A high-tech approach to medication reconciliation

Data flow directly into the EHR

There is no question that hospitals face innumerable challenges in meeting the "meaningful use" of health information technology (HIT) criteria established by the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. However, it is also becoming clear that among the first to benefit from HIT enhancements are hospital EDs, where the ability to access patient information quickly can be especially important.

The ED at Inova Alexandria Hospital in Alexandria,VA, is a case in point. With the touch of an icon, clinicians here can quickly find out what prescriptions a patient is taking, regardless of where in the country these prescriptions were filled, explains Martin Brown, MD, FACEP, chairman of the Department of Emergency Medicine at Inova Alexandria Hospital. This capability is part of a pilot program involving the Northern Virginia Regional Health Information Organization (NoVaRHIO), the non-profit group established in 2007 to facilitate the electronic exchange of health information for providers in northern Virginia. However, project administrators say the idea is to eventually expand this capability to all providers in the region, and to extend the information-sharing capacity to include laboratory results, radiologic studies, and other health information as well. Experts say the pilot offers an early glimpse of efficiencies and safeguards that will be possible when the nation's health care infrastructure has been completely wired.

While NoVaRHIO operates in the interests of all the region's hospitals, physicians, and residents, it was clear early on that Inova Alexandria Hospital was best suited to be the pilot site for this project, says Brown. "NoVaRHIO needed a pretty big site that was willing to participate," he says. "It was a risk [for the hospital] in terms of time commitment and operational complexity, but it was worth taking that risk given the potential benefits."

The considerable groundwork for the project was completed by IT consultants, who worked with NoVaRHIO and the hospital's IT department before clinicians were ever involved, says Brown. This phase of the project involved creating the IT tools needed to get different databases to communicate with each other. However, Brown points out that the system is still being tweaked to operate more efficiently.

"What is unique about this project is that we are completely integrating [the pharmacy data] into the electronic health record at Inova Health Systems," explains Edmond Magny, PMP, an HIT expert who is managing the project for NoVaRHIO. When a query for a patient's medication history is made to the system, the information flows directly into the health record for the physician to consume, he adds.

"It allows physicians to stay within their native electronic health record as opposed to going to a different portal or going through several steps," he says. "Physicians are very keen to do exactly what they are trained to do, and not having to do 15 steps in order to get somewhere, so making sure it fits into their workflow is absolutely critical."

For this kind of seamless information sharing to take place, information coming into the hospital from a pharmacy benefit manager [PBM] must be transformed into a continuity of care document (CCD), a standard type of document that any certified electronic health record must be able to accept, explains Magny. And this is the critical step that the health information organization provides.

While the IT aspects of the project are complex, clinicians have found the tool to be user-friendly. "It took just a few minutes to show physicians and physician assistants how to use the system," says Brown. "For nurses, it is just a little bit more complicated because they are responsible for documenting the medications, but it is still very simple."

Since the approach is still a pilot, the hospital decided to ask patients for their consent before querying the IT system for the patient's medication history, says Brown. This takes place right at registration, and thus far, 80% to 90% of patients have agreed to the search, and the rest of the patients probably just don't understand what they are being asked, he says.

It takes a few minutes for the pharmacy record to feed into the hospital's electronic medical record, but "by the time I pick up the patient in the back, there is something for me to click on that will show me what was sent from the [PBM]," says Brown. "The patient might have filled a prescription in Los Angeles three days ago or filled it around the corner two months ago, but it will show up there."

A nurse or physician always confirms with the patient that he or she is taking the indicated medications, but the hospital has found the information to be accurate in every case thus far, says Brown. And there have been some instances where the information may have prevented serious adverse events.

For example, Brown recalls the case of a woman who came into the ED and provided the nurse with information about what medications she was taking, but when the nurse clicked on the icon for the medication history information, she learned that woman was taking Coumadin, a blood thinner that is known to interact with many medications. The woman forgot to mention that she was taking Coumadin.

"Patients may know some or most of the medications they are on, but they don't always know which ones are important, and they can forget the important ones," says Brown. "That has happened more than once."

The capability is also valuable in instances where elderly or chronically ill patients who take several medications come into the ED and aren't sure of the specific names of all of their medications. The ED at Inova Alexandria hospital isn't a trauma center, but Magny points out how helpful this information would be in cases where the patient is incapacitated.

"If the patient is unconscious and came via ambulance, and all you have is the driver's license in his wallet, how is the doctor going to know if the patient is taking anticoagulants, antibiotics, or anything else?" says Magny. "You really don't know, so you are taking a guess, and medication errors are one of the biggest causes of adverse events in a hospital."

At press time, the medication history pilot at Inova Alexandria still had a few more months remaining, and technical glitches were still being worked out, according to Brown. But he anticipates that the approach will become routine practice in the ED.

"We think this kind of system will improve the safety of our medication practices in this department," says Brown. "We haven't proved that yet. It is still too early in the game to say we have proof that is the case, but it seems intuitive and logical that if this information is proven out to be consistent and reliable, that our medication use in the ED and our diagnostic and treatment decisions in the ED will be inherently safer based on the information we have early in the visit."

As health information exchanges (HIEs) continue to develop, Magny says hospitals will be able to further leverage their functionality and the value that HIEs provide. "Every state has at least submitted plans for an HIE. Not every state has one yet, but in the future, every state will have an HIE, if not multiple HIEs."