Med rec initiative achieves 95% compliance
Strategies constant in face of changing guidelines
One of the most challenging of The Joint Commission's National Patient Safety Goals in recent years, at least according to those trying to comply with it, is the goal dealing with medication reconciliation. It has undergone a number of iterations in an attempt to address the complaints that compliance is extremely difficult. Add to that the advent of electronic medical records, or EMRs (perceived as a boon to compliance, but often accompanied by additional challenges), and "meaningful use" standards and the challenge becomes even greater.
And yet the University of California San Diego (UCSD) Medical Center has achieved 95% compliance with its medication reconciliation processes, actually part of an enterprise-wide standard process (for the UCSD Health System).
How was such a high level of compliance achieved in the face of all these challenges? "Mostly through a lot of nagging," says Brian Clay, MD, health sciences assistant professor of medicine and a member of the division of hospital medicine, who has overseen the program. "It's something we've sunk our teeth into for six or seven years; our forms underwent four or five revisions, for example."
The first step in assessing and improving compliance, he notes, involved chart auditing. "I won't say it was totally automatic; it was mostly spot-checks and audits conducted retrospectively," says Clay.
The audit data was sent back to all departments, so they were informed as to what their compliance level was. "Way back when we did it on paper," Clay says, "we empowered nurses to contact doctors if they thought the medication review for admitted patients was not complete."
In addition, he continues, "we kept after people." Now, he adds, in the face of meaningful use requirements the system's EMR has a built-in alert that provides a "hard stop" to the doctor if a patient gets up to the floor and medication reconciliation has not been done. "It's kind of like a speed bump," Clay explains.
The alert does not actually prevent additional action on the computer; the user can choose to ignore it. However, adds Clay, "it comes back in an hour if reconciliation is not done, and it dogs them."
UCSD's medication reconciliation process got its start in 2005, shortly after the NPSG was released. "It was conceived and put together by the pharmacy, bedside nurses, and physicians," Clay recalls. "We went through the National Patient Safety Goal language, some of the very minimal literature available at that time, and tried to piece together individual work steps looking for the right things to do."
Over the course of several months a set of paper forms was created for physicians in order to standardize the format of the admission meds list, and a different form was used for discharge.
"At the time of discharge, the provider would complete the form, telling the patient which medications to continue, which were changed, and which should not be taken any more," says Clay. "For any changed medications or new medications needing a prescription, we had a second form, which was a valid prescription for pharmacies." In those days, a carbon copy was made for the chart, with the original going to the patient.
Not surprisingly, the initial forms did not go without a hitch, so they underwent revisions. "The task force continued to meet with end users about what was good and bad," Clay says.
In late 2005, the hospital started going live on electronic orders, with formal rollout in 2006. "But we still did not have clinical electronic documentation, which put us at a disadvantage," says Clay. "We were asking providers to write down information on the forms, but then turn to the computer and order all meds separately."
The "all-paper" method was actually more successful, says Clay, "but we knew go-live was coming, so we worked in this hybrid fashion for quite a long time." Several attempts were made to build a documentation piece, but the EMR being used at that time was "not very welcoming; it was clunky — not very nimble," Clay recalls. So the effort was abandoned until 2008.
"As with any paper form we had legibility problems, so we added some areas to discharge screens in the computer and asked the provider to type in the medication list," says Clay. "We used prompts to spit out separate medication lists of 'new,' 'same,' 'altered,' and 'should be stopped.'"
Finally, says Clay, that system was "sun-setted," and the Epic EMR was launched in February 2011. "At that time we were able to get rid of the forms because you could document in the system and order directly from it," notes Clay. "We were very happy to get rid of the whole paper enterprise and move forward with an EMR that supported medication reconciliation; it was kind of a long process to get to a single format."
While the new system is much cleaner, it's not perfect, says Clay. "In an electronic system you have 'leftovers,' drugs that are on the list that the patient is not on anymore," he says. "That old material could perpetuate throughout the system. There's not a good way to automatically clean that up because it takes a provider decision to determine that a medication is old."
Accordingly, he says, he has launched "a big education effort" to make providers aware of that weakness. "We have put together some fake patients with common problems, like obsolete meds, and we do one-on-one real-time training with physicians to show how it should be dealt with in the system."
This training will take place over the next six months with internal medicine residents and hospital medicine physicians, Clay says. "We will then have about 120 of them certified to be competent to use the Epic system to reconcile medications," he explains.
In addition, he shares, newly developed materials are being provided to the physicians regarding how to perform reconciliation in the system.
One of the most challenging of The Joint Commission's National Patient Safety Goals in recent years, at least according to those trying to comply with it, is the goal dealing with medication reconciliation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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