Medication reconciliation is so important to the wellbeing of patients that proof it is done is something that is required by accreditors. But who should do it? Is there someone who is best placed to do it? And if there are multiple people who could do it, do any of them know who is doing it?
A research letter in the March issue of the Journal of Hospital Medicine looked at how various providers — pharmacists, physicians, and nurses — felt about medication reconciliation, who they thought should be doing it, and the problems that arise when there is a “lack of role clarity” surrounding the issue.1
Almost 80 clinicians completed a survey that included questions on whose job it was to complete medication reconciliation at different points during a hospitalization, attitudes about the issue, and barriers to getting the job done, and done well, according to the study. There was little agreement among the respondents about whose job it was from admission through discharge, although most agreed a doctor should decide what drugs a patient should be on during hospitalization and after discharge. There was some disagreement between the kinds of physician — attending and resident — on who got to make that decision, but that it was a doctor was fairly well agreed upon.1
Pretty much everyone agreed that having an accurate list of medications improved patient care, but when asked if any clinician aside from yourself should be responsible for a medication list, 73% of nurses and 52% of pharmacists said yes, but just half of residents and 29% of attending physicians agreed.1
“I think everyone knows this is important, and most doctors do this, even if they do not always write it down,” says lead author Kirby Lee, PharmD, MA, MAS, associate professor of clinical pharmacy at University of California, San Francisco (UCSF) and a clinical pharmacist at the university’s medical center. “Electronic records have a check box for it, but that does not tell you how well the process has been done. And there is no benchmark for it. There is no metric for compliance or for doing it right. Everyone struggles with it. And there are other things that are hot topics now that have replaced this issue in the public eye.”
The process, done well, is time consuming, Lee admits. Medical records are often outdated, patients go to multiple doctors in multiple health systems with computer systems that do not talk to each other. Sometimes the patients are old and confused. Sometimes the patients do not speak English and there is no medical translator readily available.
And yet, he says, you still have to endeavor to do this and do it right.
Divide and conquer
In an ideal world, Lee says physicians or other prescribing providers like nurse practitioners would be the ones to do all the medication reconciliation because they are the ones who make the decisions on what a patient is taking, “and the only way to make a good decision on what to prescribe is to look and see what they are already on,” he says.
In a hospital, where there are multiple physicians and other providers involved, it is better to have a multidisciplinary team which then divides up the task. One member may handle the job on admission, another may look at it on discharge. Different people may have different levels of expertise, he says.
While this is not one of those hot topics like unplanned readmissions, it is something that should be on the quality radar, and you can run a good quality improvement project on it. Lee says a good benchmark to use is discrepancies. “Look at how accurate the person who takes down the medication list is compared to what the patient actually takes. Do they include vitamins or other supplements that patients often do not think of as drugs? Do they include over-the-counter drugs like ibuprofen?”
It is easy to do random audits of a few patients a month and provide constructive feedback. “The issue of forgetting vitamins is a low risk discrepancy,” he says. “But if you forget to write down Warfarin, or put an inaccurate insulin dose, the risk goes way up.”
Lee says that kind of project is “a great use of quality improvement resources and can really help physicians.” You can zero in on patients who take a lot of medications, have multiple comorbidities, or take medications with a high risk of interactions. Patients with chronic illnesses, frequent ED flyers, and those who are more likely to have unplanned readmissions are also good patients to consider auditing. “You do not have to audit every patient, but focus on the panels of patients with the highest risk,” he says.
The general cut-off for “a lot” of medications is 10, he adds, and high-risk medications include those like insulin and anticoagulants, and other medications where the dosages change regularly.
At UCSF they have considered doing a medication list clinic, telling patients they would do a free comprehensive medication interview, but “the patients are not that interested,” he says. “They do not want to come back to the hospital after discharge, and only 20% of them bite.” They are trying again, but this time having physicians refer patients to the clinic.
Use interviews, EHRs
Another idea Lee says they are toying with is to use nursing assistants and pharmacy techs to interview patients and update the electronic health records of patients while they are in the hospital. “In the general medicine hospitalist world, you get all comers, and they really struggle with this issue,” he says. “If you develop a small service of people who are not making decisions about what patients take, but who are just cleaning up the medical record for the physician and inputting clean information, that could be very helpful to the doctors.”
More than one program like this was done in emergency departments using pharmacy technicians with good results, according to published studies.2,3
“This seems like one of those tasks that is a pain in the butt,” says Lee. “But from a patient safety standpoint, and an efficiency standpoint, it is vital. You get this right on admission and again on discharge and you really do save time and improve quality of care. Think outside the box regarding medication reconciliation. You do not have to do something for every patient. But for the patient on 25 meds who has heart failure and diabetes? Medication reconciliation could make a life or death difference.”
For more information on this topic, contact Kirby Lee, PharmD, MA, MAS, Associate Professor of Clinical Pharmacy, Department of Clinical Pharmacy, University of California, San Francisco. Telephone: (415) 502-8182. Email: email@example.com.
- Lee KP, Hartridge C, Corbett K, Vittinghoff E, Auerbach AD. “Whose job is it really?” Physicians’, nurses’, and pharmacists’ perspectives on completing inpatient medication reconciliation. J Hosp Med. 2015 Mar;10(3):184-6. doi: 10.1002/jhm.2289.
- Hart C, Price C, Graziose G, Grey J. A program using pharmacy technicians to collect medication histories in the emergency department. PT. 2015 Jan;40(1):56-61.
- Sen S, Siemianowski L, Murphy M, McAllister SC. Implementation of a pharmacy technician-centered medication reconciliation program at an urban teaching medical center. Am J Health Syst Pharm. 2014 Jan 1;71(1):51-6. doi: 10.2146/ajhp130073.