Getting on the Same Page:

Challenges in Medication Reconciliation Across Settings for

Older Adults

Heather Young, GNP, PhD, Paul Gorman, MD, Valerie King, MD, Karl Ordelheide, MD,

Dale Kraemer, PhD, Misha Pavel, PhD, Terri Bianco, PharmD

Samaritan North Lincoln HospitalOregon Rural Practice Research Network

Oregon Health & Sciences UniversityOregon State University

Funded by the Agency for Healthcare Research & Quality

4 Local Pharmacies 4 Local Pharmacies

6 Clinics 6 Clinics

Rural hospitalRural hospital

SNF/REHABSNF/REHAB

3 Assisted Living3 Assisted Living

RxSafe in Lincoln City OregonRxSafe in Lincoln City Oregon

Basic Steps in Medication UseBasic Steps in Medication UseEach with different information and Each with different information and

different technologydifferent technology

PrescribingPrimary Care Clinician

Fax/Paper recordElectronic Medical Record

MonitoringFacility, pharmacy,

and clinic staff

DispensingPharmacists

Proprietary Software

AdministeringALF/SNF staff

Paper Med Admin RecordFax

Clinical Problem Clinical Problem Everyone has different informationEveryone has different information

Population at risk: adults with multiple health Population at risk: adults with multiple health problems, advanced age, frailty, multiple providersproblems, advanced age, frailty, multiple providers

OvermedicationOvermedication duplications within class, between classduplications within class, between class discontinued medicationsdiscontinued medications

UndermedicationUndermedication errors of omissionerrors of omission

Wrong medicationsWrong medications amaryl~reminyl; foradil~toradolamaryl~reminyl; foradil~toradol

InteractionsInteractions

It is easier to move the patientsIt is easier to move the patients

Assisted Living

SNF

Hospital

Clinic

Communication: fax, foot, phone

Home health

Different Source DocumentsDifferent Source Documents

Different Different ConventionsConventions

Different Different NeedsNeeds

Goal of RxSafe:Goal of RxSafe:Get to everyone on the same pageGet to everyone on the same page

RxSafe

PrescribingPrimary Care Clinician

MonitoringFacility and pharmacy staff

DispensingPharmacists

AdministeringFacility

RxSafe: RxSafe: Overall Goals of ProjectOverall Goals of Project

Single Medication ListSingle Medication List AccurateAccurate CompleteComplete CurrentCurrent AvailableAvailable

Secure access forSecure access for PrescribingPrescribing DispensingDispensing AdministeringAdministering MonitoringMonitoring

BenefitsBenefits Reconcile lists and Reconcile lists and

terminology terminology Eliminate duplicationEliminate duplication Improve adherenceImprove adherence Reduce interactionsReduce interactions Improve effectiveness of Improve effectiveness of

decision supportdecision support Provide platform for Provide platform for

practice improvement practice improvement Early detection of Early detection of

anomaliesanomalies

Evaluation PrioritiesEvaluation Priorities

Valid, reliable measure of differences Valid, reliable measure of differences among lists among lists

Describe the extent and nature of the Describe the extent and nature of the differencesdifferences

Determine clinical significance of the Determine clinical significance of the differencedifference

Identify priority areas for interventionIdentify priority areas for intervention

Existing MeasuresExisting Measures

Limited to counting events:Limited to counting events: Frequency by patientFrequency by patient Total number of eventsTotal number of events Events per patientEvents per patient May or may not include counts by May or may not include counts by

subcategories (drug name, dose, frequency, subcategories (drug name, dose, frequency, etc.)etc.)

Usually have a gold-standard list (may be Usually have a gold-standard list (may be physician reviewing records)physician reviewing records)

Limitations of Existing MeasuresLimitations of Existing Measures

Not designed to compare across >2 listsNot designed to compare across >2 lists

Based on event-driven reconciliation (e.g., Based on event-driven reconciliation (e.g., hospital discharge) rather than ongoing hospital discharge) rather than ongoing reconciliation process as occurs in long reconciliation process as occurs in long term care settingsterm care settings

Do not combine dimensions (e.g. Do not combine dimensions (e.g. discrepancies and harm likelihood / discrepancies and harm likelihood / severity) but tabulate these separatelyseverity) but tabulate these separately

RxSafe Functionality RxSafe Functionality

Collect information from all existing listsCollect information from all existing lists PharmacyPharmacy ClinicClinic Residential FacilityResidential Facility

Render the lists as similar as possibleRender the lists as similar as possible Order the lists to maximize similarityOrder the lists to maximize similarity Identify potential spelling and translation errorsIdentify potential spelling and translation errors Provide interface for efficient and easy comparisons Provide interface for efficient and easy comparisons

of the medication listsof the medication lists

Record ComparisonRecord Comparison

RxSafe List ComparisonRxSafe List Comparison

SNF/Rehab

Mary Jones Dr. Smith DOB 12/12/12

Temazepam

Aricept

Warfarin

Oxybutinin

Lisinopril

Ferrous sulfate

Dyazide

Augmentin

Atenolol

Clinic

Augmentin

Oxybutinin Aricept

Lisinopril

Coumadin

Atenolol

Dyazide

Phenergan

Temazepam

Pharmacy

Oxybutinin

Coumadin

Dyazide

Atenolol

Lisinopril

Donepezil

Augmentin

Temazepam

Fe Gluconate

Hospital

Lisinopril

Augmentin

Donezepil

Coumadin

Atenolol

Oxybutinin

Diazide

Phenergan

Temazepam

Proposed Metrics for EvaluationProposed Metrics for Evaluation

DisorderDisorder Sorting, spelling, sameness - Assessment is Sorting, spelling, sameness - Assessment is

based on the number of operations required based on the number of operations required for reconciliationfor reconciliation

DiscrepancyDiscrepancy Magnitude of differenceMagnitude of difference Hazard ProbabilityHazard Probability Hazard SeverityHazard Severity

CombinedCombined

Human Reconciliation Process:Human Reconciliation Process:Task SummaryTask Summary

Within list cleanup – organize entries (making Within list cleanup – organize entries (making sense of spelling mistakes, remove duplicates)sense of spelling mistakes, remove duplicates)Select one list as the reference listSelect one list as the reference listSort the other lists to match as closely as possible Sort the other lists to match as closely as possible the reference listthe reference listFor each itemFor each item Find the closest potential matchFind the closest potential match If correspondence is not foundIf correspondence is not found

Find transformations that would minimize differencesFind transformations that would minimize differencesDetermine if the best transformation is feasibleDetermine if the best transformation is feasible

If possible transform to equivalent (translate, calculate)If possible transform to equivalent (translate, calculate) If not possible to transform, note the discordanceIf not possible to transform, note the discordance

Pilot Study: Empirical EvaluationPilot Study: Empirical Evaluation

Lists for 23 residents were collected from:Lists for 23 residents were collected from: Facility Facility Clinic Clinic Pharmacy Pharmacy

Lists were transcribed and reordered by a Lists were transcribed and reordered by a trained pharmacy techniciantrained pharmacy technician

3 experienced clinicians coded the lists3 experienced clinicians coded the lists

Evaluation of DiscordanceEvaluation of Discordance

Reorder lists to maximize similarityReorder lists to maximize similarityJudge the correspondence for each itemJudge the correspondence for each item I – IdenticalI – Identical E – EquivalentE – Equivalent M – MissingM – Missing N – Not the sameN – Not the same D – DuplicateD – Duplicate

Hazard likelihood scale Hazard likelihood scale Hazard severity scaleHazard severity scale

ResultsResults

The average number of items per list was The average number of items per list was 14.514.5

The total number of prescription items was The total number of prescription items was approximately 334approximately 334

Differences in ListsDifferences in ListsClinic vs. Facility/Pharmacy vs. FacilityClinic vs. Facility/Pharmacy vs. Facility

I = Identical; E = Equivalent; M = Missing; N = Not the Same

# #

Proportion of DifferencesProportion of Differences

Methodological issuesMethodological issues

Unable to find suitable existing method to Unable to find suitable existing method to reconcile multiple medication list sourcesreconcile multiple medication list sourcesTime intensive to review due to Time intensive to review due to Different order of medications on listsDifferent order of medications on lists Inconsistent brand vs. generic name useInconsistent brand vs. generic name use Dosage calculations (e.g., 2 – 20 mg tablets Dosage calculations (e.g., 2 – 20 mg tablets

vs. 40 mg)vs. 40 mg)

Timing issues (synchronizing information) Timing issues (synchronizing information) – “dirty MAR” vs. monthly reviews vs. clinic – “dirty MAR” vs. monthly reviews vs. clinic recordsrecords

Additional Methodological IssuesAdditional Methodological Issues

Medication records serve different Medication records serve different purposes in different places (e.g., billing, purposes in different places (e.g., billing, organizing tasks, providing reminders for organizing tasks, providing reminders for non-medication activities)non-medication activities)

In addition to the number of discrepancies, In addition to the number of discrepancies, the potential clinical significance is the potential clinical significance is important – hazard risk and potential important – hazard risk and potential severity. Cannot evaluate severity using severity. Cannot evaluate severity using standard schema due to lack of required standard schema due to lack of required data (e.g., assessment of adverse effect)data (e.g., assessment of adverse effect)

Next stepsNext steps

Fine tune the quantitative approach for Fine tune the quantitative approach for describing number, type and severity of describing number, type and severity of discrepanciesdiscrepancies

Complete data analysis for baseline, then Complete data analysis for baseline, then data over time and post-interventiondata over time and post-intervention

Add observations at key times of Add observations at key times of reconciliation (monthly review, clinic visit, reconciliation (monthly review, clinic visit, etc.) to describe process and to quantify etc.) to describe process and to quantify time and human resources for this tasktime and human resources for this task