Bringing the Outside In

June 24, 2011
For most patients, a busy emergency room is probably the worst place to remember what medications they're taking. But since Jan. 1, 2006, when The

For most patients, a busy emergency room is probably the worst place to remember what medications they're taking. But since Jan. 1, 2006, when The Joint Commission's (Oakbrook Terrace, Ill.) new patient safety initiative was announced, hospitals risk losing accreditation if they don't use some form of medication reconciliation to prevent medication errors.

Donna Staton
On that date, The Joint Commission's patient safety initiative — Medication Reconciliation — became a required element for hospital accreditation. Medication reconciliation requires that a complete and current list of a patient's medications be obtained at the start of the patient's care, updated during the course of care, and communicated to the next care provider.

Simply asking, "What medications are you taking?" used to be the first, and sometimes only, step towards reconciliation. But in a growing trend, new IT solutions to integrate external (outside that hospital) and internal medication histories make for more efficient and accurate medication reconciliation. And both providers and vendors are embracing it.

This year Fauquier Health System, an 86-bed community hospital in Warrenton, Va. entered into a joint venture with DrFirst (Rockville, Md.) for co-development of an IT product that met the needs for medication reconciliation within the hospital. "There are a lot of hospitals that are using automated processes for this," says Donna Staton, CIO of Fauquier. "But for us, the ability to bring the outpatient medication record into the process is the real differentiator."

Staton was new to her position when the Joint Commission mandate was announced. "In my new role, I was working diligently with a lot of different stakeholders to find where some of the biggest areas of pain were. Medication reconciliation certainly bubbled to the top. It was new, nobody knew how to do it well, and it was a very paper-based process."

Physician-nursing focus groups at Fauquier kept suggesting solutions and Staton listened. She decided it looked like an opportunity where technology could make the process more efficient.

Many Fauquier physicians with admitting privileges were already using DrFirst's Rcopia product as an e-prescribing tool for patients in their private practices. It was slowly trickling into the inpatient setting as doctors used it to send over their discharge medication orders — but it was disrupting the existing nursing workflow. "You can't just throw something into the system and not talk about what the impact is going to be," Staton says. That prompted her to open a dialog with the vendor.

Staton says DrFirst had a concept for an acute care medication reconciliation offering and shared it with her. "We decided to enter into a joint venture for co-development of a product that met the needs for medication reconciliation in the hospital." Both the hospital's nurse informaticist and the director of pharmacy were instrumental in the early development process, she says.

"Brigham and Women's Hospital (Boston) did a study called, 'Building a Case for Medication Reconciliation,’” says Cameron Deemer, CEO of DrFirst. "They found the number-one barrier is unreliable patients by a fair margin. That's what we're trying to address."

Deemer says though DrFirst's core business is e-prescribing, this was an opportunity to help create a connected community. "Fauquier Health System already had Rcopia users affiliated with the hospital. It was a great place for us to develop and roll out this reconciliation technology."

How does the system work? By integrating with different prescription databases such as RxHub (St. Paul, Minn.), Rcopia and the pharmacy benefit management system, DrFirst is able to pull prescription information over to the hospital for the patient in question. From there, nurses and physicians can go in and interact with the information and re-interview the patient. The final data set reflects the medications the patient is currently on and flows it back into the CIS system in the hospital. "We want our CIS to be the system of record," Staton says.

Deemer says the DrFirst system used by Fauquier is a Web-based application that searches and brings back the ambulatory medications. It allows order writing, report printing, and brings back the medication information from different practitioners and care venues. Finally, it writes the discharge medications using the Rcopia system.

"At Fauqier, because of Rcopia's use, they can get up to an 80 percent hit rate because most everyone is covered by either RxHub or one of the physicians. At other places it's a mixed bag. The best possible scenario is when a hospital is not only using the product for medication reconciliation, but also sponsors e-prescribing for the physicians," says Deemer. "Then it's a great closed loop."

Deemer adds that getting the patient's prescribing data has an additional benefit. "The hospital not only gets a feel of what the patient is taking, but what they've been prescribed, which can be useful if someone isn't taking their meds." There's also space for new data entry when the patient is interviewed and asked to verify the medication list.

Fauquier was using Meditech (Westwood, Mass.) for their CIS and Staton says they had a choice of using a point-to point-interface or an interface engine to Meditech. "We chose Iatrics Systems (Boxford, Mass.) for the third-party interface because they had a strong relationship with Meditech and understood how to get information in and out of Meditech in an intelligent manner."

She says the interface hasn't gone without its challenges. "It's like anything else," Staton says, Off-the-shelf is easy, something new is a learning process. But they worked closely with us and were very responsive."

The system went live at the beginning of June 2007. Staton says Fauquier took a phased approach for the pilot because there were three distinct functions of the reconciliation process: the admissions, where all the outpatient medication information is collected; then the reconciliation if the patient transfers to a different level of care; and then the discharge process. "We stepped into it slowly with the last piece coming on in August."

She says the hospital benefited by taking this slow phase-in approach because it gave it the ability to change direction quickly, if necessary, without having a huge ripple effect on the user community.

Staton says the biggest challenge was managing the expectations of her doctors because many clinicians by nature don't like change. The doctors who were using Rcopia already knew what to expect. For the others, Stanton says, "you have to break it down into, 'How is it going to make my life easier?' The real benefit is that now, rather than using paper, you can do it electronically, from home, or the office. You don't have to come into the hospital to do your discharge."

Staton is keeping a close eye on her medication error metrics, "We expect to come back in 90 days and 180 days and look at how we're doing on a quarterly basis," she said. "What I'm hoping to do with this in time is a regional medication record."