Medication Harmony: A Framework to Save Time, Improve Accuracy and Increase Patient Activation

Abstract

Incompletely reconciled medication lists contribute to prescribing errors and adverse drug events. Providers expend time and effort at every point of patient contact attempting to curate a best possible medication list, and yet often the list is incomplete or inaccurate. We propose a framework that builds upon the existing infrastructure of a health information exchange (HIE), centralizes data and encourages patient activation. The solution is a constantly accessible, singular, patient-adjudicated medication list that incorporates useful information and features into the list itself. We aim to decrease medication errors across transitions of care, increase awareness of potential drug-drug interactions, improve patient knowledge and self-efficacy regarding medications, decrease polypharmacy, improve prescribing safety and ultimately decrease cost to the health-care system.

Introduction

Patients receive prescriptions from multiple clinicians and often use more than one pharmacy. They may take over-the-counter (OTC) medications and herbal supplements. For patients and clinicians alike, constant reconciliation of a medication list has been a Sisyphean task. Discrepancies and inaccuracies among medication lists are linked to errors in prescribing and self-administration. Clinicians often settle for a list that is “good enough,” yet contains numerous errors. These errors translate into adverse drug events (ADEs) and often result in increased morbidity, mortality, hospital readmission, and increased health-care-related cost^1–4. In the United States, the cost of ADEs is estimated at $76.6 billion in the ambulatory setting alone⁵.

Numerous studies have assessed how to decrease ADEs, and hospital readmission rates^6–11. Some form of intervention to obtain the “best possible medication history” over typical care has repeatedly shown to decrease error rates on the medication list. Research to date has primarily focused on improving the accuracy of a singular medication list and decreasing ADEs. Thus far, however, there has not been much consideration to the amount of institutional infrastructure and person-time needed to complete such tasks and how often the task must be repeated.

Some studies have suggested cost-benefit by paying pharmacists to reconcile the best possible medication history upon hospital admission, a process that can take more than 30 minutes per patient¹². Broader system changes include creating leadership positions, changes in workflow, management teams, “reconciliation champions”, interdisciplinary teams, encouragement from those who are “less than enthusiastic” to participate, and other daunting barriers to implementation^13,14.

Currently, the “gold standard” of obtaining the best possible medication history involves a pharmacist compiling patient history, obtaining patient and office medication lists, pharmacy data, and discharge summaries upon admission. Approaching discharge, the pharmacist reviews changes in medications, describes indications and reviews discontinued medications^15,16. Post discharge, the pharmacist contacts the patient again to resolve any unanswered questions. Many institutions are not yet current with these best practices or have limited pharmacy staff to complete such tasks. The process of medication reconciliation is then delegated to nurses or physicians who often do not have time or resources to ensure a high-degree of accuracy. Although this workflow is effective for a single hospitalization, it is a laborious task that must be repeated at every transition of care and does not address the issue of creating multiple out-of-date medication lists.

Medication managers through mobile applications and institution-based systems currently exist, however, under fractured infrastructure^17–19. A hurdle for federation is the siloing of information in institution-specific systems (Figure 1). These systems fail to communicate with one another and patients are often responsible for the input of all medications by hand. Even with interoperability and communication among systems, keeping multiple lists synchronized remains challenging.

Figure 1.

Current structure of the outpatient medication list

Although an approach such as “Blue Button” allows patients read-only access to their own information, a user must be actively engaged and obtain separate log-in information and credentials at each institution they receive care. Additionally, patients do not have the ability to easily modify the data provided by “Blue Button”. A consolidated, shared, patient- and physician-modifiable view of a medication list hasn’t been successfully implemented.

To achieve provider buy-in we need to overcome the tremendous time and effort needed to keep an accurate medication list. We must increase patient activation²⁰, and where appropriate, family members, by offering them utility in keeping a list. For most patients, the list represents an array of unpronounceable names of various colored pills that he blindly takes. We must incorporate common-language, actionable information while minimizing patient effort for information loading and updating of their medications.

Envisioning a Solution

A solution should allow patients, providers, institutions and pharmacies to eliminate disparities among a medication list that is used across various environments. It must be:

• Widely visible while protecting patient privacy

• Modifiable by patients, caregivers, and practitioners, and family members where appropriate

• Institution agnostic

• Able to easily fit into the current framework of medication reconciliation so that minimal disruption in workflow is caused.

The solution must also encourage patient activation and aid in comprehension. Therefore, it should:

• Easily capture OTC medications

• Pre-populate the list to avoid confusion and fatigue

• Provide knowledge regarding drug information, including pill images

• Alert for potential interactions

A benefit to such a solution is a faster and more accurate medication reconciliation process thus reducing ADEs from inadvertent prescribing errors.

Using the HIE to centralize the medication list and establish a “single source of truth”

Practically speaking, a dedicated, stand-alone database and accompanying application to act as a medication manager must be implemented. For many locations, a HIE is established to help share data among various providers. As a hospital or a physician office registers its EHR as a provider on a HIE, so too will the medication manager. By doing so, it will be able to interact with other “trusted” systems on the network. Its job will be to maintain a database of an individual’s medications by gathering information from other institutions that have recorded medications (Figure 2). Linking the medication manager into the HIE enables a dedicated provider of medication information. Furthermore, providers such as PCPs, specialists, hospitals and nursing homes will have access and the ability to update the list.

Figure 2.

Centralized Medication Manager

Under the proposed solution, a patient would register for this service via a web site or a smart-device application. Identity would be verified and the user authenticated. Exchange of health information over a HIE requires patients to accept the terms and conditions of their local HIE. For example, Massachusetts has an opt-in policy for patients. Consent is possible online and one can opt-out at any time²¹. This process can be accomplished within the medication manger app itself.

Interoperability

To be viable, the solution must be able to fit within current workflow situations. Although difficult to imagine within our current EHR landscape, effort is currently underway towards interoperability. We must be forward thinking and design for such a future. By using the same infrastructure an EHR uses to pull information from a Surescripts® Medication History data source, the EHR would also be able to pull information from the medication manager. In addition, as an EHR is able to send an e-prescription to a pharmacy, it would also be able to send a message to the medication manager. The medication manager would have the capability to consume HL7-NCPDP SCRIPT e-prescriptions, the National Council for Prescription Drug Programs standard for transmission of prescription information^22–27 to update information. In the future, it could also run as a SMART application²⁸ utilized as a web-app, mobile device-app or trusted service within an EHR.

Data federation and reconciliation

Once verified, medication information would be federated from available sources (Figure 3). Pre-population of data can be accomplished by gathering data from inpatient and outpatient visits via EHR generated Consolidated-Clinical Document Architecture (C-CDA) documents. Pharmacy data can be gathered from Surescripts data. It is possible that at some point in the future, pharmacies would be willing to expose patient fill information onto the HIE as well, providing an additional data source.

Figure 3.

List federation and reconciliation

Once the data is collected, a matching algorithm would be applied to find overlaps and eliminate duplicates²⁹. Patients would have the ability to verify and change any of the listed medications. In addition, the patient would be able to add other prescribed medications not appearing on any lists (i.e. from providers not participating in the HIE or older, yet still active, medications). Over-the-counter medications, less commonly captured by traditional methods, can be added via bar-code scan, text-matching input or optical character recognition (OCR) software.

Updating the medication list can occur at transitions of care, patient-provider interactions, or at any time by the patient. Primary users of this system will be providers who will rely on it to maintain an accurate list of medications that can be shared and updated by other providers; health-care institutions, who will use it to more easily reconcile medications during points of transition; and patients who will be able to add, delete, modify and verify OTC and prescribed medications. Each time a patient or provider logs in, a query will be performed and if information more recent than the last time of reconciliation is discovered, it will be presented for reconciliation. This way, every time the list is accessed, a pro-active and pre-population approach to reconciliation is taken. Doing so, will increase accuracy and fidelity of the medication list in addition to preventing fatigue from demanding that the list be created from scratch. The combination of these services will make it easier for patients to have a list that reflects the true medications that they are taking.

Encouraging patient engagement; using an interactive interface that provides information

Patients are left to their own devices to maintain a medication list. Either they write out a list (which is often out of date and lacks vital information such as dose and frequency), use a list printed from their PCP office (often containing cross-outs, corrections, omissions and out of date information), bring a bag of pills, or rely on their memory^30–32. Such solutions typically don’t provide access to other useful information such as images of medications, indications, drug class, or potential interactions. Apps that focus on adherence typically require that the patient hand enter all medications. These applications are vendor specific, and although it may be able to print or show a list to others, there is not a standardized way to integrate that information across platforms. For the elderly or medically complex patient who may be on multiple prescription and over-the-counter medications, the full medication list may not be captured sheerly due to the initial time investment needed to complete the process.

Using government resources, such as RxNorm, MedlinePlus, and RxImage provided by the National Library of Medicine, a well-designed medication manager can provide services such as brand and generic name, dose, frequency, images of the medications, common indications, convenient links for more detailed drug information, and an interaction checker. The combination of these services will aid in patient-education in addition to recognizing possible unintentional polypharmacy. In addition, the medication manager will provide an opportunity for dialogue regarding differences in the way that medications are prescribed and taken. Discontinued medications can be moved to a separate list keeping track of prior medications (Figure 4).

Figure 4.

Patient view of current medications

Time and safety benefits

When a patient presents to the hospital or doctor’s office, providers attempt to fulfill the Joint Commission’s requirement to “maintain and communicate accurate patient medication information”³³, and thus undertake the process of formulating the best possible medication history. As mentioned, this is time-consuming, and non-scalable job that includes collecting lists from various sources. In addition, errors are common and often result in ADEs. Under the proposed solution, these lists would be instantly and electronically obtained and compared. (Figure 3) The job of formulating an accurate medication list is simplified to resolving discrepancies among the lists.

On admission, a decision regarding whether to stop, continue or modify each medication is made. The proposed system would not be involved with medication management during an inpatient stay. On discharge, the admission list is compared to the inpatient list and the discharge medication list is formulated. As described above, the discharge medication list would be available to the centralized medication manager either via an e-prescription or C-CDA document and accessible by outpatient providers and the patient, decreasing confusion regarding an accurate discharge medication list. Available drug class information and interactions help ensure safer prescribing habits. Additionally, since all providers will be referencing the same list, prescribing errors secondary to ignorance of other medications the patient is on should be decreased.

Barriers

No comprehensive solution for solving the problem of the multiple inaccurate outpatient medication lists exits at this time. It is an important problem to tackle, and clearly a difficult one. We acknowledge that the implementation of this framework will require cooperation among several groups, however, we must look towards designing a solution to battle the inefficiency and lack of scalability that is today’s normal. The result of our current system is wasted time reconciling patient lists in addition to the high cost of ADEs. Convincing patients to remain diligent in keeping an up-to-date list is difficult. Physicians are typically slow to adopt new technology and are resistant to tools that ask them to check more boxes. Secure storage and sharing of electronic information is a challenging task. HIEs are local and an organized network to connect them must be considered. Finally, one must demonstrate that cost savings is worth the expenditure of implementation. Each problem deserves attention and must also be considered together when designing a comprehensive solution.

Medication Harmony

The triple aim of medication reconciliation is: reasonable time to reconcile, high level of accuracy, and improved patient activation. Instead of each patient and provider struggling to maintain an individual copy of a medication list, the list will be shared among providers and audited by providers and the patient himself. Increased coordination, safety, and education afforded by the centralized list will clearly have the greatest benefit for the patient who verifies and modifies the medication list. However, within the proposed solution, it is important to recognize that active patient involvement is not necessary for maintaining a medication list. Even without active patient involvement, centralization among physicians, hospitals, and pharmacies should be sufficient for obtaining a reasonable proxy to the medication list. In addition, providers can be assured that changes made during a provider-patient interaction will permeate to all other providers. Therefore, instead of each provider having a partial medication list that is often inaccurate, each provider will be able to view the same federated list and can change and prescribe medications more safely. The expectation is that if the task is not overwhelming to the provider, he will be more willing to ensure the accuracy of the list. Finally, a centralized system aids the institutions and individuals attempting to reconcile medications at every transition of care. The process of reconciliation requires significant time and resources. It is a process that is repeated often and at every outpatient visit or transition of care. Tremendous efficiency gains will be realized by implementing the above framework.

Conclusions

“You’ve got to be very careful if you don’t know where you are going, because you might not get there.”

- Yogi Berra

Research identifying medication management problems and solutions supporting such a framework has thus far been considered individually. Patients are willing and able to interact with electronic medication tools to manage their health¹⁸. Medication lists are currently being stored electronically and can be accessed by trusted sources via an HIE. Considerable time and effort is made reconciling the medication list at each transition of care. Inaccuracies in the medication list result in ADEs causing poor patient outcomes and increased cost. We believe that the momentum of the health care system flows towards interoperability, the sharing of data, and the promise of decreased cost. Our lab has started development of this idea into an existing project involving elder care management.

A comprehensive solution involves:

• Providing a pre-populated list with easily accessed and actionable information for patients

• Patients and providers working off the same list

• Simplifying and saving time during the process of medication reconciliation

• Encouraging legislation allowing for easier transmission of medical information over trusted networks

• Continued maturity of the FHIR standard and the opening of APIs by EHR vendors

• Financial incentives that continue to emphasize decreasing hospital readmission rates and preventable events

We must utilize the trusted network provided by a HIE and automate the federation of information from multiple sources into a central database. Most importantly, by allowing the patient access to the same list used by providers, patient input into the list will more accurately reflect the daily medications actually taken and allow safer prescribing practices. Imagine a future where patients, doctors, hospitals and pharmacies have easy access to a complete and accurate medication list. We have the potential to drastically reduce adverse drug events both inside and outside the walls of a healthcare setting and should strive to accomplish such goals.

Funding

This work was supported by the Agency for Healthcare Research and Quality grant number R01HS021495 in addition to training grant T15LM007092-23 from the National Library of Medicine.