Part of a series on primary care challenges and their solutions.
Medication reconciliation is something we do every day, in the clinic and in the hospital. It shouldn’t be as hard as it is.
A patient with multiple medical problems returns for a fifteen minute quarterly visit. He saw his cardiologist three weeks ago and was told to double his metoprolol.
There are two ways to catch this change: when the cardiologist’s office note comes in, or as we check the patient in for his visit.
The cardiologist’s office note, generated by one of the leading EMRs, runs seven pages and contains entries about immunizations, fall risk and other quality measures of little relevance in specialty care. On one of the last pages, tucked away in a nondescript paragraph, at the very bottom, waiting for me to find it, is the notation that my patient’s metoprolol dose was doubled.
Primary care doctors like me have exactly zero time scheduled to review the approximately 100 scanned documents that fill our electronic inboxes every day. We steal time from our scheduled patient visits, or work from home at night to sign them off. How long does it take to find the hidden dose change in the cardiology note? How many clicks does it take to change the patient’s medication list in my own EMR?
The second chance we have to catch the dose change is when the medical assistant, who has zero training in pharmacology, checks the patient in for his fifteen minute with his PCP. Medication reconciliation should ideally happen at every visit. So should a number of other things, like asking about ER visits, immunizations, fall risk, smoking, alcohol use, domestic violence and so on. Often, harried MAs ask, “are all your medications the same?”, and the primary care visit rolls on.
When a patient is hospitalized, the Admission History and Physical lists their home medications. Even when I refer a patient to the hospital for admission and send along our medication list, I was told that our biggest hospital has a pharmacy technician sit down with the patient to make up their medication list, ignoring the one I sent along. (We are working on ways to make our transfer documents harder to ignore – something like the gigantic key chains some gas stations use for their rest room keys.)
Next, the hospital changes the patient’s statin to the only one they stock, their proton pump inhibitor to their house brand, their ACE inhibitor or angiotensin receptor blocker to their own formulary alternative, and so on.
When the patient is discharged, sometimes they get told not to take the medicine they’ve been on for years and which is covered by their insurance, but the hospital alternative. Sometimes the discharge medication list has both the original and the substitute, like the patient I saw the other day who had both pravastatin and Lipitor on his list.
In a parallel universe, or perhaps in this one some time in the future, “med wreck” might just be “med rec”:
There will be a new EMR mandate that medical office notes that fill more than one page or screen will be required to have a summary that can be located on top without scrolling. But in the meantime, that is something we could do ourselves right now. When i reread my own notes or those of my colleagues, putting a thumbnail synopsis with medication changes on top could save a lot of time, reduce aggravation and probably avoid some errors.
Once we have interoperability between EMRs, several things will become possible:
Patients’ medication lists will be updated by every provider each patient sees as easily as all my iTunes purchases show up on my iPhone, iPad and, should I choose to ever fire it up again, my MacBook. In the meantime, each primary care prescriber needs to take responsibility for their patients’ medication lists. That needs to be part of our time with the patient, because non-providers can’t be expected to spot every problem in a medication list; they are not trained to do that. When a one month supply of a medication can cost more than a car payment, our attention to medication reconciliation is crucial for society and for the pocketbooks of our patients. It is also a critical safety issue when medication prescribing or monitoring errors occur in the care of 12% of British general practice patients (http://www.gmc-uk.org/about/research/25043.asp) and 56% of Austrian patients with chronic disease and polypharmacy (http://www.ncbi.nlm.nih.gov/pubmed/23132894). I don’t have US statistics, but i have no reason to think patients are any safer here.
Each patient’s Personal Health Record will be updated by all involved providers through their own EMRs, just like I started this post on my favorite word processor on one device and made some changes and corrections on the fly on the other.
Physicians will have seamless access to pharmacy records and we will have even better access to insurance formularies than my present EMR has. My screen tells me if a drug is in the red, yellow or green category, but since the pharmacy’s computer knows what the copay is, mine will naturally know that too.
No EMR or pharmacy computer will allow entering an allergy without a comment on type and severity of the reaction. And allergy lists will be shared. But “allergy: amoxicillin” doesn’t cut it. There is a difference between a mild rash from amoxicillin when you had mono and a life threatening anaphylactic reaction.
I think the technology for what I am fantasizing about is here right now. I don’t know why nobody has introduced it to primary care medicine yet. But, until we have the perfect set of tools, we physicians need to buckle up and take responsibility for “med rec”, because we have the training and experience for it. We need to rely on other team members to free us up by doing things that don’t require our training, like data and order entry.
That will be another topic for “Welcome to my World”.