Mercy Health to put med reconciliation online
Patients transferred with clear med orders
The Joint Commission in 2006 initiated a new standard that demands "accurate and complete reconciliation of medications across the continuum of care," but nurses and case managers at Mercy Health Center in Oklahoma City were way ahead of them. Long troubled by discrepancies in patients' in-hospital and at-home medications, they already had a solution in the works.
An interdisciplinary team including nursing, physical therapy, speech therapy, occupational therapy, clinical dieticians, pharmacy, pastoral services, medical records, radiology, case management, and a physician representative created a computer-generated discharge home medication order (now an order) that already has reduced duplication and adverse medication events, and is poised to do more.
Eventually, with the addition of a new computer system expected in about two years, the discharge home medication order will generate a medication history that will follow patients through subsequent discharges and admissions, giving clinicians an immediate account of what medications the patient has been prescribed in the hospital and at home.
"When we first put it out [in 2004], medication reconciliation wasn't a safety standard," according to Donna Poole, BSN, RN, nurse manager, who served as nursing informatics coordinator for the project. "We were just doing it because our nurses were asking for help, so we created a tool to help."
The medication reconciliation 'battle'
Medication reconciliation can be one of the more dreaded aspects of care coordination, and a holdup in the discharge planning process.
"We're still battling it," even with the automated order, Poole says.
Patients come into the hospital on medications that their hospitalist might decide to continue, temporarily suspend, end altogether, increase, or pair with other medications; when the patient is ready to return home, it's not uncommon for the patient and family to be confused about what medications to resume, continue, or quit once they leave the hospital.
The discharge home medication order is a computer-based form in three versions drugs brought in at admission, to be continued or changed; medications the patient is prescribed in the hospital, to go with him or be changed at transfer; and medications that the patient is to take at home after discharge. It is populated with hospital formularies as well as home medications so that providers have a clear list – eventually it will cross-match formularies and home meds of what the patient is taking at each step of the way. At admission, during hospitalization, and at discharge, the physician can access the form; change, add, or take away medicines; change doses, and make substitutions, leaving behind an up-to-date, clearly understandable record of the patient's medications and physician's orders. [See sample discharge order].
Because the current computer system doesn't allow the tool to function at what Poole envisions its full capacity to be, there is a good deal of free-text entering that has to be done; eventually, the form will self-populate quickly, and medications will be sorted with like medications and formularies automatically, rather than alphabetically as they do now.
For the time being, nurses have to call physicians who haven't yet adopted the task of filling in the forms themselves, and go down the list to fill out the forms – [which is] time-consuming, Poole admits, but worth it.
"I had a good example recently," says Poole, who does floor duty on occasion. "I had a patient, and suddenly they're going home. The doctor has written orders for the patient to go home, and hadn't printed a [discharge medication] form, so I told the patient it would be about 45 minutes before they could leave, so I could call the doctor to get the [list of] home meds.
"The patient said that I didn't need to do that, that the doctor had told him just to keep taking the medications he was on at home and an additional script he had handed them. So I got out the list of the medications he'd been taking in the hospital; there were two meds that he had been taking in the hospital that he was not taking at home. The family was not sure about those; neither was I as the nurse. I called the physician, and he clarified that indeed, he did want the patient to continue those, but made a change in the frequency. It would have been very easy for them to leave without knowing what the doctor intended for them to take."
Progress isn't held up by wait for computers
As she waits for the computer system that will take the process to near its full capability, Poole says a challenge in the meantime is getting the hospital's 800 physicians to sign on to the process.
"Our nurses are online, but the physicians aren't yet, so we have half paper outputs, half online," she explains. "We still have to generate paper forms to get compliance. But in two years, we'll be totally computerized."
And while inconvenient for now, Poole says the process is still an improvement that is getting better all the time. What started as a worksheet has now become an order sheet, she adds.
"We're working hard on our processes to get us the safest we can be right now we can't wait two years," she explains.
When the system is fully computerized, when a physician opens a patient profile, he or she will see a populated list of medications the patient is already on, and will indicate that he or she has reviewed the medications and whether any changes should be made. The process is repeated at discharge, so the nurse or social worker planning the discharge will have an accurate order at his or her fingertips for advising the patient about the medications to take at home. (The form itself stays with the patient's record, and doesn't go home with the patient.)
A review of the tool in 2006 found the form reduced discrepancies in frequency and dose and reducing therapeutic drug duplication at the time of discharge. Resolution of discrepancies in frequency improved by 65% with the tool. Resolution of discrepancies in dosages improved by 60%, and therapeutic drug duplication was addressed in 58% more cases.1
Transfer form vetted through Six Sigma
Mercy's medication reconciliation phases are being analyzed using Six Sigma, and while the discharge reconciliation form has yet to undergo analysis, the transition form used when patients move from one level of care to another within the hospital has been through the quality evaluation.
"Transition is one area we could catch adverse drug events, and we've perfected that," Poole says. "We have been getting very good compliance on transition."
Compliance at admission will be easier once the process is fully computerized. When patients in the system are admitted to the hospital, the list in their profile will repopulate with their home medications and any medications that were added during their last hospitalization a "historical meds list," Poole says.
One finding that Poole and her colleagues found interesting after the reconciliation order for discharge was in use is that the number of medications ordered at discharge didn't decrease it increased. The 2006 study concluded that the form at that time, a worksheet rather than an order prompts the doctor to clearly specify all discharge medications "instead of giving the common order to 'discharge home, and continue home meds.'" 1
Reference
1. Poole DL, Chainakul JN, Pearson M, et al. Medication reconciliation: A necessity in promoting a safe hospital discharge. J Healthc Qual 2006;28:12-19.
Source
For more information, contact:
- Donna Poole, BSN, RN, Nurse Manager, Mercy Health Center, Oklahoma City, OK. E-mail: [email protected].
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