"Bring your meds."
It's a ubiquitous instruction by admissions and office staff when scheduling patients. But how effective is this so-called, "brown bag" review process? Does it reliably result in a complete picture of the pills patients are taking?
We know patients are poor historians. 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 reconciliation, the list of medications in an electronic health record (EHR) includes only those prescribed within the system.
National patient safety initiatives have increased the importance of reconciling medications in the inpatient setting and during transitions. Yet the Institute of Medicine has found that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital. And data show that 26% of readmissions are medication related.
Here's why it's time to get serious about this.
1. Despite mandates, medication reconciliation is remarkably inconsistent.
Based on recent qualitative research conducted with dozens of health system clinical leaders, we found tremendous variability in the consistency and quality of medication reconciliation. It can vary by time of the day, day of the week, and compliance with the organization’s standard policies. Some hospitals employ the evidence-based approach of using pharmacy staff to reconcile at each transfer point. Others don't. Necessary phone calls to the pharmacy and/or prescriber offices don't always happen, especially during overnight shifts. And given the resource and time scarcity in the outpatient setting, reconciliation is frequently rushed, incomplete, or not done at all.
All this variability spells trouble for patient safety, potential adverse drug events (ADEs), and possible readmissions.
2. Time constraints are trumping safety.
Patient safety must always be the overarching reason for everything we do. We owe this to patients; most especially the elderly and the vulnerable, polypharmacy patients who require additional clinical support. What we learned in our research, however, is that patient safety is at the top of the pyramid in principle, but not always in fact. Despite clinical leaders recognizing the need for better medication reconciliation, if doing so adds time or steps, it may not get done, or it is done shoddily.
Hospital admissions and discharges are complex processes. Medical office schedules are chockablock with appointments and have little wiggle room for additional steps. But medication reconciliation is serious business. We must create a way to be more thorough and consistent by changing the way things are done. Patients are counting on us.
3. Medication reconciliation creates an opportunity to discuss adherence.
About 50% of the time, patients don't take their medicine. The reasons are many, but when clinicians probe to uncover them, they can unlock barriers and find solutions to help patients feel better and stay well.
There is an intimate, interrelatedness between adherence and medication reconciliation. Clinicians can ask about the patient's knowledge of the disease state. Explain how a medication impacts the trajectory of their condition. Learn whether the patient is experiencing adverse reactions or side effects. And delicately determine whether non-adherence has something to do with affordability or access. (The American Medical Association has developed an online training module with practical ideas for adherence conversations).
Medication reconciliation and adherence are not divorced discussions and the additional few minutes can make a huge difference in the patient's outcome.
4. EHRs aren't solving the problem.
Our interviews uncovered some inconvenient truths about EHR medication reconciliation features. Although these features may satisfy a regulatory requirement, they are not doing much to improve patient safety.
The common, EHR "checkbox" feature is intended to simplify the medication reconciliation process by giving clinicians the opportunity to review medications and check a box if the patient is still taking them. The reality is that this feature is cumbersome and time-consuming. Often, users check all the boxes so they can click "Next" and keep moving through the screens to finish documenting the visit.
The unintended consequence is not improving safety, and possibly even causing harm.
5. Data gaps are a major issue.
Even if the EHR contains a properly reconciled and accurate list when the patient presents in your facility, it's still missing data from providers and facilities that are not connected to your EHR. These gaps create the ongoing potential for therapeutic duplications, interactions and dosage discrepancies, unless a thorough medication reconciliation is done consistently at every point in the care continuum.
6. Medication reconciliation is vital to preventing readmissions.
Here's a common scenario: The patient with a recent ischemic stroke visits his internist a week after discharge. The medical assistant who rooms him discusses his new discharge medicines, which include warfarin, but doesn't ask what's already in his medicine cabinet; it turns out that he is on citalopram, which was prescribed by a psychiatrist unbeknownst to his internist. The patient ends up continuing to take his citalopram together with warfarin, which elevates his INR and impacts his bleeding risk. A few weeks later, the patient has a hemorrhagic stroke and ends up back in the hospital.
Yes, straightening out issues like this is complicated. Process and training issues as well as workforce shortages and budget cuts all have an influence. But it's time we get serious about addressing them. Mandates, safety initiatives, and EHRs haven't moved the needle all that much. It's time to figure out how we can.
 Reconcile Medication at All Transition Points, http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.aspx
 26% of Readmissions are Medication Related, Study Shows, Anuja Vaidya, August 21, 2017, Beckers Hospital Review. https://www.beckershospitalreview.com/quality/26-of-readmissions-are-medication-related-study-shows.html
 Connected Health Strategies Market Research, May 2018.
 Lee JK, Grace KZ, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial. JAMA. 2006;296(21):2563-2571.