July 2009 FEATURE ARTICLES
Patient Safety
Health System Automates Medication Reconciliation
Solution extracts information directly from the clinical system throughout a patient’s stay and at discharge.
By Don Levick, M.D., Sandra Haldeman and Michelle Beck
Medication reconciliation has proven to be
challenging for the Lehigh Valley Health Network (LVHN), which
has wrestled through a variety of challenges to implement a
medication reconciliation solution to help proactively manage
patient medications at each step. LVHN’s approach has tightened
the process by providing technology support to the clinical
workflow, thereby preventing potential errors before they occur.
LVHN is a large, academic community health network based in Lehigh Valley, Pa., with three campuses, operating 984 acute-care beds. During the past seven years, the hospital has invested more than $100 million in information technology.
LVHN had medication-reconciliation processes, but they were not consistent and were mostly paper-based. Although there was some application support for writing discharge instructions, it was not universally used by LVHN’s physicians.
Staff confirmed that the ongoing adoption of technology had already eliminated paper from most clinical processes. Since physicians essentially do their work from wireless notebooks, staff knew patient safety could be improved by replacing the paper process with a standard medication-reconciliation process supported by information technology.
According to estimates by the Institute of Medicine, 1.5 million preventable adverse drug events take place each year. Findings by the Institute for Healthcare Improvement indicate that as many as half of those errors can be attributed to poor communication at care transition points, such as when the patient is transferred or discharged.
This understanding led the Joint Commission to make reconciling a patient’s medications across the continuum of care the subject of National Patient Safety Goal (NPSG) 8. For healthcare organizations working to implement this goal, however, the obstacles have been so problematic that the Joint Commission decided to hold off on factoring evaluation of NPSG 8 into accreditation decisions in 2009.
Tackling One of the Last Paper Processes
LVHN’s clinical system, the GE Centricity Enterprise system (LastWord version), is central to the clinical process. Much of the data needed for the medication-reconciliation process is already stored in the system, such as demographics, allergies and current inpatient medications. The hospital’s goal was to build a tight process that took advantage of the data already available.
When the initial search for vendors with medication-reconciliation solutions turned up none, LVHN turned to The Menon Group, a company with expertise developing applications that integrate closely with the GE clinical system. The Menon Group was already developing a discharge-instructions application and LVHN’s requirements were an extension of that effort.
After seeing a prototype in early 2007, LVHN decided to proceed with a new discharge-instructions/medication-reconciliation solution that would extract information directly from the clinical system to support reconciling medications throughout a patient’s stay in the hospital and at discharge. Patients would receive clear, legible discharge and medication instructions in patient-friendly language, and the medication list would be available for future admissions.
A team was assembled representing the needs of nursing, physicians, pharmacy, quality and information services. "This team’s goal was to integrate medication reconciliation with the electronic medication-management process," says Leroy Kromis, Pharm.D., LVHN medication safety officer. "To begin the process, we utilized our ‘plan-act-study-do’ continuous quality improvement methodology, created a small test-of-change to pilot our process and developed assessment tools that are required under the Joint Commission’s performance-improvement standards."
The transitional trauma unit was selected for the pilot, because the environment offered high interaction with nurses, physicians, physician assistants and other clinicians, which would provide the needed workflow feedback. An iterative process was used between the LVHN team and The Menon Group to gather and incorporate feedback from the pilot unit. The initial design, for example, displayed medications to be reconciled in a list. With feedback from users, a side-by-side view was developed that makes comparing medications faster and easier.
Any significant change upsets the workflow at first until users become facile with the system, so staff put resources toward supporting users on each unit. First, unit-specific education was provided before going live. When going live, daily nursing informatics and information services coverage were provided on the unit from 8 a.m. until 8 p.m. for up to one week. In addition, 24/7 on-call support and regular rounding were provided. Super users were trained on each unit to provide ongoing support. As of the end of April, nearly all units at all three hospitals were up and running.
Using the system is now mandatory for nurses, who must document a patient’s home medications within 24 hours of admission. Nearly half of LVHN physicians are community-based, so the approach was taken to continuously encourage and support their unique workflow needs as they adopt the new system. The focus has been to get the application into their hands and let them try it out, which has led to some changes and enhancements to the system.
Much of the data needed for the medication reconciliation process is already stored in the system. The hospital’s goal was to build a tight process using an application that could take advantage of the data already available.
"This product is evolving through a responsive project team and input from an interdisciplinary group of physicians, nurses and ancillary staff," explains Robert Murphy, M.D., LVHN-Muhlenberg medical director. "By engaging the physicians at the ground level, a tool has been developed to meet our organizational need to drive patient safety while valuing the physicians’ time and efficiency. Once we have a critical mass of acceptance, the paper will evaporate naturally."
Step-by-Step Medication Reconciliation
The medication-reconciliation application supports each step in the workflow. When a patient arrives for admission, the admitting nurse documents the home medications with assistance from the patient or his agent. If the patient has been to the facility before, patient demographics, previously documented allergies and the most recent list of home medications are available as a starting place.
Even if all the details are not available at the time of admission, the system allows the nurse to document partial information. If the patient does not know the name or other details about a medication, for example, the nurse can document text, such as "a little blue pill for blood pressure," or "no home meds."
At any time during the patient’s stay, clinicians can compare current inpatient medications, home medications documented at admission and medications planned for discharge in a side-by-side view. Medications are grouped according to therapeutic class (using the American Society of Health-System Pharmacists database) for easy analysis. Each time a physician performs reconciliation, the system makes note of it for reference.
The physician documents diet, activity and other instructions for the patient. When the patient is ready for discharge, the physician reviews the medications and finalizes the discharge medications. The nurse then has responsibility for finalizing the instructions, including medications, and reviewing them with the patient.
With a paper process, last-minute medication orders could be missed easily. With this system, the discharge nurse is alerted to any medication changes, even if they take place at the last minute.
In a recent case, an infectious disease specialist ordered an antibiotic immediately before discharge. When the nurse was finalizing the discharge instructions, the system alerted her that a new medication had been added. From the patient’s perspective, the information they take home is clear, legible and easy to understand. The printed instructions provide information to reference, as well as contact numbers for questions. This reduces the potential for medication instructions to be misunderstood by patients.
"The reconciliation piece allows a great opportunity to decrease medication errors at the time of the patient’s transition home," says LVHN medical staff president-elect Michael Pistoriam, D.O. "It also gives us the chance to ensure that our patients are going home on the appropriate medications."
In addition to the positive impact on patient safety, this project also represents a small step toward community-based data sharing. Physicians within the organization already have access to a wealth of clinical data about their patients. In the future, more of that information will be able to be shared among other hospitals and independent physician practices.
For more information on
Menon Group solutions
From the Catalog
According to www.menongroup.com : The Discharge Instructions/Medication Reconciliation application from The Menon Group provides the tools to review and reconcile all patient medications with speed and accuracy at key transition points during the patient’s stay. Further, it helps the care team provide complete care instructions and perform accurate discharge medication reconciliation when the patient is ready for discharge. Key features: Document home medications at admission; reconcile inpatient medications with home medications and discharge medications at any time; document medication reconciliation; order and reconcile medications at discharge; document instructions for each patient; give easy-to-understand instructions to the patient.
Don Levick, M.D., M.B.A., is the medical director of clinical informatics; Sandra Haldeman is the director of clinical applications; and Michelle Beck, M.B.A., is the manager of clinical applications for Lehigh Valley Health Network.