. How should that be determined?
The question is, how do you determine who is responsible for medication reconciliation if nobody’s responsible? Some might say, “I don’t have time for it.” Others might say, “I know it makes sense, but I have to do x, y, z instead.”
Organizations that do medication reconciliation well create a quality improvement program around the process. The literature – and resources like the MARQUIS Implementation Manual and the and the MATCH Toolkit – recommend that organizations develop a charter and garner executive leadership immediately. The charter should clearly delineate roles, responsibilities, and accountability. You’ll have your clinical champions who are nurses on the unit, pharmacists on the unit, and other clinicians. You might have a social worker. You’ll have IT. You’ll have a lot of people who have clear roles and responsibilities outlined in that charter. If you want to do medication reconciliation correctly, you have to start with a medication management process.
This material was prepared by the Institute for Healthcare Improvement in collaboration with the Atlantic Quality Innovation Network/IPRO. The Atlantic Quality Innovation Network/IPRO is the Medicare Quality Innovation Network Quality Improvement Organization for New York State, South Carolina, and the District of Columbia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.11SOW-AQINNY-TskC.3-15-08