Medication reconciliation is a key component to patient safety and wellbeing. Just two years after The Joint Commission issued its National Patient Safety Goals and mandatory requirements for accreditation, many healthcare organizations are still struggling to accurately and completely reconcile medications across the continuum of care.

For Washington-based Valley Medical Center (VMC), creating, rather than finding a solution meant first understanding how medications flow through the organization and identifying handoff and communications points. As the largest non-profit healthcare provider between Seattle and Tacoma, VMC serves more than 400,000 residents via a central hospital in Renton, as well as 12 community clinics throughout King County.

The Joint Commission’s patient safety goals, which specifically impact the medication reconciliation process, are Goals 8A and 8B. Goal 8A requires a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. Goal 8B requires that the patient’s accurate medication reconciliation list (complete with medications prescribed by the first provider of service) is communicated to the next provider of service, whether it be within or outside the organization. The next provider of service checks the medication reconciliation list again to make sure it is accurate and in concert with any new medications to be ordered/prescribed. The complete list of medications is also provided to the patient upon discharge from the organization.

The Paper Process

Before the issuance of the regulations, VMC had a loose process in place where Nursing collected the home medication information on a paper form. Physicians collected similar information and put it in their history and physical examination record. According to VMC Director of Pharmacy Services Ron Williams, one of the medical center’s goals was to provide a process where the information was still collected, but could safely be shared for all disciplines to see. “Most of the computer solutions out there have too many steps where paper was required to move the process along and ultimately we felt we had to go out and develop something on our own,” says Williams.

As a first step in the process of discovery, VMC formed a medication reconciliation team made up of nurses from throughout the facility, pharmacy representatives, unit secretaries, physicians from key areas, the chairmen of the pharmacy and therapeutics committee as well as IT personnel. “We were charged with coming up with a solution to obtaining the list of medications patients were taking at home, which meet the 8A requirements, and then coming up with the 8B requirements of using that list when prescribing new medications within the facility,” explained Williams.

Within six months the committee had assembled a paper process that met 8A requirements, but quickly realized that meeting 8B would need an electronic solution. Mary VanHoomissen MBA, RN, who at the time was a clinical project manager at VMC, was enlisted as project manager (PM) for the as yet unidentified electronic solution and began working directly with the medication reconciliation team. “We realized that the paper process was too cumbersome and we needed something that allowed us to enter data once, that persisted over time and was better for the patient at discharge,” says VanHoomissen.

Creating the Team

As PM, VanHoomissen set up a requirement session with physicians, nurses, pharmacists and IT staff. The group went through the reconciliation process step by step to be sure that the requirements clinicians expected to see in the application would be there. “What really worked for this project was having COO Paul Hayes as executive sponsor, the director of pharmacy leading the medication reconciliation committee, physician champions, the director of acute care nursing services and Director of Outcomes Management Elaine Lobdell, all involved,” says VanHoomissen.

A central player in the process and a key member of the medication reconciliation committee was Dewey Howell M.D., Ph.D., who at the time had just completed VMC’s family practice residency program. As a physician with a keen interest in IT, Howell began working directly with VMC’s IT department as a part-time consultant. Howell had already created two software programs and would eventually go on to found Design Clinicals Inc., to bring his solutions to the healthcare market.

Howell’s first software solution, called Patient Pilot, was a hand-held application based on a Palm OS that allowed family medicine physicians to track patient panels and other patient management functions for the residency network. The other application responded to a need in family medicine residency and is known as OB Tracker. “I was frustrated by a number of the software applications available as they weren’t very clinician friendly and they largely seemed to get in the way of what I wanted to do instead of making my job better,” says Howell.

As Howell began outlining the application based on challenges and needs identified by the medication reconciliation committee, a rapid development cycle, which began on paper in November of 2006, evolved to an actual model of the software in early 2007. All the while, Howell and VanHoomissen met monthly with the executive medical committee. “One of the problems with a lot of software in our industry is that it is designed in somewhat of a vacuum and then people go out and try to find problems that it solves afterwards and ways to market it,” says Howell. “I take a different approach, which is to have your thumb on the pulse of where the pain points are for clinicians and doctors and solve that specific point with technology that makes sense.”

The Solution

Howell’s first prototype of the application contained just slightly more than 100 medications. With tens of thousands of potential medications and pharmacy solutions available, Howell knew that they would need help in creating the extensive drug database. Both VMC and Howell had a significant working history with California-based First Databank Inc.; Howell chose the company’s CPOE-ready drug database OrderView Med Knowledge Base. OrderView’s “Orderable Medication” concept would facilitate clinicians’ use of drug descriptions based on patient parameters for completing medication orders in one or two mouse clicks. “I had worked with First DataBank previously and knew that they were creating databases that work like clinicians think,” says Howell.

Howell was soon able to put together a software prototype using a Web platform. While the early prototype involved inactive screens that simulated the look and feel of the finished software, it provided the necessary view of eventual functionality that led to the go-ahead for completion of the finished software. This process lasted for five weeks and once consensus was reached, the goal was to deliver the finished solution by early summer. Within six months, Howell had developed a product called MedsTracker to meet the needs of not only the transfer and discharge of patients but also to include the 8A requirements of producing the list of medications the patient was using at home. Additionally, Howell and VMC were also responsible for making the solution work in non-hospital areas, such as clinics and ambulatory care areas encompassed within the healthcare enterprise.

“We had two days set aside for clinician review in February in our IT training room where we projected the application on screen and walked through the process a step at a time to gain user acceptance,” says VanHoomissen. “We also had the application on a training computer so that they could physically interact with the application.”

The Solution in Practice

Pharmacists at VMC utilize McKesson’s Horizon Meds Manager for medication management, so all of the medication orders that come from the nursing units are entered by pharmacists prior to the nurses administering the doses. MedsTracker is able to grab information from this and other McKesson solutions utilized by VMC. According to Williams, an example would be if a patient is in one of VMC’s offsite ambulatory care clinics and they are using the Horizon Ambulatory Care program. MedsTracker would grab the patient’s medication profile from the clinic and hold it in the database for future review by healthcare providers. “If that patient was then admitted to the hospital, we would already have a built list that just needed confirmation with the patient on admission and possibly add some new medications,” says Williams.

Additionally, MedsTracker streamlined patient transfers from one part of the hospital to another. As an example, when patients were transferred in or out of surgery, critical or progressive care units, the doctor would be able to see the home medications as well as the medications that were prescribed during the stay. The solution allows them to have a complete record of the patient’s medication history when they are making decisions of what medications to continue on the transfer.

At the time of discharge, MedsTracker shows the list of home medications as well as those that were prescribed during the stay. It enables physicians to select which medications their patients need to continue when they leave the hospital. Physicians then print out discharge instructions in patient-friendly language, along with drug monographs for the patients. They also print out prescriptions for the patients to take home and to their pharmacy—all with the click of a button.

Additionally, the system also notifies the primary care physician of the medications that the patient is on when they leave VMC, thereby meeting all of the requirements of The Joint Commission on 8A and 8B. “The system also does something not required by The Commission: When we admit a patient into our facility, it faxes information to the primary care physician, informing them their patient has been admitted into our hospital and these are the medications they are taking when entering our facility,” says Williams.

Training

Training users would prove to be a massive undertaking with some 900 clinicians involved. In order to ensure full compliance by staff—particularly physicians and surgeons—Howell and the medication reconciliation committee devised a mandatory competency test for physicians, nurses, respiratory therapists, pharmacist and anyone that would be touching the system. The key to the competency testing was enforcement by the medical executive committee.

VMC first concentrated on the top 200 physician admitters to the facility by going to their offices or setting up training rooms where they could run through the competency in a morning or noon session. By the time VMC went live on April 3, 2007, greater than 93 percent of all physicians had completed their competency training and were ready to begin using MedsTracker.

According to VanHoomissen, a unique training component was Howell’s creation of a competency environment separate from the testing environment. This allowed VanHoomissen to clearly track those who had and had not completed the competency. As they stepped through the reconciliation stages, the competency environment tracked their clicks. If the clinician followed the steps in the process exactly, they were done in 15 minutes.

Outcomes

While VMC continues to monitor workflow and compliance issues, successful implementation is ultimately about patient safety. In order to track patient understanding and thus satisfaction with the entire discharge process including medication reconciliation, VMC dedicates a staffer to make follow-up phone calls after discharge to 100 percent of patients that are discharged from medical or surgical units. According to Director of Outcomes Management Elaine Lobdell, the staffer noted a significant drop in the number of questions related to medications and the confusion centered on them.

In order to measure competency and compliance over time, the application tracks by week, month, quarter and year, giving VMC an overall as well as a unit-by-unit assessment of the automated medication reconciliation process verses the former manual process. “We went from zero reconciled at discharge to 91 percent in the first three weeks, and the average time to reconcile takes less than four minutes per patient, says VanHoomissen. “Someday, we are all going to be that patient, so I want it to be the best it can be for everyone.”

As healthcare organizations seek out solutions and partners in the struggle towards 100 percent compliance in medication reconciliation, clinicians continue to let the driving force be patient safety and wellbeing. “And, we didn’t have to wait for major developments with some of the key vendors out there,” says Lobdell. “We were able to internally develop this solution that is capable of pulling together information from our clinical record, pharmacy and other information systems. From my perspective, the most important and exciting aspect of this project has to do with the impact on patient care as we are significantly widening the margin of safety for our patients.”