Monday, September 18, 2017

Medication Reconciliation

The Medication Reconciliation Process
Medication reconciliation has become a term that is much en vogue after the Joint Commission and electronic health record (EHR) manufacturers got a hold of it.  Medication reconciliation (MR) basically means that anytime a patient changes health care setting there needs to be a procedure in place to assure that their medications are not changed as a result of that transition - no medication errors can be made.  The best example is a patient goes from an outpatient setting into a hospital for surgery, has the procedure done and is discharged.  This care transitions would require a medication reconciliation at the time of admission and another one at the time of discharge.  Prior to the EHR, a physician would just transcribe the admission orders rewriting or modifying the patient's outpatient medication as necessary.  With the EHR, the MR can be rapid if the patient and the medication are already in the system, or it can be a very slow process if they have to all be entered from scratch.

In my 22 years of inpatient experience, I have a lot of experience with this process.  I would be the recipient of shopping bags full of medications and learn that some patients were taking greater than 20 medications at a time.  Most of my time on inpatient units, I was in charge of reconciling all of the patient medications - medical and psychiatric on the patients I admitted and discharged.  In extreme cases this process alone could take an hour on either end.  It got a lot worse over time because more people were inserting themselves in the process.  Pharmaceutical benefit managers learned to demand  an entirely new prior authorization process, even for medications that the patient had been taking for years - at the time of discharge.

The reconciliation process has several modifications based on the care model.  For example, in less acute care settings where physicians are not present in the facility at all hours, on-call staff call in and do remote medication reconciliation.  Before the EHR that would involve a discussion with nursing staff who would review the medication, the patient's status and put in the orders.  The physician would countersign these orders the next day.  In current EHRs, there is a med reconciliation section and there may be an expectation that the reconciliation occurs at the time of admission.  Nursing staff will typically enter the medications from available bottles or pharmacy records.  The physician has to pull up the record remotely, review the patient's status with nursing staff, and sign off on the entered medications.  In some systems, only the basic prescription is ordered and the physician will have to complete numerous fields before the inpatient orders are complete.  Modern EHRs invariably include drug interaction software with very low thresholds and all of those warnings need to be clicked through and dismissed before the patient's usual medications can be resumed.  It is a very slow and inefficient process compared to before the EHR.

One of the rationalizations for the MR in the EHR is patient safety.  Regulatory bodies like the Joint Commission are very big on safety factors and they should be.  The EHR was supposed to greatly reduce errors due to illegible written orders, but in this case the physician was giving verbal orders to nursing staff.  A quick glance at the graphic at the top of the page illustrates some of the thought and decision making that needs to go into this process.  There is really no known way to make it fool proof.  Subjective determinations about medications and medication safety are being made at every step of the way.  Errors in MR still occur largely because of the assessment required by nursing and in this case psychiatry.  The easiest way to conceptualize this is to think about people who take prescriptions and whether they take the medication exactly as it is prescribed on the label.  The commonest problems involve patients taking their medications at the wrong time or all at once.  Often they have been advised by their physician to make a change but the prescription has never changed.  In many cases they have stopped the medication and want to restart it.  The prescribing physician may not know that the patient is using alcohol, other substances, or nutritional supplements with the prescription.  Continuing medications, stopping them or modifying them requires significant clinical judgment and there may be a lot of uncertainty about the history obtained.

Medication reconciliation is a complex and potentially lengthy task.  It works best with experienced nursing staff who can get the best information to the prescribing physicians and then physicians who have good clinical judgment and flexibility to adapt to changing histories.  It is a potential area for artificial intelligence applications.  AI could assist nursing staff without replacing them.  We need an optimal algorithm and a full description of the decision space associated with this process.  Most importantly we need computer applications that support staff rather than getting in their way and requiring staff support of their own.

One of the most interesting aspects of the current conceptualization of medication reconciliation is how it is perceived by administrators and regulators.  The idea that medications can be entered into a piece of software that is essentially a word processor and that makes things right is almost magical thinking to me.  All of the hard work leading to that conclusion (see graphic and beyond) is not only ignored - but nobody seems to get credit for it.  It is the old rationalization: "If it isn't documented it didn't happen."  This is clear proof that most of what happened isn't documented.  If would be impossible to function if it was.  At some level it appears that all of this hard work was produced by the EHR and not physicians and nurses.  Credit to the geniuses who came up with the software and the administrators who decided to put it in.  How did we ever practice medicine without them?

We end up documenting what we are told to document and it is a poor substitute for what actually happened.  Some of the underlying reasons for that documentation are almost always political.    

George Dawson, MD, DFAPA

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