"Bring your meds."
It's a ubiquitous instruction by admissions and medical office staff when scheduling patients. But just how effective is this so-called "brown bag" review process? Does it reliably result in a complete picture of a medication regimen and all the pills patients are taking?
It is well known that patients are poor historians of their medical and medication history. One study showed that about two-thirds of all patients were unable to provide a medication list that matched their pharmacy-prescribed drugs — and that's not even taking into consideration over-the-counter drugs, vitamins, supplements, and other important considerations when documenting a medication regimen. We know that balls get dropped due to the complexities of intake, whether for a scheduled admission or an emergency. And we know that without an effective medication reconciliation process, the list of medications documented in an electronic health record (EHR) will only include those prescribed within the system.
National patient safety initiatives have increased the importance of reconciling medications in the inpatient setting and during transitions. In fact, it's been more than 15 years since The Joint Commission added medication reconciliation as a National Patient Safety Goal. Yet the Institute of Medicine has found that poor communication of medical information at transition points is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital. And data show that 26% of readmissions are medication related.
Understanding the Challenges and Importance of Medication Reconciliation
If we hope to bring about meaningful changes that can improve safety, reduce costs, and ultimately save lives, we must gain a better understanding of why medication reconciliation is such a challenge and why it's such a critical process that deliver benefits which can go well beyond the process itself. Here are six of the reasons why it's time to get even more serious about medication reconciliation.
1. Medication reconciliation remains remarkably inconsistent.
Research has found that there is tremendous variability in the consistency and quality of medication reconciliation. It can vary by time of the day, day of the week, and who is performing medication reconciliation and is often performed in a manner noncompliant with an organization's standard policies. Some hospitals employ the evidence-based approach of using pharmacy staff to reconcile medications at each care transfer point while others take a different approach. Essential phone calls to the pharmacy and/or prescriber offices to request and obtain medication information don't always happen, especially during overnight shifts or when operations are busier than expected. Given the resource and time scarcity in the outpatient setting, medication reconciliation is frequently rushed, not completed, or not performed at all.
All this variability spells trouble for patient safety, potential adverse drug events, and possible readmissions.
2. Time constraints are trumping safety.
Patient safety must always be treated as a priority, with every decision made and process performed with safety at top of mind. This is important for all patients, but especially the elderly and more vulnerable patients, such as those with complex medication regimens who require additional clinical support. What research has showed us is that while patient safety is at the top of the pyramid in principle, reality is often a different story. Despite clinical leaders recognizing the need for better medication reconciliation, if doing so properly and completely adds time or steps, it may not get done, will be completed shoddily, or will be delayed, as we know is often the case for medication reconciliation post-discharge (MRP).
There's no denying that hospital admissions and discharges are complex processes. Physician office schedules are packed with appointments and have little wiggle room for additional steps. But medication reconciliation is not a process that should be squeezed in when time permits. We must take actions and create a way for providers to be more thorough and consistent in performing medication reconciliation at every care transition — without fail. Patients are counting on us.
Fortunately, there are proactive steps that provider organizations can take to improve the accuracy and efficiency of medication reconciliation. This video examines five best practices.
3. Medication reconciliation creates an opportunity to discuss medication adherence.
About 50% of the time, patients don't take their medicine. There are many reasons why, including the cost of filling and refilling prescriptions, forgetfulness, lack of understanding about their medications, and the inability to access pharmacies. When clinicians work to uncover the cause of medication non-adherence, they can then unlock barriers and provide solutions to help patients better adherence with their regimen, feel better, and stay well.
There is an intimate, interrelatedness between medication adherence and medication reconciliation. Consider that clinicians can ask about the patient's knowledge of the disease state, explain how medications impact the trajectory of their condition, learn whether the patient is experiencing adverse reactions or side effects to their medications, determine whether non-adherence involves affordability or access, and then offer meaningful, patient-specific solutions that can achieve meaningful improvements.
Medication reconciliation and adherence are not divorced discussions, and the additional few minutes spent covering them together can make a significant difference in a patient's outcome.
4. EHRs aren't solving the problem.
Research has uncovered some inconvenient truths about medication reconciliation features in electronic health record systems. Although these features may satisfy a regulatory requirement, they are often doing little to improve patient safety and may be causing more harm than good.
The common EHR "checkbox" form/feature is designed to simplify (i.e., fast-track) the medication reconciliation process. It gives clinicians the opportunity to review the medications in a patient's chart and check a box if the patient is still taking them. When presented with this option, users can be tempted to check all the boxes so they can click "Next" and keep moving through the screens to finish documenting the visit. One could argue that this shouldn't qualify as performing medication reconciliation when it's that easy to complete a process which can then lead to potentially harmful consequences.
5. Data gaps are a major — and often overlooked — issue.
Even if an EHR contains a properly reconciled and accurate medication list when a patient presents in the facility, there's a high probability that it's missing data from providers and facilities not connected to the EHR. These gaps create the ongoing potential for problems such as therapeutic duplications, interactions, and dosage discrepancies, unless a thorough medication reconciliation is performed consistently at every point in the care continuum.
Note: It has long been Cureatr's stance that points #2 ("Time constraints are trumping safety"), #4 ("EHRs aren’t solving the problem"), and this point concerning data gaps are at the heart of not only medication reconciliation issues but suboptimal medication management as a whole. Providers are not to be blamed for problems with medication reconciliation; they simply lack the time and training to properly manage medication-related assessments and often do not have access to the comprehensive and contextual information regarding a patient’s medical and medication history. That's why Cureatr has made it its mission to solve this problem by providing comprehensive, 360° medication information and high-touch interventions by board-certified pharmacists with accredited residency training. Learn more by clicking here.
6. Medication reconciliation is vital to preventing readmissions.
Here's a common scenario: A patient with a recent ischemic stroke visits their internist a week following discharge. The medical assistant who rooms the patient discusses the new discharge medicines, which include warfarin, but doesn't ask what's already in the patient's medicine cabinet. It turns out that the patient is on citalopram, which was prescribed by a psychiatrist unbeknownst to the internist. The patient continues to take the citalopram together with warfarin, which elevates the international normalized ratio (INR) and impacts bleeding risk. A few weeks later, the patient has a hemorrhagic stroke and is readmitted to the hospital.
Straightening out issues such as those identified in this example can be complicated, and there are factors that can make removing barriers to poor medication reconciliation more difficult, such as workforce shortages and budget cuts. While some challenges can be resolved, others will inevitably come along. What matters is ensuring that regardless of the challenges faced by healthcare providers, performing the medication reconciliation process properly and completed must never be an option. It should be considered and treated as a requirement — after all, it is.
We know that mandates, safety initiatives, and EHRs haven't moved the needle all that much for medication reconciliation. The good news is there are solutions available that can make an impactful difference for organizations looking to give medication reconciliation the attention and support it deserves. At Cureatr, we've created an eBook that can help you improve medication reconciliation. It's available as a free download here.