Medication Reconciliation to Improve Quality of Transitional Care (Indiana)

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Summary:

Medication errors account for approximately 20 percent of all medical errors in the U.S. This significant source of error can cause injury and fatality, and occurs in all health care settings and all transitions in care. Recent studies have shown that electronic medication reconciliation for hospitalized patients can decrease medication discrepancies and significantly improve outcomes in transitional and ambulatory care. Relatively little is known, however, about the extent to which medication reconciliation systems improve clinical outcomes.

This project integrated an electronic medication reconciliation system with an electronic prescribing system and evaluated whether the resulting system altered the rate of medication reconciliation and the incidence of medication errors. This new module imported information about pre-admission medications and allowed clinicians to make corrections and annotations about them. The list of reconciled medications was available for use during ordering of inpatient medications. At discharge, the system prompted clinicians to indicate reasons for not creating new prescriptions for any pre-admission medications.

The specific aims of this project were to:

  • Integrate an electronic medical reconciliation system with an e-prescribing system.
  • Modify an electronic health record system to incorporate medication reconciliation.
  • Conduct a randomized controlled trial of the medical reconciliation system.
  • Determine whether electronic facilitation alters medical reconciliation and the incidence of medication errors in ambulatory care.

The project team conducted a randomized controlled study in which the intervention inpatient medicine teams had access to the new module and the control teams did not. Using a 6-month ambulatory followup period after discharge from the hospital, medical records were reviewed to determine whether medication reconciliation was conducted or if any adverse drug events had occurred. Clinicians were surveyed on their experiences in managing medications, and focus groups were held to augment that information.

Analysis of the data is underway. The initial round of the survey yielded approximately 268 responses and the second approximately 60. Eighty-three percent of respondents indicated that they usually ask patients to confirm their medications. Respondents indicating the availability of tools to manage medications increased from 36 to 58 percent. Ease in working with the tools increased from 31 to 51 percent, while perceived clinical benefits increased from 77 to 83 percent. The project team concluded that the process of medication reconciliation presents significant challenges to clinicians, including the time involved and role definitions. Process definition and tool provision can improve outcomes including usefulness, perceived benefits, errors in interpreting medication information, and time required.

Medication Reconciliation to Improve Quality of Transitional Care - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018183
  • Project Period: 
    September 2009 – July 2013
  • AHRQ Funding Amount: 
    $1,181,628
  • PDF Version: 
    (PDF, 270.77 KB)

Summary: Medication errors account for approximately 20 percent of all medical errors in the United States each year. This significant source of error can cause injury or even fatalities and happens in all types of health care settings, including patient transitions between locations or care levels within a facility. Recent studies have shown that electronic medication reconciliation (MR) for hospitalized patients can decrease medication discrepancies and significantly improve outcomes in transitional and ambulatory care. Relatively little is known, however, about the extent to which MR systems improve clinical outcomes.

This study is integrating an electronic MR system with an electronic prescribing (e-prescribing) system and modifying an electronic health record (EHR) to incorporate MR. The project is taking place within Wishard Health Services, a safety-net provider for residents of Marion County, Indiana that includes Wishard Hospital and eight primary ambulatory care community health centers. Dr. Weiner serves as a member of both the technical and clinical teams of the study. The clinical team provides input and guidance for the technical team, which meets weekly to discuss and advance the system’s development.

A randomized study design allowed a controlled comparison of electronic MR and usual care. Participants included patients and their inpatient and ambulatory care providers. While the intervention was based in an emergency department and hospital, it targeted transitional care and was meant to improve outcomes for both inpatient and ambulatory care.

Participating providers were surveyed before the intervention began. With the completion of the randomized controlled trial, a second round of surveys has begun. Survey data is being collected on satisfaction with care, managing medications, and usefulness of local information systems in managing medications. Data analysis is looking at changes in the rates of adverse drug events, erroneous discrepancies, and omissions in a patient’s medication list between the time of discharge and return to ambulatory care. Associations between interventions and outcomes will be summarized regarding factors related to payer, race, gender, and age. The study will inform the question of whether electronic facilitation of inpatient MR improves completion of MR and decreases the incidence of drug-related medical errors.

Specific Aims:

  • Integrate an electronic medication reconciliation system with an e-prescribing system. (Achieved)
  • Modify an EHR system to incorporate medication reconciliation. (Achieved)
  • Conduct a randomized controlled trial of the medication reconciliation system. (Achieved)
  • Determine whether electronic facilitation alters medication reconciliation and the incidence of medication errors in ambulatory care. (Ongoing)

2012 Activities: The focus of activity was on surveying participating providers, training new users, completing the randomized controlled trial, and developing the storage database. Providers were surveyed before the intervention began; a second round of post-intervention surveys was administered in 2012. In addition, four focus group discussions were held to gain additional detailed feedback and discussion about medication management. Preliminary review of the survey and discussion analysis has indicated that participants value automated tools for managing medications because it is such a complex activity.

Meanwhile, the project team trained new users throughout the duration of the clinical trial, which was completed in 2012. Six training sessions were held and 49 providers were trained, with more than 800 uses of the intervention system logged at the end of the trial.

The study data are currently being stored in the Research Electronic Data Capture (REDCap) database, for which the project team piloted chart reviews and provided feedback to the data management group to finalize the REDCap model. Project staff reviewed a list of more than 1,000 medications to create groupings of records that identify the same drug. This was to prevent duplicate listings when drug orders are automatically imported from the EHR into the database on admission or discharge. The study team has also entered data into the REDCap system to complement automatically imported clinical data.

A training manual was developed to help reviewers collect and record the data elements. New reviewers were trained and granted access to both the EHR and REDCap systems for data entry. The data management team continues to update the REDCap drug database to reflect the study’s needs and new drug information. The project team also continues to meet with the data management group to coordinate aspects of data acquisition on a regular basis.

After overcoming some technical barriers and working to increase the usage rate of the intervention, the progress of project activities is on track as last self-reported in the AHRQ Research Reporting System. Budget spending is on target and a 12-month no-cost extension is being used to complete data analysis.

Preliminary Impact and Findings: There are no project findings to date.

Target Population: Adults, Safety Net

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Medication Reconciliation to Improve Quality of Transitional Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018183
  • Project Period: 
    September 2009 - September 2012
  • AHRQ Funding Amount: 
    $1,181,628
  • PDF Version: 
    (PDF, 187.87 KB)

Summary: Medication errors account for approximately 20 percent of all medical errors in the United States each year. This significant source of error can cause injury or even fatalities and happens in all types of health care settings, including patient transitions between locations or care levels within a facility. Recent studies have shown that electronic medication reconciliation (MR) for hospitalized patients can decrease medication discrepancies and significantly improve outcomes in transitional and ambulatory care. Relatively little is known, however, about the extent to which MR systems improve clinical outcomes.

This study seeks to integrate an electronic MR system with an electronic prescribing (e-prescribing) system and modify an electronic health record (EHR) to incorporate medication reconciliation. The project is taking place within Wishard Health Services, a safety net provider for residents of Marion County, Indiana that includes Wishard Hospital and eight primary ambulatory care community health centers. This project has a technical and a clinical team, both of which Dr. Weiner is a member. The clinical team provides input and guidance for the technical team, which meets weekly to discuss and advance the system's development. Because the proposed system requires a formative evaluation, the initial system is being reviewed by a small group of physicians and nurses who are not part of the study teams.

The randomized study design allows for a controlled comparison of electronic MR and usual care. Participants include patients and their inpatient and ambulatory care providers. While the intervention is based in an emergency department and hospital, it targets transitional care and is meant to improve outcomes for both inpatient and ambulatory care. Providers are surveyed before and after the intervention about satisfaction with care, managing medications, and usefulness of local information systems in managing medications. Additional analysis will look at changes in the rates of adverse drug events, erroneous discrepancies, and omissions in a patient's medication list between the time of discharge and return to ambulatory care. Associations between interventions and outcomes will be summarized regarding factors related to payer, race, gender, and age. The study will inform the question of whether electronic facilitation of inpatient MR improves completion of MR and decreases the incidence of drug-related medical errors.

Specific Aims:

  • Integrate an electronic medical reconciliation system with an e-prescribing system. (Achieved)
  • Modify an EHR system to incorporate medication reconciliation. (Achieved)
  • Conduct a randomized controlled trial of the medical reconciliation system. (Ongoing)
  • Determine whether electronic facilitation alters medical reconciliation and the incidence of medication errors in ambulatory care. (Ongoing)

2011 Activities: In an effort to integrate the MR system with e-prescribing, the study team made several refinements to the user interfaces to increase the speed of the system, improve the dictionary of medications, and refine the text-based output. The team also continued to make efforts to increase accessibility of preadmission medication lists and allow the system to integrate data collection from different pharmacies. Both of these goals were achieved.

To inform the intervention design, the project team implemented a brief survey in 2010 to ask physicians about satisfaction with local tools and resources for managing inpatient medications, ease of managing medications, and accuracy of medication lists as noted in medical records. More than 200 survey responses were received in 2011 and analysis of preliminary survey results was done. The project team is conducting focus-group discussions to gain additional detailed feedback about medication management and the project. Two of the focus groups have met and at least one additional group is planned for 2012.

Meanwhile, the clinical trial is underway, with more than 800 uses of the intervention system logged at the end of 2011, among approximately 5,000 admissions. Multiple training sessions have been conducted to introduce the study to intervention team members and evening float physicians. There has been a gradual increase in the use of the system. During the last quarter of 2011, the study staff shadowed four users for several hours and recorded observations and suggestions about how to improve the system.

As last self-reported in the AHRQ Research Reporting System, the progress of project activities is on track. The budgeted funds are significantly underspent, however with some of the more time-intensive activities underway in 2012, the project team anticipates that the rate of spending will increase.

Preliminary Impact and Findings: There are no project findings to date.

Target Population: Adults, Safety Net

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Medication Reconciliation to Improve Quality of Transitional Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018183
  • Project Period: 
    September 2009 – July 2012
  • AHRQ Funding Amount: 
    $1,181,628
  • PDF Version: 
    (PDF, 364.61 KB)


Target Population: Adults, Safety Net

Summary: Medication errors account for approximately 20 percent of all medical errors in the United States each year. This significant source of error can cause injury or even fatalities and can occur in all types of health care settings, including patient transitions between locations or care levels within a facility. Recent studies have shown that electronic medication reconciliation (MR) for hospitalized patients can decrease medication discrepancies and significantly improve outcomes in transitional and ambulatory care. Relatively little is known, however, about the extent to which MR systems improve clinical outcomes.

This study seeks to integrate an electronic MR system with an electronic prescribing (e-prescribing) system and modify an electronic health record (EHR) to incorporate medication reconciliation. The project is taking place within Wishard Health Services, a safety net provider for residents of Marion County, Indiana which includes Wishard Hospital and eight primary ambulatory care community health centers. This project has a technical and a clinical team, both of which Dr. Weiner is a member. The clinical team provides input and guidance for the technical team, which meets weekly to discuss and advance the system’s development. Because the proposed system requires a formative evaluation, the initial system is being reviewed by a small group of physicians and nurses who are not part of the study teams.

The randomized study design allows for a controlled comparison of electronic MR and usual care. Participants include patients and their inpatient and ambulatory care providers. While the intervention is based in an emergency department and hospital, it targets transitional care and is meant to improve outcomes for both inpatient and ambulatory care. Providers are surveyed before and after the intervention regarding satisfaction with care, managing medications, and usefulness of local information systems in managing medications. Additional analysis will look at changes in the rates of adverse drug events, erroneous discrepancies, and omissions in a patient’s medication list between the time of discharge and return to ambulatory care. Associations between interventions and outcomes will be summarized regarding factors related to payer, race, gender, and age. The study will inform the question of whether electronic facilitation of inpatient MR improves completion of MR and decreases the incidence of drug-related medical errors.

Specific Aims:
  • Integrate an electronic medical reconciliation system with an e-prescribing system. (Ongoing)
  • Modify an EHR system to incorporate medication reconciliation. (Upcoming)
  • Conduct a randomized controlled trial of the medical reconciliation system. (Upcoming)
  • Determine whether electronic facilitation alters medical reconciliation and the incidence of medication errors in ambulatory care. (Ongoing)

2010 Activities: Activities focused on developing the prototype for the MR system, which was operating in trial mode at the end of 2010. A working interface is expected to be completed in early 2011. Throughout the year, input on the prototype was sought from the project's clinical team and then tested with an additional group of physicians for further feedback. Multiple rounds of feedback led to several technical changes to the application, including a necessary performance enhancement to speed entry of medications by decreasing repetitive access to the network. Imported medication lists were updated so that Medicaid claims could be reflected. The application was finalized with the activation of a prompt that will appear at the time of discharge. The prompt is intended to remind providers to review pre-admission medication lists. A “wish list” of additional technical enhancements was also collected, based on feedback from early testers and users. For staff that rotates into the medicine service, training materials for using the system were developed.

The project team also designed and implemented a brief survey to ask physicians about satisfaction with local tools and resources for managing inpatient medications, ease of managing medications, and accuracy of medication lists as noted in medical records. Institutional review board approval for the survey was received in July 2010 and the survey was implemented in the fall to obtain baseline information from providers. The survey is being conducted both electronically and on paper to the providers who are rotating into the medicine service, whether they are in the control or intervention group. The study team has received approximately 130 surveys of an overall target of 200. The project team anticipates that some of the survey questions will not be applicable to some of the respondents, and may therefore exclude some of the results from the analysis. The goal is to include between 150-160 surveys in the analysis.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The grant team reports that progress is mostly on track in terms of aims and milestones. The budget is reportedly under-spent but the project team anticipates that spending will eventually catch up, as the delay is typically due to the lag time between when work is performed and when invoicing is received by the subcontractors. Dr. Weiner checks in monthly to ensure that invoices are paid in a timely manner.

Preliminary Impact and Findings: There has been much success in terms of technical development. In terms of who should be documenting the medication history and conducting medication reconciliation, a lack of consensus was observed about who could or should perform this task and therefore medical housestaff could benefit from training on the roles of physicians and pharmacists in this regard. The team has received input from different groups, including providers and pharmacists, about how reconciliation should be done. The project team hopes that bringing these groups together will lead to consensus about how and by whom reconciliation is done, which may in turn set an example for other institutions.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report

Citation:
Weiner M. Medication Reconciliation Technology to Improve Quality of Transitional Care - Final Report. (Prepared by Indiana University, Indianapolis, Indiana under Grant No. R18 HS018183). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 416.7 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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