July 2012

RPMS PharmacyMedication Reconciliation, Patient Wellness

Handout, and Outside Medication

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Facilitators

Wil Darwin, PharmD, CDE• ABQ IHS Area Pharmacist Consultant• ABQ IHS Area RPMS/EHR Consultant• ABQ, NMKendall Van Tyle, PharmD, BCPS, NCPS• Pharmacist Informaticist/Residency Director• Northern Navajo Medical Center• Shiprock, NM

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Objectives• Understand this presentation will be Pharmacy-Centric• Recall the MU requirements for meeting the Med Rec Performance

Measure• Design the necessary components and required documentation for

meeting the Med Rec Performance Measure• Integrate the use of the Patient Wellness Handout in the Med Rec

process• Compare and contrast the Outside Medications functionality with

Outpatient and Inpatient medications functionality• Explain why Outside Medications data population is important in

maintaining a complete medication profile• Utilize the principles, practices, and techniques for documenting

patient reported medications

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Points To Consider….

• Configure RPMS-EHR optimization.• CAC and Rx Informaticist to configure components:• EHR GUI template may require optimization.• Configure RPMS PDM.

• Chronic vs Acute Meds: There is a Difference!• The RPMS logic of MU reports.

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Points To Consider….

• RPMS-EHR is dynamic and is always changing: • Med Tab versus Order Med Tab.• Expiration Logic: Meds may expire between

visits.• Medications can be discontinued by RPh.• Medications can become “lost” to providers:• Poor documentation = lack of a reference point.

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Expiration Logic Patch APSP 1013 Changes

• Non-Controlled Substance: Issue Date + 366 days.• Controlled Substance: Issue Date + 184 days.• Expiration date will change when prescription is filled:

• Prescription with no refills: Release Date + Days Supply.• Prescription with refills: Expiration date will be when filled, then

changes to Release Date of Last Fill + Days Supply.• If release date of last fill is delayed such that:

• Non-controlled Substance:• .• .

• Controlled Substance:• .• .

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Roadmap for this Presentation

• Review Medication Reconciliation Documentation (Patient Education Code).

• Use the Patient Wellness Handout to assist with Medication Reconciliation Process.

• Review Outside Medication processes.

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Medication ReconciliationWhat is It?

• What is driving the requirement?

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As defined by the APhA and ASHP

• Medication Reconciliation is the comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns.

• This process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are rewritten or adjusted, or if the patient has added nonprescription medications to [his or her] self-care.

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Introduction

• Med Rec is a complex process.• Med Rec impacts all patients who move

through a healthcare system.• Med Rec list is a comparison of a patient’s

current medication regimen against the prescriber’s med orders.

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Goals of Med Reconciliation

• Improve patient safety.• Assist in identification of chronic medications

across the continuum of care.• Encourage patients to become more involved

with their healthcare.• Improve compliance with accreditation

standards regarding med reconciliation.

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Why Perform Med Rec?

• Med Rec is a process to decrease med errors and patient harm.

• It allows for obtaining, verifying, and documenting the patient’s current prescription, OTCs, and herbals when the patient is seen in the clinic.

• It allows for considering the patient’s home meds when meds are being ordered in clinic.

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Why Perform Med Rec?

• It allows for comparing the patient’s home meds to ordered meds to identify unintended discrepancies.

• It allows for verification of the patient’s home meds and discussion of unintended discrepancies with the prescriber for resolution.

• It provides an updated med list and communicates the importance of managing med information to the patient at the end of the patient visit.

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Literature Review

• Errors that occur in prescribing/ordering phase are primarily due to lack of drug knowledge and patient information.1,2

• One study showed that over 70% of drug-related problems were recognized only via patient interview.3

• Time & participation barriers• Med history often gathered from sources

other than the patient interview.4

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Literature Review

• Studies in a variety of clinical settings have shown substantial discrepancies.4-8

• Up to 27% of all hospital prescribing errors attributed to incomplete medication history.9

• 33% of patients discharged from the ICU had one or more chronic med omissions.10

• 22% of drug discrepancies may have resulted in patient harm during hospitalization and 59% if continued after discharge.11

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Literature Review

• Reduced rate of errors after implementation of med rec process at admit, transfer and discharge.12

• 213/100 admissions to 63/100 admissions• Reconciliation by pharmacists of

discrepancies in admission medication histories and orders decrease opportunities for med errors and potential harm.13,14

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Medication Reconciliation

• Who is Responsible?• Everyone – the patient, nurse, provider, pharmacy.

• Process must be clearly delineated:• Everyone must be trained & trained again.• Consistency is key.• Customize to your facility’s work flows.

• Meaningful Use Logic (MU):• ONLY the M-MR education topic counts.• PWH Med Rec is useful and can be used to meet other

MU measures.

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Example Outpatient Med Rec Process

Nurse/Nursing Assistant • Call patient into exam room.• Screen patient.• Enter chief complaint and vitals

via EHR.• Document health screenings

(tobacco, alcohol, depression, domestic violence).

• Print/Generate PWH Med Rec.• Populate M-MR.Patient • Review PWH Med Rec while

waiting for provider.• Assist in record update.

Provider• Review PWH Med Rec with patient

to determine required updates (new meds / outside Rx, DC’d meds, OTC/ herbal).

• Order needed medications.• Document updated med list in EHR

progress note.Pharmacist• Resolve any discrepancies.• Give new PWH Med Rec to patient to

compare with home meds.• Populate M-MR on PharmEd.• Place new list in chart as a static

reference point.

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Example Urgent Care or Emergency Room Med Rec Process

Triage Nurse • Call patient into exam

room.• Screen patient.• Enter chief complaint

and vitals via EHR.• Print/Generate PWH

Med Rec.• Populate M-MR.

Provider/Nurse• Review PWH Med Rec with patient

to determine required updates (new meds / outside Rx, DC’d meds, OTC/ herbal).

• Order needed medications.• Document updated med list in EHR

progress note.Pharmacist• Resolve any discrepancies.• Give new PWH Med Rec to patient to

compare with home meds.• Populate M-MR on PharmEd.• Place new list in chart as a static

reference point.

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Example of an Inpatient Med Rec Process

Nurse• Admit patient to floor.• Complete assessments.Pharmacist (admit)• Print/Generate PWH Med Rec.• Review PWH Med Rec with

patient to determine required updates (new meds / outside Rx, DC’d meds, OTC/ herbal).

• Consult with provider as needed.• Document updated med list in

EHR progress note.• Populate M-MR.

Provider• Review Pharmacist note.• Order needed medications.• Document updated med list in

EHR progress note.Pharmacist (Discharge)• Resolve any discrepancies.• Give new PWH Med Rec to

patient to compare with home meds.

• Populate M-MR on PharmEd.• Place new list in chart as a static

reference point.

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Pharmacist Screening Process

• Med Management: Two-step method/process:• Roll-and-Scroll Process• EHR GUI Process

• RPh can control the med list in RPMS and EHR.• RPh can use their clinical judgment to manage,

delineate, and execute the med list.• This will aid and “stage” a clean med list for the

provider to view in EHR.• The pharmacist is a “Med Rec Specialist.”

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Roll-n-Scroll Med Management

• Chronic Med designation: CHRONIC MEDICATION: YES// • Acute Meds management – Recommend to Leave alone • RPh may need to DC duplicates meds• RPh may need to DC expired meds (protocol based)• RPh will need to manage Chronic Meds in the RPMS

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EHR GUI Med Management

• Managed in the MED tab• Organize:

• Chronic Only• Older than 6 months• Alphabetized med list

• Review Med List• Re-designate

discontinued” meds and duplicate meds as non-Chronic

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• EHR GUI Med Management• Document M-MR

Patient Education in EHR

• Managed in the Patient Education tab, Pharm Ed Button

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Patient Wellness Handout (PWH)(Med Rec)

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PWH – Med Rec

• Developed by National IHS OIT team • Letter format for the patient, patient friendly• PWH Med Rec Contains:• Patient Demographics• Current documented food and drug allergies, and

adverse reactions• Outpatient Medication profile:

• Active Med• Outside Med• Unknown Med

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The PWH and Meaningful Use

• PWH – Med Rec (Menu Set Measure):• An important tool, but has NOTHING to do with MU reporting

logic for MED REC• PWH – Clinical Summary (Core Measure - EP):

• Printing of the PWH DOES figure into the logic: must be provided to patient within 3 days

• Required: meds, allergies, recent labs, problem list• MUST be configured using PWH menu (not PCC/VA health

summary)• PWH – Patient Reminders (Menu Set - EP):

• Printing DOES figure into MU logic• Must be configured using PWH

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The PWH and Meaningful Use

• How to configure the PWH for MU:• ftp://ftp.ihs.gov/pubs/EHR/EHR_MU_Configurati

on_ScavengerHunt_Eligible_Professionals/MU_Guide_EP_10.pdf

• Does the computer know the difference?• Numerator for MU measures (Core, Menu Set –

Reminders) pulls how many times the PWH is printed for certain populations:• Content on the PWH is unknown to the computer• Can meet the numbers, without the correct content

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Medication Tab: New(+) Button

• Best Practice model of managing meds in one area.

• Managed in the MED tab:• Use the New (+) Button• May need to be configured

• XX > EP > ORWDX NEW MED > set at system level• o = outpt med menu• i = inpt med menu

• CAUTION: Ordering medications in the ORDERS Tab is now discouraged. Use the Med Tab whenever possible to maximize available features within the EHR.

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Medication Tab: New (+) Button

• Click New (+)

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Primary Med Order Menu

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Secondary Med Order Menu

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Outside Medications (Non-VA)

• Facilitates Med Reconciliation• End-user documents in EHR:• Provider or Nurse driven• Facilitates with communication

• Does not need to be finished by pharmacy• Each Med need to be defined in PDM:• Includes any herbals, vitamins, OTCs, etc.

• Entries are checked for allergies and drug interactions (if matched in PDM)

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Outside Medications (Non-VA)

• RPMS Configuration:• Marked as “X” or Non-VA in the PDM drug file

• References:• See power-point presentation on “Non-VA Meds”• ftp://ftp.ihs.gov/rpms/patches/ehr_0110.06o.pdf

(EHR Patch 6 notes)• ftp://ftp.ihs.gov/rpms/patches/ehr_0110.07o.pdf

(EHR Patch 7 notes)

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Outside Medications (Non-VA)

• Do not use the AORX function!!• Any active meds entered through ORX should be entered

into Outside Medications and inactivated in ORX• DORX = Delete Outside Rx can be used to reconcile

• Do not use the mnemonics (ORX) and (OTC) in the drug name!!• For historical purposes, previous ORX and OTC entries

should be inactivated and new entries entered into PDM and marked appropriately to be used in the Outside Medication Package (X) or to be used for e-Prescribing (O)

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Outside Medications (Non-VA)

• In the Outside Medication section:• Right click Outside Med• Click New Medication

• Or:• Select Outside Medication section • Click New (+)

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Outside Medications (Non-VA)

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Unknown Drug Misc

• “Unknown Drug Miscellaneous” definition name.

• Build in PDM file.• Instruction outlined in EHR Patch 6 notes.• An alert flag notification can be configured for

the OI name. Then the drug can be entered into PDM.

• Another option is to run a report to capture data for PDM update.

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Outside Med and Unknown Drug Misc

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Outside Med and Unknown Drug Misc

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Conclusion

• Medication Reconciliation addresses medication changes at various patient care events.

• Process can reduce medication related events and avoid negative patient outcomes.

• It requires a multidisciplinary team approach.• It requires planning and communication systems to be

in place between institutions of care.• It uses the EHR to document the process.• It is vital to ensuring patients are instructed and

educated on optimal medication use.

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Take Med Rec SERIOUS• Solicit (from patient): Meds (all) and allergies each encounter• Examine: Review at each outpatient and inpatient clinic areas.

Look for discrepancies.• Reconcile: Compare home list and list in RPMS-EHR. Make

changes when needed.• Inform: Inform and educate patient and caregiver about their

medications.• Optimize: Optimize med doses to target guidelines or to improve

outcome.• Reduce: Reduce polypharmacy issues.• Update: Update med list with appropriate changes.• Share: Share with patient, caregiver, and all other providers.

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References1. Leape, L.L.; Bates, D.W.; Cullen D.J.; et al. Systems analysis of adverse drug events. JAMA.

1995; 274:35-43. 2. Lesar, T.S.; Briceland, L.; Stein, D.S. Factors related to errors in medication prescribing. JAMA.

1997; 277:312-317.3. Folli, H.L.; Poole, R.L.; Benitz, W.E.; et al. Medication error prevention by clinical pharmacists

in two children’s hospitals. Pediatrics. 1987; 79:718-722. 4. Beers, M.H.; Munekata, M.; Storrie, M. The accuracy of medication histories in the hospital

medical records of elderly persons. J Am Geriatr Soc. 1990; 38:1183-1187.5. Lau, H.S.; Florax, C.; Porsius, A.J.; et al. The completeness of medication histories in hospital

medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol. 2000; 49:597-603.

6. Manley, H.J.; Drayer, D.K.; McClaran, M.; et al. Drug record discrepancies in an outpatient electronic medical record: frequency, type, and potential impact on patient care at a hemodialysis center. Pharmacotherapy. 2003; 23:231-239.

7. Bedell, S.E.; Jabbour, S.; Goldberg, R.; et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med. 2000; 160:2129-2134.

8. Price, D.; Cooke, J.; Singleton, S.; et al. Doctors' unawareness of the drugs their patients are taking: a major cause of overprescribing? Br Med J. 1986; 292:99-100.

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References9. Dobrzanski, S.; Hammond, I.; Khan, G.; et al. The nature of hospital prescribing errors. Br J

Clin Govern 2002;7:187-93.10. Bell, C.M.; Rahimi-Darabad, P.; Orner, A.I. Discontinuity of Chronic Medications in Patients

Discharged from the Intensive Care Unit. J Gen Intern Med 2006; 21:937-941. 11. Sullivan, C.; Gleason, K.M.; Groszek, J.M.; et al. Medication Reconciliation in the Acute Care

Setting, Opportunity and Challenge for Nursing. J Nurs Care Qual 2005; 20:95-98.12. Rozich, J.D.; Resar, R.K.; Medication safety: one organization's approach to the challenge.

JCOM. 2001; 8:27-34.13. Bond, C.A.; Raehl, C.L.; Franke, T. Clinical pharmacy services, hospital pharmacy staffing and

medication errors in United States hospitals. Pharmacotherapy. 2002; 22:134-147.14. Gleason, K.M.; Groszek, J.M.; Sullivan, C.; et al. Reconciliation of discrepancies in

medication histories and admission orders of newly hospitalized patients. Am J Health-Syst Pharm 2004; 61:1689-1694

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Questions and Discussions