patient centered medication information management and medication reconciliation maureen layden, md,...

Patient Centered Medication Information Management

andMedication Reconciliation

Maureen Layden, MD, MPHRosemary Grealish, RPh

June 13, 2012

It’s More than a List-Standardizing Patient Facing

Medication Information

VETERANS HEALTH ADMINISTRATION

Thanks to everyone!

• For all your hard work in “getting meds straight”

• It really does take a team!

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Imagine

Seamless medication information management that allows for

the best medication treatment plan evidence based medicine has to offer

customized for the Patient in front of us.

What will it take?

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What is “Medication Information”?• More than the Med List:

– Healthcare Team: Name of the medication, Instructions, Indication, Refill History, Prescriber, Pharmacy

– Patient/Caregiver: Brand/Generic/Nickname, How I take it, Why, When I need to call for more, Who I call, What it looks like: “The little red pill for my heart”

• Context:– Healthcare Team: Allergies/Adverse Reaction, Adherence Data, Drug-Drug,

Drug-Disease Interaction, Past Medication History– Patient/Caregiver: Barriers to taking medications, Preference, Tools to help

take medications• Resources

– Healthcare Team: Clinical Pharmacy, Order Sets, Algorithms, Online Support, i.e. Up-to-Date

– Patient/Caregiver: Family/Friends who are in healthcare, Inserts, Pamphlets, Classes, Online Search, i.e. MedLine Plus, soon MyHealtheVet Veterans Health Library! 6


How do we use this information?

• Pharmacy – Order Pharmacy Processing Dispensing– J.D. Power & Associates 2012 Customer Service Champion

• Administration– Bar Code Administration

• Care Coordination• Clinical and Shared Decision Making• Education• Adverse Drug Event reporting and management• Adherence Detection and Management• And much more…

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Medication Reconciliation -->Medication Information Management

Medication Reconciliation

• What medication information did the Healthcare Team(s) recommend?

• What is the Patient actually taking?

• What is the final updated Med List now?

• Does the Patient and the Healthcare Team have this updated Med List?

• Can we prove in the chart that this has been done?

Medication Information Management

• Add Context:– Why is he/she taking medications

differently – What are his/her preferences in

medications?– Are there any barriers to taking his

or her medications?– Does he/she have information,

tools, and resources to help with medications?

– Why are medications different on admission?

– Who is managing this medication?8

Healthcare Organization

Data

VANon-VADoD

IHS

Patient Data

MobileTechnology

Web ApplicationsTools at the

point of care

Medication Reconciliation is test case for self entered data, how we collect, store, and use it to meaningfully incorporate the Veterans and his or her Caregivers Voice in shared and informed decision making

Reconciliation:Presentation Layer

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Efforts you should be aware of

• Patient Self Entered Data Workgroup• National Alliance for Patient Medication

Information Standardization • E-Connected Task Force

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MEDICATION USE CRISISAdverse Drug Events (ADE’s)

• harm >1.5M annually• 75,000 hospitalizations

– ~5,000 serious harm– ~2,500 deaths– Cost ~$3.5billion

(Committee on Identifying and Preventing Medication Errors, 2006); Woods et al, 2007)

Nationally In VA (2010)

• ADE’s reported– 66,000 – 3,000 required

hospitalization– ~700 serious harm– ~50 deaths

(NCPS/ADERS, 2010, Kaboli et al., 2004 ; Lesselroth et al., JC Qual Pt Saf, 2009; 3.Pippins et al., 2008 ,Boockvar et al., Qual Saf Heath Car, 2009)

• Much is underreported

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Not on the same page

• The percentage of Veterans with complete agreement between CPRS medication lists and patient report is approximately 5%1

• The majority of discrepancies represent failures in history collection, not reconciliation2

• Errors of omission when compiling a list are common; 10-61% of hospital admissions contain an omission error; 42-59% of all admission prescription history errors are omissions3

• Approximately 25% of medications taken by patients in ambulatory setting are not recorded1

• An estimated 30% of omitted medications are expired and discontinued agents4

• An estimated 25% of omitted medications are clinically significant51. Kaboli et al, Am J

Man Care, 20042. Pippens et al, JGIM,

20083. Tam et al, CMAJ,

20054. Lesselroth et al,

unpublished5. Cohen et al, Pharm

Prac, 1998

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VA MedRecon Initiative

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Medication Use Crisis Virtual Conference

• Joint effort VHA Program Offices, DoD, and Indian Health• 16 hours of CE Programming over 4 Tuesdays in May 2012• Tracks:

– Information Management– Teams and Transitions– Optimizing Resources– Veteran and Caregiver

• 850 VA staff members participated in over 4,300 hours of CEU accredited content (DoD and Indian Health numbers pending)

• Continuing on in a monthly hour long format14


VA MedRecon Initiative—our history

1. 2007: Grassroots workgroup 2. 2008: Built Toolkit/Share Point, Workgroup meetings, Patient/Staff

Education materials, Documentation/Monitoring Strategies, and presentations

3. 2009: Became a program of VA Central Office PBM. Added Yearly Conferences and Metrics

4. 2010: Endorsed by Health Systems Committee to draft VA MedRecon Directive

5. 2011: VA MedRecon Directive Signed, MedRecon New Service Request for Information Technology (IT) tools submitted, and increased focus on IT multiple solutions

6. 2012: Medication Information Standards, Convergence of IT Medication Information Tools, and partnerships with Our Federal Partners

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Workgroups

• Office Hours• Documentation and Monitoring• Patient and Staff Education and clinical Adoption• MedRecon Series• Medication Use Crisis Series• Emergency Department and Urgent Care Medication

Management Workgroup• Nurses role in Medication Information Management• Geriatrics Extended Care and PBM Workgroup

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It’s not easy…

• Many sources of medication information– The Chart: Can’t change a med

without issuing a supply patients may not need

– Remote Meds: (from other VAMCs)

• Knowing about it• Acting upon conflicts

– Non VA Meds:(Dispensed outside VA)

• Needs manual updating

Barriers Short Term Solutions• Awareness, Documentation, Share ideas• Pull in full med list: Active, Expired, Non

VA, Pending, and Remotes. • Increased Clinical Pharmacy

participation• Workflow changes to help update the

non VA list, nurses do this in some facilities

• Pre-Visit Inquiries to Patient• Education & Monitor Compliance

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It’s not easy…

• Patient Med Information difficult to– Obtain

• Time• Tools• Trust

– Coordinate• Multiple Sources • History over time• Voice of the Caregiver

– Document• Essential Data• Context • Resources

Barrier Short Term Solutions• Awareness• Pharmacy Techs, Pill Clinics• Training and Policy• Pull in full med list into the note:

Active, Expired, Non VA, Pending, and Remotes.

• Workflow changes to help update the non VA list, nurses do this in some facilities

• Standardized Patient Med List to match the note

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It’s not easy…

• Communicating with the Healthcare Team

– Between Departments– Settings– Facilities– Non VA

• Time Stamp, “The Patients Discharge Med List must be the same as the Discharge Documentation”

– Discharge– Multiple Appointment Days

Barriers Short Term Solutions• Policy, MOUs, and Directive

– Department, Setting, Facility– VISN– Templates

• PBM Mail group for Remote Conflicts– Establish a Consult for Provider– Educate– Monitor

• No one size fits all• Coordinated Discharge

– Establish Lead– Establish the Authoritative List—usually

Patient’s Instruction

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Examples of Fugitive Meds

• Emergency Department

• Illicit Drugs

• Samples

• Chemotherapy

• Family/Neighbor/Pets

• Specialty Medications

• Herbals

• OTCs

• ICU

• Non-VA Medications• VA Meds Filled Outside VA• Once Yearly Medication• Expired Meds• Pending Meds• “Hold”• Old Medications• Medications in the Progress

note• Remote Medications• Peri-operative Care

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VA MedicationReconciliation

DirectiveDefinition

1. Obtaining medication information from patient, caregiver, and/family.

2. Comparing this to the medication information available

3. Communicating with and providing education to patient, caregiver, and/or family regarding this information.

4. Communicating this with the healthcare team(s).

The Joint CommissionReconciliation Revised

Patient Safety Goals

1. NPSG.03.06.01 EP1: Obtain information on the medications the patient is currently taking.

2. NPSG.03.06.01EP3: Compare the medication information

3. NPSG.03.06.01EP4: Provide the patient (or family as needed) with written information.

4. NPSG.03.06.01EP5: Explain the importance of managing medication information to the patient

5. PC.04.02.01: Information about treatment is provided to other service providers

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VA MedicationReconciliation

DirectiveDefinition

1.Obtaining medication information from patient, caregiver, and/family.

2.Comparing this to the medication information available

3.Communicating with and providing education to patient, caregiver, and/or family regarding this information.

4.Communicating this with the healthcare team(s).

VA MedRecon External Peer Review Pilot Program

QuestionsIs there evidence that:

1.The patient’s list of medications was reviewed?

2.Medication discrepancies with CPRS/VistA were identified?

3.Medication discrepancies were addressed in some way?

4.The patient was provided a written updated list?

5. Referred for follow-up medication management?

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MedRecon Documentation: Lessons Learned

• Avoid Duplicate Documentation • Make your templates consistent with workflow in the

clinical setting• Consider that all the minimum documentation

requirements do not have to be captured in the template but must exist somewhere in the note

• Engage the end-users in developing tools• Must essentially help us help the patient, “What did the

patient come in on, what did she leave with, and why?” (VA Hospitalist)

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VISN 1 Page 1 Note

An Example of MedRecon within a Templated note from VISN 1:

93yo MALE, accompanied by wife presents to Urgent Care with chief complaint of Left Lower Abdomen pain, overlying the area he has given himself insulin shots. Has been using the exact same spots (LL abdomen AM RL Abdomen PM)due to Parkinsons, neuropathy, blindness, etc.No redness, heat, rash, pus, swelling noted by wife or patient

ROS: No Fever, Chills, Sweats, fatigue, no nausea, vomiting, constipation, diarrhea, urinary frequency, urgency, pain. Parkinson’s stable. Chronic Drooling, no sore throat, cough, SOB, appetite, weight hasn't changed. Feels well/at baseline otherwise.

ACTIVE PROBLEMS:Code Description 465.9 Acute upper respiratory infections of unspecified site (ICD-9-CM 735.8 Dystrophic Toenails (ICD-9-CM 735.8)251.2 Hypoglycemia (ICD-9-CM 251.2)527.7 Sialorrhea (ICD-9-CM 527.7)V53.2 ADJUSTMENT HEARING AID……..

Because of age, complexity of regiment, and complaint MedRecon was initiated to screen for medication issue.

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VISN 1 Page 2 NoteACTIVE MEDICATIONS:Active Outpatient Medications (including Supplies):*taking differently ** not takingAMLODIPINE BESYLATE 5MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY FOR HEART**AZITHROMYCIN 250MG TAB TAKE TWO TABLETS BY MOUTH EVERY DAY ACTIVE FOR 1 DAY, THEN TAKE ONE TABLET EVERY DAY FOR 4 DAYS FOR INFECTION --Finished With these BD ULTRAFINE MINIPEN NEEDLES 3/16 X 31G USE NEEDLE(MINPEN ACTIVE 3/16) UNDER THE SKIN AS DIRECTEDCARBIDOPA 25/LEVODOPA 100MG TAB TAKE ONE AND ONE-HALF ACTIVE TABLETS BY MOUTH THREE TIMES A DAY TO CONTROL MUSCLE MOVEMENTSCYANOCOBALAMIN 1000MCG/ML INJ INJECT 1 ML INTRAMUSCULARLY ACTIVE MONTHLY (MAIL TO PATIENT)INSULIN HUMULIN 70/30 INJ PEN 3ML INJECT 30 UNITS(PEN) ACTIVE UNDER THE SKIN TWICE A DAY FOR DIABETES Recent decrease due to hypoglycemiaLISINOPRIL 40MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY TO ACTIVE CONTROL BLOOD PRESSURE**MEMANTINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE Not taking this per providerNon-VA ASPIRIN 81MG EC TAB 81MG BY MOUTH EVERY DAY ACTIVENon-VA CALCIUM 250MG/VITAMIN D 125 UNT TAB 2 TABLETS BY ACTIVE MOUTH EVERY DAYNon-VA MULTIVITAMIN CAP/TAB 1 TABLET BY MOUTH EVERY DAY ACTIVENo Remote Meds

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VISN 1 Page 3 Note

ExamVSS-Labs-Etc…

A/P 1. Hematomas Secondary to Insulin injection techniqueChem 7 CBC, UA wnl Glucose is post prandial afebrile--may use warm packs watch for signs of fever, redness, swelling, worsening symptoms of pain call or return to clinicReceived info on insulin injections, will use a more lateral and upper abdomen approach, upper arms, thighs. No signs of abdominal process such as diverticulitis—wife will watch for increase pain, fever, etc and report ASAP. Refer to PCP, Diabetic Teaching for follow up

2. Insulin Dependent DMWife will check blood glucose and report if numbers increase as an indicator of systemic disease. He should continue to have BS <200. Note he has recently had his insulin decreased. If no better in one week, call or return to clinic, sooner if worse.

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VISN 1 Page 4 Note

Outpt. VISN 1Medication Reconciliation Clinical Reminder:

1. The patient's medication list was compared with CPRS and reconciled.

2. Discrepancies were identified, addressed, and discussed with the patient/caregiver.

3. All changes in medications, including all non-VA/Herbals/OTC medications were entered into CPRS.

4. Medications the patient should no longer take were discontinued, except for the Memantine will leave to PCP—Pt instructed to discuss with PCP

5. A copy of this reconciled medication list was given to the patient and his care giver. The patient/caregiver was instructed to update this list, discard old lists, and take this list to their next appointment, whether with a VA or non-VA provider.

*5 Health Factors

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Pilot in Rheumatology Clinic: Dallas Dialogue

VISN 17 Dialogue Page 1

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May is MedRecon Awareness Month

Goal:1. Promote, Recognize, Educate and Share!2. Competition: Best Champion, EducationDocumentation Strategy, and Improvement Story !

There once was a vet who was illThe doctors were puzzled until…

They looked in his chart:The doc missed the part…

Where the patient stopped taking the pill!Mark McConnell, MD

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There is important research being doneCompliments of Dr. Blake Lesselroth, Portland Informatics Center

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VA MedRecon IT Projects• VA Point of Service Kiosk• Medication Image Library• Mobile Applications

– Patient Facing– Clinical Facing

• MyHealtheVet– My Recovery Plan– Secure Messaging– Ask a Pharmacist– Play it Safe!– Blue Button

• Health Informatics Initiative• Health Risk Assessment• Integrated Electronic Healthcare Record (with DoD and TriCare)• Veteran Lifetime Electronic Record 35


VetLink Self-Service Kiosk Initiative

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• Patient specific printed document

• Reviewed daily by the patient and nurse

• Patient involved in what to expect each hospital or outpatient clinic day

• Enhances patient safety by encouraging the patient to ask questions if something seems different then planned.

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Double dagger indicates non-VA sources of data

Retrieving Nationwide Health Information Network Documents from VistAWeb

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VLER:View of Summary of Care Record

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Aggregated View - Medications

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My Recovery Plan: My Meds

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Mobile Technologies: Summary of Care AppSummary Information View

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FAQS

20. What about specialty clinic, same day surgery, and diagnostic areas? Do they need to do MedRecon?

– Regardless of the type of encounter, the act of collecting medication information from the patient must be initiated when medications will be administered, prescribed, modified or may influence the care given. The types of medication information to be collected in different patient circumstances must be defined in local policy. Reconciling the information collected from the patient with the organizations information based on local policy must be completed prior to medications being administered, prescribed, modified, or care given. The education of patients and family members on their medications remains a critical element of good clinical care.

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FAQS

5. What constitutes “Best Effort” or “Good Faith Effort” in our attempts to obtain medication information from the patient and/or caregiver?

– The patient may be unwilling or unable to talk about their medications. Information should be obtained from the electronic medical record and caregivers, if they have been authorized by the patient to speak on their behalf. This should be documented in the electronic medical record so if information is not obtained, the next healthcare team can continue the effort.

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Setting Specific Considerations• ED/UCC Consider

– Giving a med list at triage for patients to review– Having a MedRecon Dialogue template to pull meds in the note for review– Updating Med list directly or import into discharge instructions

• Multi-appointment Day Consider– Alerting providers to at least finish orders, preferably the note– Encouraging patient to make sure he/she has the update list in hand– Last appointment reprints an updated list—beware of “Pending”

• Admission Consider– Highlighting why home meds were held/discontinued so next team can prepare to

restart, etc.• Discharge Consider

– Engaging discharge team to of follow process that ensures med lists are the same on the Instructions as in the Discharge Documentations

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• Ask the patients what they are taking at home, document this and note the differences from their plan

• Identify and document their barriers to adherence• Make sure the admission includes why meds have been held,

added, discontinued• Consider at discharge, what he or she was taking, what we thought

they were taking, the inpatient meds, and what he should go home on—there may be unaddressed issues that will require a plan to communicate and follow up

• Ask for help from your team, consultants, colleagues, and caregivers

What we can do today

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• Create an expectation that med management will be discussed at every visit

• Inquire about how your patient manages there meds, who helps, what we can do to help

• Foster an understanding that meds are hard to take, that sometimes things go wrong, and the most important thing is to communicate concerns before changes are made to meds

• Ultimately patients are in charge of their information and need to manage it

What we can do now

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Seamless

His care giver requires support

“My son Mike is a 30yo Veteran, he has TBI, and is confined to a wheelchair. There are a lot of

things to keep track of, meds, appointments, you name it.”

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Seamless

His care is customized“I have a team working for me and my son,

home health aid, visiting nurses, my pharmacist, case manager, and PA—not to

mention my great PACT team and specialists.”

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Seamless

She is connected virtually

“I rely on my caregiver support coordinator Renee. In the beginning, when Mike came home from Bethesda, I SM’d her everyday.

She set me up with telehealth so I am connected with the team ‘realtime’.

Yesterday, I showed them a rash on the video phone”

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Seamless

The caregiver’s data plays a role in his care“Somehow, all the meds are in MHV, including all my comments and issues,

where they come from and why we take them.

If they are due for renewal, I get a ping.”

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Seamless

She is connected to the community“We had to call 911 at a family gathering and we were off to St Marks Emergency. When they found out Mike is a Veteran, I signed a form and they had everything they needed

from the VA--just like that.

In fact, Renee knew and pinged me. Mike ended up going home and now I see the St Mark’s

notes and everything on MHV.”

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Seamless means

They should expect no less

• All of our mobile applications, or web enabled programs, our point of service products work together

• Patients and their Caregivers are connected to us and their voices are heard

• Wherever they are, whenever they need it, with whatever tools they have we will have their back

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Questions?

• Thank You!

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patient centered medication information management and medication reconciliation maureen layden, md,...

Documents

medication information

healthcare teams

list standardizing patient

medications different

pharmacy patientcaregiver

aware of patient self

clinical pharmacy

adherence data