Designing the Process Part II

D. Designing your Process - Example Models

To help illustrate key elements and principles described in this toolkit, the following are example design models for medication reconciliation highlighting the concepts of: "one source of truth," a multidisciplinary approach, and integrating medication reconciliation into workflow.

Inpatient and outpatient practice settings and different medical record systems (an electronic medical record, a paper-based system and a hybrid system [electronic and paper-based]) are provided to illustrate examples in a variety of healthcare environments.

D1. Inpatient Practice Setting

Example #1 - Integrating Medication Reconciliation within Handoffs and Transitions in Care Upon Hospital Admission

One goal for medication reconciliation is to standardize and simplify the process throughout your organization. Oftentimes, there are nuances that may exist within various practice settings creating challenges for medication reconciliation when patients transition through your hospital. It is important to recognize and understand these nuances, modify them as appropriate to minimize variations, and then integrate them into your overall process design.

For example, let's say a patient directly admitted to an inpatient unit is your CORE PROCESS, which is illustrated in the diagram below.

Medication Reconciliation Inpatient Process: Admission Origin - Direct Admission to an Inpatient Unit (CORE PROCESS) (PPT)

Earlier in this section, tools were provided for you to map out the various admission points in your organization. Now, consider a couple questions:

• How can each of your admission points be integrated into your core process?
• Could a discipline(s) within each admission point initiate building your "one source of truth" and/or confirm the list with the patient for "accuracy and completeness?" This can help support reconciliation efforts on the inpatient unit once the patient's medication orders are written and treatment plans are determined.

Below are example diagrams to illustrate how admissions through ambulatory surgery, procedural areas, the Emergency Department or Labor and Delivery (Triage) areas can all be integrated into the core process design during hospitalization.

Medication Reconciliation Inpatient Process: Admission Origin - Ambulatory Surgery Unit or Procedural Area to an Inpatient Unit (PPT)

Medication Reconciliation Inpatient Process: Admission Origin - Emergency Department to an Inpatient Unit (PPT)

Medication Reconciliation Inpatient Process: Admission Origin - Triage/Labor and Delivery to an Inpatient Unit (PPT)

Example #2 - Medication Reconciliation Upon Admission, Intra-Hospital Transfer and Discharge in a Hospital with an Electronic Medical Record

a) Admission

The Med Profile within a patient's electronic medical record is the "one source of truth" for viewing a patient's inpatient medication orders and prescription/home medication list all in one location. The Med Profile is pulled into forms or presented during situations when patients' current medication lists are obtained and documented (i.e., making the right thing to do easier).

Within an electronic medical record, incorporating medication reconciliation steps into a physician's workflow may include:

• Prompts to complete medication reconciliation when placing an admission or post-op order set
• A form integrated with the "one source of truth" to document and/or confirm the patient's current medications
• A selection of radio buttons to indicate the accuracy and completeness of the patient's medication list
• A comment section to document needed follow-up and the plan for home medications (i.e., discontinue, continue, etc.) in relation to the intended treatment goals for the episode of care

Below is an example of a physician medication reconciliation form within an electronic medical record. In this example, the physician is presented with the form when placing an admission or post-op order set.

Example - Physician Medication Reconciliation Form within an Electronic Medical Record (PDF)

Depending on the care unit, incorporating medication reconciliation steps into the nurse and/or pharmacist workflow may include:

• Receiving a task after the physician completes medication reconciliation to verify home medications documented by the physician with the patient, family and/or other sources
  • Verification is an important step as patients oftentimes forget to mention medications or omit over-the-counter/herbal supplements during the initial medication collection.
  • This verification step also provides an educational opportunity to teach patients about the medications ordered for them in the hospital in relation to their home medications, and comment on any differences.
• Enabling nurses and/or pharmacists to first page the physician if the patient's home medication list is blank and then start the list, adding medications they learn about during the patient interview.
• Adding, deleting or changing any discrepancies in the home medication list and discussing changes with the physician.
• Reconciling home medications with current inpatient orders.
• Clarifying unintended discrepancies (i.e. discrepancies that are not explained by the current care plan, by the patient's clinical status or formulary substitution) with the physician for resolution.
• Completing a discipline-specific form with radio buttons and comment sections to document interactions and clarifications with patients, other sources and the prescriber.

Below are examples of a nurse and pharmacist medication reconciliation forms within an electronic medical record.

Example - Nursing Medication Reconciliation Form within an Electronic Medical Record (PDF)

Example - Pharmacist Medication Reconciliation Form within an Electronic Medical Record (PDF)

b) Intra-hospital Transfer

When a transfer order is placed indicating the patient is ready for transfer to another unit within the hospital, the physician may receive a prompt or reminder to perform medication reconciliation. Instructions may be included for the physician to:

• Assess current medication orders and make any changes or modifications in preparation for the new level of care
• Review the patient's pre-admission medication list. For example, home medications initially held may now be appropriate to restart upon transfer.

Nurses and/or pharmacists may be involved during intra-hospital transfers to ensure medication orders for the new level of care are consistent with desired treatment plans and to provide an independent double check that pre-admission medications initially held are appropriately restarted.

c) Discharge

Physicians may be prompted or reminded to perform medication reconciliation when placing a "discharge order," indicating the patient is ready for discharge. A discharge checklist could also be created listing elements that need to be completed prior to discharge (ex. remove heplock, perform medication reconciliation, prepare discharge medication list, educate patient, etc.). The goal for discharge reconciliation includes:

• Comparing the patient's pre-admission medication list with the patient's current inpatient medications.
• Updating the patient's pre-admission medication list, if needed, to reflect the medication regimen the patient will be discharged with. This list may be integrated into Discharge Instructions (for patient) and Discharge Summary (for next provider of service).
• Communicating the patient's discharge medication list (e.g. via email, voicemail, fax or paper documentation) to the next care provider (includes primary care physician).
• Giving the patient's medication list to the patient/caregiver at discharge, highlighting any changes.

Below is an example of an electronic discharge instructions template, with contents suitable for customization.

Electronic Discharge Instructions Template (PDF)

Discharge medication reconciliation may be integrated within the nurse and/or pharmacist's discharge workflow with a prompt or instructions to:

• Contact the physician if the patient's discharge medication list is not updated and/or complete (note: when establishing roles and responsibilities for preparing patients' discharge medication lists, it should be clearly understood that a blanket statement such as "resume home medications" is not acceptable).
• Contact the physician to clarify patient questions prior to discharge

Below is an example of a nursing Discharge Form to illustrate this step.

Example - Nursing Discharge Form within an Electronic Medical Record (PDF)

Documentation information contained within the example physician, nurse and pharmacist medication reconciliation forms will be discussed in "Education and Training" section.

D2. Outpatient Practice Setting (e.g., Procedural Areas; Same Day Surgery Unit; Emergency Department)

Example #3 - A Team Approach for Medication Reconciliation within an Outpatient Setting

Similar to hospitalization, outpatient areas may also adopt a team approach (i.e., physicians, nurses and pharmacists) for medication reconciliation.

• The nurse may start building the "one source of truth" upon entry to your organization.
• Verification and updates can occur by the physician in preparation for the procedure or surgery.
• The nurse and/or pharmacist can then screen and reconcile medications to be administered during the episode of care against this list.
• Upon discharge, the physician can review the patient's home medication list to determine if any additions, deletions or modifications need to be made based on the episode of care.
• The nurse and/or pharmacist can then review the discharge medication list with the patient/caregiver to ensure the patient fully understands new medications added and/or any modifications or deletions.
• The patient's discharge medication list is communicated to the next provider of care (PCP, nursing home, another hospital, etc.).

Example #4 - Integrating Medication Reconciliation in an Outpatient Setting with a Paper-Based or Hybrid (Paper Plus Electronic) System

For outpatient areas still on paper, a paper form to document patient's current medications upon admission (i.e., "one source of truth") can be developed for screening patient's current medications against medications to be administered during the episode of care to assess for any potential drug interactions or contraindications.

This form can also be used at the time of discharge for:

• Determining if any additions, deletions or modifications need to be made to the patient's home medications based on the episode of care.
• Updating the patient's prescription/home medication list accordingly and highlighting any changes for the patient.

The list can be reviewed with the patient/caregiver by the nurse and/or pharmacist to ensure the patient fully understands their new regimen and/or any modifications or deletions. The list should be communicated to the next provider of care (PCP, nursing home, another hospital, etc.) and a mechanism for this to occur should be determined.

As an example, below is a paper-based medication reconciliation form, suitable for customization and use within an outpatient area, such as a procedural area.

Medication Reconciliation Form for Procedural Areas (PDF)

Some areas may utilize a hybrid approach - paper-based and electronic medical records. For example, upon entry (admission), an electronic medical record may be used to document patients' current medications within a "one source of truth." Paper discharge instructions tailored for a specific procedure/surgery may be utilized at discharge.

Within a hybrid system, physicians may update the patient's pre-admission medication list accordingly within the electronic medical record. This list could be printed out to supplement paper discharge instructions currently in use. Alternatively, each discharge medication could be transcribed by hand onto the paper form to create a complete discharge medication list for the patient. Creating an electronic discharge medication list to supplement paper discharge instructions may help decrease transcription errors when copying prescription/home medications within the electronic medical record onto paper discharge instructions.

Below is an example of a discharge medication list template which may be prepared within an electronic medical record and then printed out to supplement paper discharge instructions.

Example Discharge Medication List Template (PDF)

E. Special Considerations

E1. External Transfers

An external transfer patient is defined as a patient that is transferred from a hospital outside of your own system to your hospital. Such transfers may occur based on patient or provider request, specialty services required or for additional acute care needs. External transfer patients have additional complexity in regards to medication reconciliation because three sources of information require review and reconciliation:

• Patient's list of medications prior to their hospitalization
• Medications that are being administered to the patient at the outside hospital prior to transfer
• Medications ordered at your hospital

If your organization receives transfers from other hospitals, you should ensure a process is in place to address these reconciliation needs. Adequate communication and handoffs from the sending facility is critical to ensure all medication therapies are addressed and reconciled during the assessment and development of the patient's care plan at your organization.

E2. Limited English Proficiency

Patients with Limited English Proficiency (LEP) are individuals for whom English is a second language and/or may have a limited ability to speak, read, write or understand the English language at a level that permits them to interact effectively with healthcare providers. Learn more about interpreter services  to facilitate communication and interaction when obtaining medication histories and providing medication education to patients with LEP.

F. The Ideal Medication Reconciliation Process

If your medication reconciliation process could be entirely customized without any limitations or barriers, what would it look like?

The following describes core components of an ideal medication reconciliation process:

• Fully electronic and automated
• Standardized process across all care settings
• Multidisciplinary, team approach
• A single list (i.e., "one source of truth"), utilized by all clinicians within a care setting, to document and validate patient's current medications upon admission (entry). Ability to electronically convert home medication documentation into a medication order for administration during the episode of care and to electronically convert into a prescription upon discharge.
• Electronic access (connectivity) and integration of patient's medication information from various sources (i.e., patient's current medication information from community pharmacies, physician offices, past medical records, etc.) which could automatically populate your electronic medical record.
• Fully integrated into the clinician’s workflow with effective prompts, reminders and/or forcing functions
• Fully integrated into the management of patients' medication regimens (not considered an "additional task")
• Healthcare information technology with advanced clinical decision support that (a) integrates documented care plans with the patient's current (i.e., home) medication regimen obtained from various sources (i.e., patient, community pharmacies, multiple physicians, etc.), (b) compares this information to the medications ordered during the episode of care, (c) electronically identifies unintended discrepancies, and (d) alerts clinician of discrepancies, by type of discrepancy (i.e., omission, commission, different dose, etc.), for resolution.
  • Easily accessible and viewable screens to review identified discrepancies (ex. side-by-side view of home medications and ordered medications with skip patterns to highlight omissions or other types of discrepancies)
  • Identified discrepancies presented in order of severity (i.e., omission of an anticoagulation or blood pressure medication prioritized above omission of a calcium supplement for the same patient).
• Electronic capabilities to assist clinician with auto-substitution upon admission based on formulary implications with capability to revert back upon discharge.
• Messages sent directly to physician's pagers or inboxes when updates or changes to the patient's home medication list occur (i.e., med history updated based on new information from patient's family) and/or when discrepancies are identified and require clarification.
• Electronic, seamless process to communicate medication lists and any resulting changes to the next provider(s) of service.
• Patients and/or caregivers are active participants in medication reconciliation

Although some organizations are working towards this ideal,^4,5 this may not be achievable in many instances due to:

• Vendor dependent systems may have limited customization capabilities
• Current healthcare environment is complex and fragmented
• Many healthcare systems lack interfaces to access information across care settings and privacy concerns exist with data sharing
• Every care environment has unique needs
• Family and staff may have unique needs
• Resource requirements and availability of resources may vary

Ideally, the goal should be to develop healthcare information technology with advanced clinical decision support for medication reconciliation in an effort to improve patient safety.

G. Pilot-Testing Your Solution

You have designed your medication reconciliation process to meet the needs of your patients, staff and regulatory requirements. Now, you are now ready to pilot test your process.

Before instituting your pilot, you should consider the following questions:

• Where would you like to pilot test your process?
• Are the areas chosen for your pilot already engaged and bought-into the process?
• What mechanism will be in place to give and receive feedback from front-line staff during the pilot?
• What support structure will be put in place to support staff during the pilot period?
• What role can your leadership team play in the pilot?
• Are your stakeholders engaged and have roadblocks been identified and removed prior to piloting in those practice settings?
• What are your process measures (quantity; adherence to process) to determine compliance during the pilot?
• What are your quality measures to determine impact on patient safety?

There are many different ways to approach pilot testing. Some ideas include:

• A unit that directly admits patients
• One medicine unit and one surgical unit
• One team of physicians or one service, such as hospitalists
• Engaging a few clinicians to use your form for a few days on their patients

Regardless of the approach, the goal is to test the process for a few days, identify and correct major gaps within the process, and confirm its utility within current workflow. The process should continue to be enhanced and the pilot testing expanded as appropriate.

Although design team members are often eager to pilot their work, you should also include front-line staff who were not involved in the design. They will be able to:

• Provide additional insight into how intuitive your new design is
• Identify training requirements
• Identify additional areas for improvement

The Institute for Healthcare Improvement has more tips on how to pilot test changes including an example related to medication reconciliation. (Accessed June 11, 2007)

For giving and receiving feedback during a pilot, small focus groups lasting approximately 15-30 minutes could be conducted. This may be an effective means to exchange dialog about the process. This could also be used as an opportunity to thank those who agreed to participate in the pilot.

Below are some example questions that may be utilized during focus groups with physicians. These can be adapted for use with various disciplines and practice settings.

Medication Reconciliation Interview Questions for Physicians (PDF)

Incorporating a structured, robust auditing and feedback structure to identify design flaws and to understand underlying root causes for medication reconciliation failures (i.e., knowledge deficits, lack of buy-in, system design issues, etc.) is important during the pilot. It is equally important to highlight successes and compliment individual contributions. For more information on measurement, see the Assessment and Evaluation section.

Lessons Learned

There are several key elements regarding medication reconciliation that are important to realize before getting started, especially as they apply to any practice setting (i.e., inpatient; outpatient) and any type of medical record system (i.e., electronic, paper-based or both).

• There is no electronic substitution for a thorough medication interview with patients and/or their caregivers to obtain and verify current medication regimens. If patients and/or caregivers are able to participate in an interview, clinicians should inquire about what medications patients are taking and how they are taking them to identify discrepancies or uncover potential medication problems.
•  Until healthcare information technology with advanced clinical decision support becomes advanced to the extent of:
  
  • Integrating documented care plans with the patient's current (i.e., home) medication regimen obtained from various sources (i.e., patient, community pharmacies, multiple physicians, etc.)
  • Comparing this information to the medications ordered during the episode of care.
  • Alerting clinicians to discrepancies identified electronically, medication reconciliation will remain a "manual" process.
• Medication reconciliation should be weaved into the culture and practices for safe medication management.
• Medication reconciliation should be an integral part of handoffs and communication during transitions in care.

References:

1. The Joint Commission: 2007 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Joint Commission Resources, 2007, p. NPSG-6-7
2. Frequently Asked Questions for The Joint Commission 2007 National Patient Safety Goals: Questions about Goal 8 (Reconcile Medications). (PDF) Accessed June 10, 2007.
3. Quinn RE, Faerman SR, Thompson MP, McGrath MR and St. Clair LS. Becoming a Master Manager: A Competing Values Approach. 4th ed. New Jersey: John Wiley & Sons, Inc.; 2007:71.
4. Poon EG, Blumenfeld B, Hamann C, et al. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform Assoc. 2006; 13:581-592.
5. Kaboli PJ, McClimon BJ, Hoth AB, et al. Assessing the Accuracy of Computerized Medication Histories. Am J Manag Care. 2004; 10(part 2):872-877.