Wednesday, June 13, 2012

Med Reconciliation and Midlevels

Sorry folks - I know it's been a few weeks since my last post. Blogging is fun, but it's hard work. New CMS regulations on Order Sets, Meaningful Use, HIE, EMR/EHR... It keeps a CMIO busy!

Anyway, so now onto this post. Working in front-line applied medical informatics, I see some general healthcare trends evolving. Some are predictable, other's aren't. Here's one of the things I've noticed recently, that might be encouraging to the midlevels (PAs, NPs, CRNAs, and Midwives) in the audience.

What I'm seeing : As three trends merge -
... it's becoming very clear to me that the demand for accurate electronic med reconciliation practices will go up inside hospitals.

The problem is that this is not the always the easiest thing to do. Just assembling medications and allergies at the point-of-entry can be complicated, having to potentially reconcile up to seven data sources (patient, family, PCP, specialist, pharmacy, chart, and med database). Many hospitals hire a position (pharm tech, or other equivalent position), just to compile the list of home medications.

But then, once you have the list, entering them into an EMR can be a challenge.

Once you have them in the EMR, then, you can perform electronic med reconciliation. It's one thing to do it at the point of admission and discharge to your hospital - It's another to do it at every transition of care.

But knowing that the goal is for med reconciliation at every transition of care, I sometimes wonder : Who will do this, and how? Especially in some areas where there are frequent transitions of care (e.g. your perioperative areas), how will you manage those medications?

Some feel surgeons should be responsible for med reconciliation of their patients in the perioperative period. The challenge, however, is that surgeons are often under intense pressure to get back to the OR, or else there are OR delays which cause a whole different set of issues.

It's also common for anesthesiologists to care for patients in the post-operative setting - But again they face pressure to go back to the OR, to avoid delays, so they mainly only focus on the immediate medication needs of the patient.

So it's not unusual for the conversation to then lead to hospitalists managing the medications for the surgical patients, especially in the post-operative period. (After all, who better to manage medications than someone trained in a medical specialty, right? :) )  The challenge here is often that hospitalist services may not be able to handle the additional workload, without expanding their workforce, and hiring an extra hospitalist can be pricy.

And so, I suspect many organizations will start to look at midlevels as a more cost-effective way of  helping to fill this need. And so, my impression : The demand for midlevels (PAs, NPs, RNAs, Nurse Midwives) will continue to increase in the near future.

How much will it increase? I suspect as long as midlevels are more cost-effective than hospitalists, the demand for them will go up. So if I wanted to play futurist, I would guess the increased demand would drive midlevel salaries up until they reach that of an average hospitalist - and at that point I think the demand would level off :

Of course, this trend will depend on many factors, including regulatory issues, licensing/credentialing issues, physician supply issues, and other state and federal controls on physician and midlevel training. And my prediction could be totally wrong! I'm going to keep scanning the horizon, but I suspect the healthcare organizations of the future will use midlevels with a solid oversight and supervision model, that allows them to give high quality care for less.

Any dissenting opinions? Feel free to comment below!

1 comment:

Ted Ray said...

As a pharmacist, I will have to admit that medication reconciliation is an obsession with me. Having been on numerous committees and part of several initiatives, it is a given that capturing and documenting the medication history of the patient, from various sources, is the rate-limiting step to meet the NPSG. Perhaps the 'mid-level' practitioner would be an additional resource to take on this task given the increasing importance of collecting the data. I would make the case that the pharmacist (rather than a pharm tech) is in a unique role to bring additional value to the process.

My 'obsession' has brought me to a company called newMentor ( which has developed a solution for, among other things, medication reconciliation. Although it can't replace the various methods of obtaining and building an initial 'Home Med List', it will streamline the reconciliation process at transitions of care and discharge. It's a simple and elegant solution to functionality deficits inherent to the current crop of EHRs.

Thanks for your blog, and keep up the great work!

Ted Ray, R.Ph.