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 -

• Meaningful Use
• The National Patient Safety Goal for Med Reconciliation (See this great summary from the American Society of Health System Pharmacists)
• Relative polypharmacy

... 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!

What is Medicine Reconciliation, anyway?

So recently I've been hearing and reading a lot about medicine reconciliation.

Medicine reconciliation is the safety practice that, it seems, The Joint Commission has recently announced they will set new expectations for.

A friend of mine, who went to an IHI conference last year, told me that on a wall full of posters of "problem subjects", the "Med Reconciliation poster" seemed to have the most hospitals reporting challenges.

So what is this Med Reconciliation thing, anyway?

• Is it a mythical creature that people see, but nobody ever really gets a picture of?
• Is it something that inspires poets and artists, because it's so intangible?
• Is it something that we can even achieve?

Most practicing physicians learned in medical school that it's "good practice to rip up and re-write all the orders when a patient comes out of the OR". Most practicing physicians are also used to documenting the patient's home medication list in an admission H&P. The interesting thing : These are both different facets of the same med reconciliation picture.

So then, I think one of the biggest challenges in implementing "Med Reconciliation" is that it's so hard to nail down. What is it, exactly? Who does it? And how? 

So I thought I'd share some answers.

WHAT IS MED RECONCILIATION?

I. THE PREMISE :
 First, the premise is simple : It's all about safety.

Med reconciliation is built on the basic premise that a physician and a patient work best together, when they're with eachother. For the purposes of this discussion, I've lovingly decided to call the "place where they work with eachother" the "Patient Care Cubicle" (instead of the industry term, "Level of Care" which is a little confusing.).

The process is then pretty simple. To perform med reconciliation, a physician needs two separate documents :

1. The 'home medication list', to know what the patient is 'usually on'.
2. The 'active medication list', to know what the patient is 'currently on' while sitting in this "patient care cubicle".

And the steps for doing med reconciliation? A doctor should basically follow these four steps :

1. Look at the Patient
2. Look at the HomeMedList
3. Look at the CurrentMedList
4. Make a new CurrentMedList!

This allows a physician can make the decision : What meds does the patient need to be on right now.

So remember, the recipe for med reconciliation needs these four ingredients :

   MED RECONCILIATION = [ Patient ] + [ Physician ] + [ HomeMedList ] + [ CurrentMedList ]

(While they are connected, remember - Med reconciliation is NOT the process of collecting the home med list - But you will need to collect the home med list before a doc can do med reconciliation.)

So... when does a physician actually do these four steps of "med reconciliation"? Optimally, it happens at two times :

1. When the patient appears in your cubicle (in hospital terms this is known as a "change in level of care")
2. When the patient has had some significant event (like delivering a baby, a code blue, a surgery, etc.)

So far, so good. Now comes the implementation challenges.



B. THE BASIC IMPLEMENTATION

The first thing you might do to map out the implementation of med reconciliation, is to make a general map of all of the "patient care cubicles" your patient might pass through, when he/she goes through your hospital. Typically, this map will start with the outpatient cubicle, and end with the outpatient cubicle. (On discharge, then, you need to do med reconciliation one last time to define the "new home med list", aka the "discharge medication list").

So if each "cubicle" has the patient and a physician :

1. The physician covering the "outpatient cubicle" is the primary care physician.
2. The physicians covering the other cubicles are the ones you assign.

And so if you need two lists - The home med list, and the current med list - To perform med reconciliation, you can see by the above slide that the first challenge will be getting the home med list available in your ED.

This brings us to some challenges with med reconciliation...



C. THE FOUR BIG CHALLENGES

The first challenge is just getting the home med list in your ED. How long does it take to actually assemble the list of home medications? (Remember : THIS IS NOT MED RECONCILIATION YET - Collecting this list is probably the thing most commonly confused with the term "med reconciliation".)

I did an informal study of this, while working clinically last year, and found that my median time for most adult medical inpatients was about 20 minutes. About 2/3 of my population was less than this, but about 1/3 of my patients were more than this, and there were some significant outliers - some patients took up to 45 minutes or more. (While slightly tongue-in-cheek, I called the standard I used the "mother standard", figuring I would work to achieve the same accuracy I would expect for my own mother.)

The reason it can take some time to assemble is this : There are up to seven data sources a person can use to assemble the home medication list. They include :

1. The patient - Who usually knows their home med list... but not always.
2. The family - Who is often helpful at establishing an accurate med list, but not always
3. The PCP - Who is usually accurate, as long as the office is open and they know what the specialist might be prescribing, so...
4. The specialist - Who sometimes needs to be contacted for clarification about new specialty medications
5. The outpatient pharmacist - Can be helpful to get a broad view, assuming the pharmacy is open and the patient doesn't use a mail-order pharmacy
6. The previous chart - Can also be helpful, assuming the last visit wasn't too long ago
7. The "insurance-based electronic prescription database", available at some hospitals - Which also still sometimes takes time to sort through, and you have to make certain assumptions...

So if the first step is to assemble this list in the ED, then the first challenge is to figure out who will assemble this list, and how?

Curiously, if you examine med reconciliation needs in the ED department, it usually falls along these steps :

1. Triage desk Officer : Generally drug classes are most important, not actual drug names. (E.g. a triage officer may consider bringing someone in if they are on blood thinners, or antibiotics.)
2. ED physicians : Generally drug names are most important, sometimes doses. Most ED visits are short, so there has not traditionally been much focus on doing med reconciliation in the ED. Of course, if we expect ED physicians to perform med reconciliation, they will need more information. (Some patients do miss medication doses while waiting for care in the ED.)
3. Inpatient Physicians : Here is where the drug, dose, route, frequency, indication, and last dose are most important, because the patient staying in-house will need to continue the right medications at the right times.

Because of these varying needs, at these different levels, it's sometimes hard to figure out who's responsible for how much of the puzzle.

The second challenge, assuming you can get the home med list assembled in the ED, is figuring out : Which physicians will be responsible for actually doing med reconciliation in each cubicle?

While it's tempting to answer :

1. ED - Would be performed by ED physicians, 24/7
2. Floor - Would be performed by hospitalist physicians, 24/7
3. ICU - Would be performed by intensive care physicians, 24/7
4. Etc...

...the PreOP setting/OR/PACU usually presents some unique challenges (challenge #3)

The challenge for many ORs/PACUs is this : Operating room schedules are tight. Hospitals count on maximum efficiency in an operating room. Even small delays can be magnified into cancelled procedures if everything doesn't run like clockwork. Also : Surgeons and anesthesiologists spend a good part of their day in procedures that simply can't be interrupted. Briefly pulling a hospitalist out of a family meeting to "do med reconciliation" will have a very different cost than briefly pulling a surgeon / anesthesiologist out of a surgery.

To accommodate with these demands, many anesthesiologists focus mainly on anesthesia meds, and many surgeons write post-operative orders in the PACU. If the patient goes up to the floor, after the PACU, then the nurses depend on the post-op orders written by the surgeons in the PACU. Unless you create a cubicle where the PACU has the same level of care as the floor, you might have to do med reconciliation again after the patient reaches the floor.

Figuring out this workflow can be very challenging. It's why my friend, going to the IHI conference last year, saw Med Reconciliation as one of the 'top challenges' hospitals face.

The fourth, and final challenge, is deciding on the "triggers" you will use for med reconciliation. As described above, there are typically two things that should trigger a physician to actually perform med reconciliation :

1. Patient arrives in your patient care cubicle (aka "Change in level of care") - This is usually pretty easy to enforce electronically.
2. Patient has a significant change in status (e.g. delivery, surgery, code blue) - This can only be enforced by a policy/clinical practice.

So you will need to decide on these two triggers, knowing that

1. For your EMR to trigger med reconciliation electronically, you will need to organize your levels of care and their relationship to your patient locations.
2. For your staff to trigger med reconciliation during a significant patient event, you will need good policy design and education.

D. THE NEXT STEPS / SOLUTIONS

Fear not, my reader! This may seem daunting, but the problem can be solved! Many hospitals have started down this pathway already, and many more will continue as The Joint Commission and other regulatory bodies reinforce med reconciliation practices.

To help you, I've offered the following recommendations and steps you can take to advance the discussion in your own hospital.

1. Define who is responsible for collecting the home med list in the ED
2. Define what home medication information they will collect, and how? (It's challenging to figure out how many of the seven potential data sources to use, but until our whole country is wired together electronically, your organization will need to decide this.)
3. Define where this home med list will be kept, once assembled, so that every doctor in the "chain of cubicles" will be able to access it and use it to perform and document "med reconciliation".
4. Define your "patient care cubicles", where your EMR can help trigger the med reconciliation process.
5. Define your policy that will help educate physicians about clinical scenarios in which you expect med reconciliation to be performed (e.g. delivery, code blue, surgery, etc.)
6. Define which physician's will be responsible for the med reconciliation process in each cubicle, 24/7.

Regarding the unique challenges that most Operating Rooms/PACUs present, this is a very common challenge, but I'll present the following possible scenarios I came up with :

1. Your hospital might consider asking the surgeons to perform med reconciliation after the patient arrives back up on the floor. (This may cost your hospital in OR time/efficiency.)
2. Your hospital might consider transferring all post-op patients to your hospitalist group, to allow the hospitalists to perform med reconciliation on the floor. (This may cost your hospital by needing more hospitalists to care for these patients.)
3. Your hospital might consider hiring a Physician's Assistant (PA) or Nurse Practitioner (NP) to assist the surgeons with the med reconciliation process. (This may also cost money, but I believe in most settings this would be more affordable than option #1 or  #2 above.)

Enjoy - I hope this discussion has been helpful. A good sample policy to support med reconciliation is available here from the University of Wisconsin Hospital and Clinics.  Again, I'm eager for any feedback folks have. Feel free to leave your own stories about tackling med reconciliation! :)