As we look at the ARRA Meaningful Use matrix, we all see a requirement for medication reconciliation or med rec. An innocuous sounding requirement - simply reconcile a patient’s medication at the transition of care. The transition of care for Meaningful Use purposes is the movement of the patient from an ambulatory setting to an inpatient setting and vice versa. How hard can that be? As it turns out very, especially in an automated fashion! To dive a little deeper, med rec is really one component of the broader concept of the ‘continuum of care’. The ‘continuum of care’ is a concept that requires clinicians and healthcare organizations to maintain elements of responsibility for a patient’s care as they transition from one setting to another, including their home. Further the continuum of care is seen as being a seamless progression of the patient through various home and healthcare settings where planning and treatments are continuous and uninterrupted. One of the primary elements supporting the continuum of care is the maintenance and oversight of medications that patients received in an earlier setting now be continued or modified as necessary in their new setting – in other words med rec. The reason med rec is so important is that if this process does not occur, in a standardized manner, medication errors will occur and may lead to serious adverse drug events (ADEs) and harm. So how does all this work? The next couple of paragraphs give a brief overview of exactly that in a perfect, in a real world and the challenges when the two worlds collide, so onto the perfect world.

The Perfect World – The Good

Med rec is the process of identifying the most accurate list of all medications a patient is taking including name, dosage, frequency, and route. Then using this list to provide correct medications for patients across the ‘continuum of care’. Med rec is complex since it involves comparing the patient’s current list of medications, i.e., home medications, against the physician’s admission, transfer, and/or discharge orders. And – merely reviewing the meds is not sufficient. A determination needs to be made why a med might have been modified, discontinued or added for “reconciliation”. Clinicians should review previous medication orders alongside new orders and plans for care, and reconcile any differences. Further complication is that med rec should be done each time a patient moves from one setting to another, both within the hospital setting and in the ambulatory setting. (Luckily for ARRA Meaningful Use, med rec only has to occur in the care transition between inpatient and ambulatory and vice versa.) So in a perfect world at each transition of care the care team would compare the current meds to the meds on the medication list and reconcile them on an electronic system. Reality though has not quite caught up to the perfect world and unfortunately the adage “don’t let perfection get in the way of good enough” does not apply and the real world plays in the good enough zone – which is not good enough!

The Reality – The Bad

Typically ‘medication lists’ are kept by the primary care physician, in the ambulatory environment. Attempting to incorporate the medications the current physician has placed the patient along with those that any specialists or other providers have prescribed is at best difficult. Because of the lack of standardized exchange of electronic information, the process of med rec is an overwhelmingly manual process. This manual process yields a list that is a maintenance nightmare and most likely assures that up-to-date medication lists are next to impossible. The result is little capability to review potential drug-drug interactions with every new prescription or dose change.

The impact of the manual process is even more pronounced when the patient transitions from an ambulatory to inpatient setting. The manual nature of the real world makes having a complete list of ‘home’ medications available for consideration as the patient is treated in the inpatient setting nearly impossible. Again, since there is minimal information sharing between the ambulatory and inpatient settings unless the admitting physician is also the patient’s primary care physician the odds of having a reconciled list of meds are almost assured to be approaching nil.

The Risks – The Ugly

Experience from hundreds of organizations has shown that poor communication of medical information at care transition points is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events (ADE) in the hospital. In other words the lack of med rec in a standardized electronic format can profoundly impact patients through the ADEs, increased lengths of stay and most importantly they can die!!

What Can We Do - Next Steps

Recognize that the continuum of care in general and med rec specifically is a team sport, it requires a team effort and involves the healthcare providers, nursing, pharmacy staff and the patients. The reconciliation process is continuous in nature and independent of the care location or documentation methodology. In addition there are actually a handful of basic med rec steps/elements that must be followed, they are:

• Identification of the “true” medication list
• Validation of that list
• Searching for drug interactions
• Review of the medication list at transitions of care
• Appropriate communication of the medication list with patients and providers

So the bottom line - the value of med rec to delivering high quality, safe healthcare is clearly understood and in fact is mandated by regulatory agencies. Making med rec happen in the real world of care delivery can be a challenge. The challenge is eased when EMRs and other HIT are used and key stakeholders are involved. Further, the workflow integration of med rec and the exchange of key data elements between information systems are enabled and supported via a well-constructed HIT architecture. In order to make med rec happen, all these components must work harmoniously.

Allow Santa Rosa to bring our expertise to bear to help your team ensure your organization has a well-constructed, robust HIT architecture. Please contact us at http://www.santarosaconsulting.com.