Dr. Tsomides is a physician sponsor of a new med-rec initiative at WakeMed. With a steering committee that includes representatives from stakeholder services (medicine, nursing, pharmacy, administration, etc.), the group plans to hire and train pharmacy techs who will take home medication lists in the ED, lifting that responsibility from physicians’ task lists.
Is IT the Answer?
Would many of the barriers to med rec go away with universal EHR? So far, the literature has not borne out the superiority of using EHR to facilitate better med rec.
Peter Kaboli and colleagues found that the computerized medication record reflected what patients were actually taking for only 5.3% of the 493 VA patients enrolled in a study at the Iowa City VA.7 Kenneth Boockvar and colleagues at the Bronx VA found no difference in the overall incidence of ADEs caused by medication discrepancies between VA patients with an EHR and non-VA patients without an EHR.8 A group of researchers with Partners HealthCare in Boston evaluated a secure, Web-based patient portal to produce more accurate medication lists. The patients using this system had just as many discrepancies between medication lists and self-reporting as those who did not.9
Dr. Lesselroth, who has devised a patient kiosk touch-screen tool for reconciling patients’ medication lists and has faced barriers when implementing said technology, says med rec is much more “organic” than strictly mechanical. “It invokes theories of learning from the cognitive sciences,” he says. “We haven’t actually built tools that help people with their problem representation, with understanding not just how medications reconcile with the prior setting of care, but whether they make clinical sense within the new context of care. That requires a quantum leap in thinking.”
Re-Brand the Message
Drs. Schnipper and Tsomides believe that when The Joint Committee first coined the term “medication reconciliation” and advanced it as a mandate, most providers associated it with a regulatory requirement, and understandably so. Dr. Schnipper says med rec could be improved if providers think about it in the context of accurate orders that translate to greater patient safety. “After all,” he says, “hospitalists are ultimately responsible for the medication orders written for their patients.
“This is not about regulatory requirements,” he continues. “This is about medication safety and transitions of care. You can spend an hour on deciding what dose of Lasix you want to send this patient home on, but if the patient then takes the wrong dose of Lasix because they don’t know what they were supposed to be taking, then all that good medical care is undone.”
The med rec conversation has come full circle, then, as being truly an issue of delivering patient-centered care. (For more on this topic, visit the-hospitalist.org to read “Patient Engagement Critical.”) Rather than focusing on the sometimes-befuddling term of medication reconciliation, providers should see med rec as part of an integrated medication management process that aims to take better care of patients through prevention and treatment, Gleason says.
