Transcript Focus on visits with a medication change

Ambulatory Medication
Reconciliation
Caroline Keogh, MS RN
Patient Safety
Center for Clinical Excellence
Dermatology Clinical Faculty Meeting
March 27, 2014
Why is medication reconciliation important?
• Intended to identify and resolve medication
discrepancies
• Standardized process of comparing a patient’s prescribed medications to
those medications the patient is actually taking1
Meaningful Use
Medication reconciliation is critical
to preventing adverse drug reactions
which can lead to patient harm
NPSG
ACO
P4P
1.
The Joint Commission. Medication reconciliation sentinel event alert, Issue 35. 2006. Available at: http://www.jointcommission.org/sentinel_event_alert_ issue_35_using_medication_reconciliation_to_prevent_errors/
What do providers need to do?
• Focus on visits with a medication change
– Medication change:
• addition of a new med
• discontinuation of an existing med
• change in the dose or frequency of an existing med
• Reconcile medications which they prescribe
– All medications on the medication list should be reviewed
for drug-drug interactions
– PCPs and Specialists have the same standard
– Ideally, all meds should be assessed/ reconciled
BWH Ambulatory Med Rec Measurement
• % of visits with a medication change where all
medications originally prescribed by the
provider are reconciled
• Numerator: # of visits with 100% of the medications
originally prescribed by the provider reconciled
• Denominator: # of visits with a medication change
Sample Scenarios
At every visit you should review the full medication list routinely to confirm that
what you are prescribing does not interact with what the patient is already taking
Scenario
What you need to do in addition to
reviewing the med list
Med rec
metric
You don’t prescribe,
discontinue or edit any meds
at the visit
Nothing
N/A
You renew 1 medication and
don’t prescribe, discontinue or
edit any others.
Nothing
N/A
You prescribe 1 new
medication
Nothing
100%
You are seeing the patient in
follow-up and have prescribed
pain med in past; today you
prescribe abx
• Step 1: Write the new abx script
•0%
• Step 2: Click “Reconcile” in LMR and click
“taking” if the patient is still taking the pain
med and sign
•100%
Current Data
% of visits with a med change where all medications originally prescribed by the provider are
reconciled.
100
Goal
90
80
70
60
50
40
30
20
10
0
Jan-13
Feb-13 Mar-13 Apr-13 May-13
Dermatology (850 Medical Specialties)
Dermatology WHC
Jun-13
Jul-13
MOHS
FXB Dermatology
Aug-13
Sep-13
Oct-13
Nov-13 Dec-13
Jan-14
Dermatology (Newton Corner
Goal
Feb-14
Current Data
Ambulatory Medication Reconciliation
Dermatology
February 2014
% of visits with a med change where all medications originally prescribed by the provider are reconciled.
100
80
81
83
91
92
Dermatology (Newton Corner
FXB Dermatology
95
86
60
40
20
0
Dermatology (221)
MOHS
Dermatology WHC
Dermatology (850 Medical
Specialties)
Provider Data
February 2014
Provider Performance
% of visits with a med change where all medications originally prescribed by the provider are reconciled
100
90
80
70
60
50
40
30
20
10
0
A few examples…
• Patient seen for an annual visit; patient is no longer taking Zofran
– Med change = discontinue Zofran
– 10 other medications on the med list
• 7 originally prescribed by the provider (0 acted on)
• 3 prescribed by others (0 acted on)
• Needed to click Taking/Not Taking/Taking Differently/Discontinue/Edit/Renew
on all 7 originally prescribed meds to get full credit for the visit
• Patient seen for follow up visit; 2 new medications prescribed.
Diltiazem had been prescribed in the past.
– Med change = 2 new prescriptions
– Diltiazem was the only other medication on the patient’s medication
list prior to the new prescriptions, and was originally prescribed by the
provider.
• Was not reconciled during the visit
• No credit for the visit (needed to click “Taking” to get full credit)
A few examples…
• Patient seen for a follow up visit in Rheumatology
– Med change = added Humira, edited dose of
prednisone
– Reconciliation actions = renewal of folic acid,
methotrexate
– No action was taken on rifampin or synthroid (both
originally prescribed by the provider)
No credit would be given for this visit due to the
rifampin and synthroid.
Summary
• Process of Med Rec required only for visits with a medication change
• You are only responsible for Med Rec on what you prescribe
• Practice-wide implementation of a standardized med rec process
• LMR Med Rec module has been configured to help make this process
easier
• Patients are getting their current med lists through the VSR for MU
• Practices can determine the specific roles of who will participate in the
process of Med Rec
• If all practices/ depts participate in the process of Med Rec, the lists will
improve over time – this is the right thing to do for our patients
Appendix
How does this work in LMR?
How does this work in LMR?
Will reconciliation information appear in my notes?
Reconciliation actions will now appear next to each medication in the med
list when the list is imported into your notes (when you type, not dictate).
This feature needs to be enabled.
What about entering medications I did not
originally prescribe?
If a medication is entered using these fields in the Rx Pad, or edited by
clicking these fields, the medication will appear in the “Prescribed by
Others” sort
Reconciliation actions:
Medication Reconciliation
Module
Medications OR
Medication Reconciliation
module
Taking
Not Taking
Taking Differently
Edit
Renew
Add New
Discontinue
Edit
Add New
Discontinue
Activate
‘None’
Review Med List module
Taking as prescribed
Not Taking
Taking Differently
Renew
BWH Ambulatory Med Rec Measurement
The following measure is available in Report Central:
For visits at which there was a medication
change*, the % of medications on the
patient’s active medication list reconciled
•Numerator: # of medications on the patients active medication list that
had a reconciliation action signed for
•Denominator: Total # of medications on the patient’s active medication
list during the visit
For visits at which there was a medication
change, the % of medications originally
prescribed by the provider on the patient’s
active medication list reconciled
•Numerator: # of medications on the patients active medication list
originally prescribed by the provider that had a reconciliation action
signed for
•Denominator: # of medications on the patient’s active medication list
originally prescribed by the provider during the visit
% of visits with a medication change where
all medications originally prescribed by the
provider are reconciled
•Numerator: # of visits with 100% of the medications originally
prescribed by the provider reconciled
•Denominator: # of visits with a medication change where at least one
medication was prescribed by the provider
*A med change is defined as the addition of a new medication, a change in dose, frequency, strength or form of an existing medication, or discontinuation of an existing medication.
Approach to Ambulatory Med Rec at BWH
July 2013:
Spring 2010:
Fall 2011:
Ambulatory
Med Rec
Pilot with 4
operationally
distinct
practice sites
Med Rec
module
introduced
with the
LMR Fall
release
April 2012 –
March 2013:
Ambulatory
Med Rec
Collaborative
December
2012January
2013:
Informal
Collaborative
Sessions with
Primary Care
April 2013:
Coaches
begin
sending
individual
data to
collaborative
practices
monthly
Individual
data is sent
to Primary
Care
practices;
monthly
audits for
procedural/r
adiology
areas begins
December
2013:
Monthly
dashboards
are sent to
Dept Chairs