Winning the Battle for Standardization

Throughout its rich and prestigious 232-year history of service to soldiers, veterans, retirees and their families, the U.S. Army Medical Department (AMEDD) has employed cutting-edge technology complemented by solid strategic planning to provide high quality healthcare. Compliance with patient safety regulations and initiatives designed to reduce adverse events and errors also have been instrumental to AMEDD’s achievements—and its approach to medication reconciliation is no different.

Since the Joint Commission National Patient Safety Goal’s debut in 2005, AMEDD—like hundreds of civilian hospitals and healthcare systems—has pursued the idea of building a standardized process for helping its military clinicians and patients keep track of prescribed and over-the-counter medications, along with herbal and nutritional supplements, throughout the continuum of care. Like its civilian counterparts, AMEDD has encountered challenges in its efforts to build a framework supporting the standardized process such as inconsistent documentation and communication breakdowns at key transition points of medication use.

Supporting the Army’s Mobile Workforce
AMEDD is comprised of 36 major Army hospitals or large clinics, and nearly 70 Army dental facilities. Currently, all medical and dental facilities are performing medication reconciliation by documenting a patient’s medications from admissions to discharge in an array of formats using either paper or the electronic documentation and electronic medical record (EMR) system. While variance in medication reconciliation documentation is not unique to military hospitals, what is unique is that as part of their military service, active duty professionals—including medical personnel—typically transfer every three years to a different medical facility to assume a new assignment.

Providers are more productive knowing that the practice is fostering a higher level of patient safety in medication management. With all healthcare facilities utilizing the same approach, it becomes easier to interpret compliance data.

This frequency of military relocation fosters a repetitive need of having to re-learn how medication reconciliation is documented at the new location after each transfer. “Corporately, we’re looking at a highly mobile workforce employed across many facilities that use the same type of information management system,” says Lt. Col. Robert Durkee, U.S. Army patient safety program manager. “We’re examining where in the EMR system our personnel document medication reconciliation and devising an enterprisewide standardized process, that includes best practices, so when clinicians move from one facility to another, the process is exactly the same,” says Durkee. “Our objective is to reduce the opportunity for patient harm and to decrease the time required for an employee to become oriented with a new facility’s medication reconciliation process.”

First Step: Medication Reconciliation Work Group
To ensure that continuity of care is top-of-mind throughout the initiative’s planning phase, AMEDD is assembling a multidisciplinary work group charged with developing a “corporate-level” solution to inpatient medication reconciliation. Currently, 10 Army medical facilities use the Essentris EMR system from CliniComp.

The ultimate goal of bringing together this broad range of clinical experience is the generation of a unified and enterprise-systematic solution that will be embraced by the entire AMEDD healthcare team. “The Army Medical Department is very much a leader in developing a clear and workable solution to medication reconciliation with the patient,” said Lee Richard, Ph.D., RN, of the U.S. Army Patient Safety Program. “The greatest source of medical information for all healthcare providers is the patient. We want to build even stronger partnerships with our patients and beneficiaries to keep them safe during our care.”

Here are some specific strategies the work group will undertake in designing a standardized process using the EMR to enhance the value of the enterprise medication reconciliation process and to serve as a “best practice” template for future EMR installations:

Development of a home medication list: Over-the-counter, prescription and off-label drugs, as well as herbals, vitamins and dietary supplements will be documented upon admittance and updated at every encounter.

 Create automated functions: Proactive triggers will notify clinicians that medications are being prescribed for a patient by a licensed provider; this list will be compared with the patient’s home medications admissions list to enable informed clinical decisions; and, the resulting reconciled medication list will be communicated to appropriate caregivers and to the patient. These tasks will facilitate data collection and aggregation on the back-end for continuous quality improvement.

Identify all workflow points: Upon admission, at every transition thereafter, if the medication changes and warrants reconciliation, and finally, at discharge, the EMR system will map to these workflow points, providing a systematic and unified documentation process. The tracking of medications will mitigate confusion and lack of clarity among providers when supporting and/or delivering care.

 To keep the momentum going and promote support for the corporate-wide initiative, AMEDD plans to report the work group’s progress in its quarterly patient safety newsletter as well as in other communication venues.

Second Step: Enterprise EMR Documentation
According to Richard, an integrating EMR system can play an important role through automation in standardizing a facility’s entire approach to medication reconciliation and handoff communications, regardless of the number of its beds. “The intent for medication reconciliation is still there and being performed by either a 75-bed or 300-bed facility, albeit differently according to their capabilities and needs,” he says.

“But, because the EMR technology in a larger medical facility can and does vary in integration than one used in smaller facilities, it is a strong enough reason for adopting a standardized approach to deploying the EMR to automate the entire patient record process and make it accessible to all care providers,” says Richard.

An integrating EMR system can play an important role through automation in standar- dizing a facility’s entire approach to medication reconciliation and handoff communications, regardless of the number of its beds.

As part of its unified medication reconciliation plan going forward for each facility using the EMR, AMEDD plans to advance the system to the next level of streamlined clinical documentation in the same place and same format in order to initiate consistent adherence by all clinicians. To date, AMEDD has not enforced a “one way” electronic documentation process, largely because each facility has configured the system to meet customized needs.

“We’re looking at a broad corporate view of standardizing different components of the EMR system, as well as looking beyond identifying best practices and processes to more fully comply with enterprise medication reconciliation as a whole,” says Richard. “We’re concerned with how the medication information gets to the medical record and how it sustains its viability so the initial list of medications is viewed by all disciplines up until discharge.” Standardization achieved through a fully integrated EMR across the board offers distinct advantages to those medical facilities currently not using the system to its full potential.

Examples of some expected results are: Physician and nursing staff will know where the reconciliation is documented in the EMR and thus no longer have to page through the chart to find the information; multiple staff members will contribute to a unified medication reconciliation versus each discipline working in isolation; and, finally, enhanced communication and collaboration will minimize medication errors and adverse reactions.

Standardization Can Instigate Compliance
Another benefit of standardizing EMR documentation across the U.S. health enterprise in conjunction with medication reconciliation is the assurance that all Army hospitals are in compliance with standard audit processes including data reporting.

“The work group participants will develop an implementation plan to operationalize the standardized corporate approach for inpatient medical record medication reconciliation, as well as identify and develop a standardized audit mechanism for evaluating compliance with the inpatient medication reconciliation process,” says Richard.

“Simply put, instituting a corporatewide medication reconciliation response minimizes confusion if acceptable standards or intent of medication reconciliation is met,” he says. “Providers are more productive knowing that the practice is fostering a higher level of patient safety in medication management. With all healthcare facilities utilizing the same approach, it becomes easier to interpret compliance data.” Furthermore, an EMR system removes nuances from individual documentation and offers the opportunity to monitor actual compliance of the data entry electronically.

“We can pull figures and know right away whether we are doing a good job or not for reporting purposes, and the clinician doesn’t have to pull paper records to retrieve the manual chart to conduct the audit,” says Durkee.

Lessons Learned
AMEDD offers a few lessons learned, thus far, that are making a major impact already on the success of its journey to realizing a medication reconciliation standardization plan. For starters, engage the clinician end-users on the front end to understand their needs in reconciling medications. “The lessons we’re taking into the future are those already learned from clinicians involved in the medication reconciliation process,” says Richard. For the U.S. Army, getting clinician buy-in isn’t an issue. “We essentially have a close, collaborative medical staff that is already defining its needs up front for the process to work and that has already acknowledged the necessity of standardizing medication reconciliation throughout all facilities.”

Secondly, communicate that a better way to reconcile medications is possible—and only possible—through best practices, and that includes simplifying the requisite action steps on behalf of the end user. “We want this medication reconciliation process to be much easier for the staff so we can reach our end goal of safer patient care,” says Durkee. “In the long term, whatever approach is recommended as an outcome from this work group will dictate future development including customizing the EMR. Everyone has come a long way across the nation on this issue and the future is open and uncharted as to where we will go from here.”

“We’re not trying to create work,” says Richard. “We’re trying to create a mechanism that will demonstrate best practice in medication reconciliation and we’re well on our way.” HMT

*DISCLAIMER
“The appearance of name-brand products in this article does not constitute endorsement by the U.S. Army Medical Command, the Department of the Army, Department of Defense or the U.S. Government of the information, products or services contained therein.”

OCTOBER 2007