Patient Centered Medication Information Management and Medication Reconciliation Maureen Layden, MD, MPH Rosemary Grea

1. Patient Centered Medication Information Management andMedication ReconciliationMaureen Layden, MD, MPHRosemary Grealish, RPh June 13, 2012

2. It’s More than a List-Standardizing Patient FacingMedication Information

3. Thanks to everyone! • For all your hard work in “getting meds straight” • It really does take a team!

5. Imagine Seamless medication information management that allows for the best medication treatment plan evidence based medicine has to offer customized for the Patient in front of us. What will it take?

6. What is “Medication Information”? • More than the Med List: • Healthcare Team: Name of the medication, Instructions, Indication, Refill History, Prescriber, Pharmacy • Patient/Caregiver: Brand/Generic/Nickname, How I take it, Why, When I need to call for more, Who I call, What it looks like: “The little red pill for my heart” • Context: • Healthcare Team: Allergies/Adverse Reaction, Adherence Data, Drug-Drug, Drug-Disease Interaction, Past Medication History • Patient/Caregiver: Barriers to taking medications, Preference, Tools to help take medications • Resources • Healthcare Team: Clinical Pharmacy, Order Sets, Algorithms, Online Support, i.e. Up-to-Date • Patient/Caregiver: Family/Friends who are in healthcare, Inserts, Pamphlets, Classes, Online Search, i.e. MedLine Plus, soon MyHealtheVet Veterans Health Library!

7. How do we use this information? • Pharmacy • Order Pharmacy Processing  Dispensing • J.D. Power & Associates 2012 Customer Service Champion • Administration • Bar Code Administration • Care Coordination • Clinical and Shared Decision Making • Education • Adverse Drug Event reporting and management • Adherence Detection and Management • And much more…

8. Medication Reconciliation -->Medication Information Management Medication Reconciliation Medication Information Management Add Context: Why is he/she taking medications differently What are his/her preferences in medications? Are there any barriers to taking his or her medications? Does he/she have information, tools, and resources to help with medications? Why are medications different on admission? Who is managing this medication? • What medication information did the Healthcare Team(s) recommend? • What is the Patient actually taking? • What is the final updated Med List now? • Does the Patient and the Healthcare Team have this updated Med List? • Can we prove in the chart that this has been done?

9. Medication Reconciliation is test case for self entered data, how we collect, store, and use it to meaningfully incorporate the Veterans and his or her Caregivers Voice in shared and informed decision making Reconciliation: Presentation Layer

10. Efforts you should be aware of • Patient Self Entered Data Workgroup • National Alliance for Patient Medication Information Standardization • E-Connected Task Force

11. Nationally In VA (2010) MEDICATION USE CRISISAdverse Drug Events (ADE’s) • harm >1.5M annually • 75,000 hospitalizations • ~5,000 serious harm • ~2,500 deaths • Cost ~$3.5billion (Committee on Identifying and Preventing Medication Errors, 2006); Woods et al, 2007) • ADE’s reported • 66,000 • 3,000 required hospitalization • ~700 serious harm • ~50 deaths (NCPS/ADERS, 2010, Kaboli et al., 2004 ; Lesselroth et al., JC QualPtSaf, 2009; 3.Pippins et al., 2008 ,Boockvaret al., QualSaf Heath Car, 2009) • Much is underreported

12. Not on the same page • The percentage of Veterans with complete agreement between CPRS medication lists and patient report is approximately 5%1 • The majority of discrepancies represent failures in history collection, not reconciliation2 • Errors of omission when compiling a list are common; 10-61% of hospital admissions contain an omission error; 42-59% of all admission prescription history errors are omissions3 • Approximately 25% of medications taken by patients in ambulatory setting are not recorded1 • An estimated 30% of omitted medications are expired and discontinued agents4 • An estimated 25% of omitted medications are clinically significant5 Kaboli et al, Am J Man Care, 2004 Pippens et al, JGIM, 2008 Tam et al, CMAJ, 2005 Lesselroth et al, unpublished Cohen et al, PharmPrac, 1998

13. VA MedRecon Initiative

14. Medication Use Crisis Virtual Conference • Joint effort VHA Program Offices, DoD, and Indian Health • 16 hours of CE Programming over 4 Tuesdays in May 2012 • Tracks: • Information Management • Teams and Transitions • Optimizing Resources • Veteran and Caregiver • 850 VA staff members participated in over 4,300 hours of CEU accredited content (DoD and Indian Health numbers pending) • Continuing on in a monthly hour long format

15. VA MedRecon Initiative—our history • 2007: Grassroots workgroup • 2008: Built Toolkit/Share Point, Workgroup meetings, Patient/Staff Education materials, Documentation/Monitoring Strategies, and presentations • 2009: Became a program of VA Central Office PBM. Added Yearly Conferences and Metrics • 2010: Endorsed by Health Systems Committee to draft VA MedRecon Directive • 2011: VA MedRecon Directive Signed, MedRecon New Service Request for Information Technology (IT) tools submitted, and increased focus on IT multiple solutions • 2012: Medication Information Standards, Convergence of IT Medication Information Tools, and partnerships with Our Federal Partners

17. Workgroups • Office Hours • Documentation and Monitoring • Patient and Staff Education and clinical Adoption • MedRecon Series • Medication Use Crisis Series • Emergency Department and Urgent Care Medication Management Workgroup • Nurses role in Medication Information Management • Geriatrics Extended Care and PBM Workgroup

18. Barriers Short Term Solutions It’s not easy… • Many sources of medication information • The Chart: Can’t change a med without issuing a supply patients may not need • Remote Meds: (from other VAMCs) • Knowing about it • Acting upon conflicts • Non VA Meds:(Dispensed outside VA) • Needs manual updating Awareness, Documentation, Share ideas Pull in full med list: Active, Expired, Non VA, Pending, and Remotes. Increased Clinical Pharmacy participation Workflow changes to help update the non VA list, nurses do this in some facilities Pre-Visit Inquiries to Patient Education & Monitor Compliance

19. Barrier Short Term Solutions It’s not easy… • Patient Med Information difficult to • Obtain • Time • Tools • Trust • Coordinate • Multiple Sources • History over time • Voice of the Caregiver • Document • Essential Data • Context • Resources Awareness Pharmacy Techs, Pill Clinics Training and Policy Pull in full med list into the note: Active, Expired, Non VA, Pending, and Remotes. Workflow changes to help update the non VA list, nurses do this in some facilities Standardized Patient Med List to match the note

20. Barriers Short Term Solutions It’s not easy… • Communicating with the Healthcare Team • Between Departments • Settings • Facilities • Non VA • Time Stamp, “The Patients Discharge Med List must be the same as the Discharge Documentation” • Discharge • Multiple Appointment Days • Policy, MOUs, and Directive • Department, Setting, Facility • VISN • Templates • PBM Mail group for Remote Conflicts • Establish a Consult for Provider • Educate • Monitor • No one size fits all • Coordinated Discharge • Establish Lead • Establish the Authoritative List—usually Patient’s Instruction

21. Examples of Fugitive Meds • Emergency Department • Illicit Drugs • Samples • Chemotherapy • Family/Neighbor/Pets • Specialty Medications • Herbals • OTCs • ICU • Non-VA Medications • VA Meds Filled Outside VA • Once Yearly Medication • Expired Meds • Pending Meds • “Hold” • Old Medications • Medications in the Progress note • Remote Medications • Peri-operative Care

22. The Joint Commission Reconciliation Revised Patient Safety Goals • NPSG.03.06.01 EP1: Obtain information on the medications the patient is currently taking. • NPSG.03.06.01EP3: Compare the medication information • NPSG.03.06.01EP4: Provide the patient (or family as needed) with written information. • NPSG.03.06.01EP5: Explain the importance of managing medication information to the patient • PC.04.02.01: Information about treatment is provided to other service providers VA Medication Reconciliation Directive Definition • Obtaining medication information from patient, caregiver, and/family. • Comparing this to the medication information available • Communicating with and providing education to patient, caregiver, and/or family regarding this information. • Communicating this with the healthcare team(s).

23. VA MedRecon External Peer Review Pilot Program Questions Is there evidence that: • The patient’s list of medications was reviewed? • Medication discrepancies with CPRS/VistA were identified? • Medication discrepancies were addressed in some way? • The patient was provided a written updated list? • Referred for follow-up medication management? VA Medication Reconciliation Directive Definition • Obtaining medication information from patient, caregiver, and/family. • Comparing this to the medication information available • Communicating with and providing education to patient, caregiver, and/or family regarding this information. • Communicating this with the healthcare team(s).

24. MedRecon Documentation: Lessons Learned • Avoid Duplicate Documentation • Make your templates consistent with workflow in the clinical setting • Consider that all the minimum documentation requirements do not have to be captured in the template but must exist somewhere in the note • Engage the end-users in developing tools • Must essentially help us help the patient, “What did the patient come in on, what did she leave with, and why?” (VA Hospitalist)

25. VISN 1 Page 1 Note An Example of MedRecon within a Templated note from VISN 1: 93yo MALE, accompanied by wife presents to Urgent Care with chief complaint of Left Lower Abdomen pain, overlying the area he has given himself insulin shots. Has been using the exact same spots (LL abdomen AM RL Abdomen PM)due to Parkinsons, neuropathy, blindness, etc. No redness, heat, rash, pus, swelling noted by wife or patient ROS: No Fever, Chills, Sweats, fatigue, no nausea, vomiting, constipation, diarrhea, urinary frequency, urgency, pain. Parkinson’s stable. Chronic Drooling, no sore throat, cough, SOB, appetite, weight hasn't changed. Feels well/at baseline otherwise. ACTIVE PROBLEMS: Code Description 465.9 Acute upper respiratory infections of unspecified site (ICD-9-CM 735.8 Dystrophic Toenails (ICD-9-CM 735.8) 251.2 Hypoglycemia (ICD-9-CM 251.2) 527.7 Sialorrhea (ICD-9-CM 527.7) V53.2 ADJUSTMENT HEARING AID…….. Because of age, complexity of regiment, and complaint MedRecon was initiated to screen for medication issue.

26. VISN 1 Page 2 Note ACTIVE MEDICATIONS: Active Outpatient Medications (including Supplies): *taking differently ** not taking AMLODIPINE BESYLATE 5MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY FOR HEART **AZITHROMYCIN 250MG TAB TAKE TWO TABLETS BY MOUTH EVERY DAY ACTIVE FOR 1 DAY, THEN TAKE ONE TABLET EVERY DAY FOR 4 DAYS FOR INFECTION --Finished With these BD ULTRAFINE MINIPEN NEEDLES 3/16 X 31G USE NEEDLE(MINPEN ACTIVE 3/16) UNDER THE SKIN AS DIRECTED CARBIDOPA 25/LEVODOPA 100MG TAB TAKE ONE AND ONE-HALF ACTIVE TABLETS BY MOUTH THREE TIMES A DAY TO CONTROL MUSCLE MOVEMENTS CYANOCOBALAMIN 1000MCG/ML INJ INJECT 1 ML INTRAMUSCULARLY ACTIVE MONTHLY (MAIL TO PATIENT) INSULIN HUMULIN 70/30 INJ PEN 3ML INJECT 30 UNITS(PEN) ACTIVE UNDER THE SKIN TWICE A DAY FOR DIABETES Recent decrease due to hypoglycemia LISINOPRIL 40MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY TO ACTIVE CONTROL BLOOD PRESSURE **MEMANTINE HCL 10MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE Not taking this per provider Non-VA ASPIRIN 81MG EC TAB 81MG BY MOUTH EVERY DAY ACTIVE Non-VA CALCIUM 250MG/VITAMIN D 125 UNT TAB 2 TABLETS BY ACTIVE MOUTH EVERY DAY Non-VA MULTIVITAMIN CAP/TAB 1 TABLET BY MOUTH EVERY DAY ACTIVE No Remote Meds

27. VISN 1 Page 3 Note Exam VSS- Labs- Etc… A/P 1. Hematomas Secondary to Insulin injection technique Chem 7 CBC, UA wnl Glucose is post prandial afebrile--may use warm packs watch for signs of fever, redness, swelling, worsening symptoms of pain call or return to clinic Received info on insulin injections, will use a more lateral and upper abdomen approach, upper arms, thighs. No signs of abdominal process such as diverticulitis—wife will watch for increase pain, fever, etc and report ASAP. Refer to PCP, Diabetic Teaching for follow up 2. Insulin Dependent DM Wife will check blood glucose and report if numbers increase as an indicator of systemic disease. He should continue to have BS <200. Note he has recently had his insulin decreased. If no better in one week, call or return to clinic, sooner if worse.

28. VISN 1 Page 4 Note Outpt. VISN 1Medication Reconciliation Clinical Reminder: • The patient's medication list was compared with CPRS and reconciled. • Discrepancies were identified, addressed, and discussed with thepatient/caregiver. • All changes in medications, including all non-VA/Herbals/OTC medications were entered into CPRS. • Medications the patient should no longer take were discontinued, except for the Memantine will leave to PCP—Pt instructed to discuss with PCP • A copy of this reconciled medication list was given to the patient and his care giver. The patient/caregiver was instructed to update this list, discard oldlists, and take this list to their next appointment, whether with a VAor non-VA provider. • *5 Health Factors

29. Pilot in Rheumatology Clinic: Dallas Dialogue VISN 17 Dialogue Page 1

31. VISN 17 Dialogue Page 3

32. VISN 17 Dialogue Page 4

33. May is MedRecon Awareness Month Goal: • Promote, Recognize, Educate and Share! • Competition: Best Champion, Education Documentation Strategy, and Improvement Story ! There once was a vet who was ill The doctors were puzzled until… They looked in his chart: The doc missed the part… Where the patient stopped taking the pill! Mark McConnell, MD

34. There is important research being doneCompliments of Dr. Blake Lesselroth, Portland Informatics Center

35. VA MedRecon IT Projects • VA Point of Service Kiosk • Medication Image Library • Mobile Applications • Patient Facing • Clinical Facing • MyHealtheVet • My Recovery Plan • Secure Messaging • Ask a Pharmacist • Play it Safe! • Blue Button • Health Informatics Initiative • Health Risk Assessment • Integrated Electronic Healthcare Record (with DoD and TriCare) • Veteran Lifetime Electronic Record

36. VetLink Self-Service Kiosk Initiative

37. Patient specific printed document • Reviewed daily by the patient and nurse • Patient involved in what to expect each hospital or outpatient clinic day • Enhances patient safety by encouraging the patient to ask questions if something seems different then planned.

38. Retrieving Nationwide Health Information Network Documents from VistAWeb Double dagger indicates non-VA sources of data

39. VLER:View of Summary of Care Record

40. Aggregated View - Medications

41. My Recovery Plan: My Meds

42. Mobile Technologies: Summary of Care AppSummary Information View

43. FAQS 20. What about specialty clinic, same day surgery, and diagnostic areas? Do they need to do MedRecon? • Regardless of the type of encounter, the act of collecting medication information from the patient must be initiated when medications will be administered, prescribed, modified or may influence the care given. The types of medication information to be collected in different patient circumstances must be defined in local policy. Reconciling the information collected from the patient with the organizations information based on local policy must be completed prior to medications being administered, prescribed, modified, or care given. The education of patients and family members on their medications remains a critical element of good clinical care.

44. FAQS 5. What constitutes “Best Effort” or “Good Faith Effort” in our attempts to obtain medication information from the patient and/or caregiver? • The patient may be unwilling or unable to talk about their medications. Information should be obtained from the electronic medical record and caregivers, if they have been authorized by the patient to speak on their behalf. This should be documented in the electronic medical record so if information is not obtained, the next healthcare team can continue the effort.

45. Setting Specific Considerations • ED/UCC Consider • Giving a med list at triage for patients to review • Having a MedRecon Dialogue template to pull meds in the note for review • Updating Med list directly or import into discharge instructions • Multi-appointment Day Consider • Alerting providers to at least finish orders, preferably the note • Encouraging patient to make sure he/she has the update list in hand • Last appointment reprints an updated list—beware of “Pending” • Admission Consider • Highlighting why home meds were held/discontinued so next team can prepare to restart, etc. • Discharge Consider • Engaging discharge team to of follow process that ensures med lists are the same on the Instructions as in the Discharge Documentations

46. What we can do today • Ask the patients what they are taking at home, document this and note the differences from their plan • Identify and document their barriers to adherence • Make sure the admission includes why meds have been held, added, discontinued • Consider at discharge, what he or she was taking, what we thought they were taking, the inpatient meds, and what he should go home on—there may be unaddressed issues that will require a plan to communicate and follow up • Ask for help from your team, consultants, colleagues, and caregivers

47. What we can do now • Create an expectation that med management will be discussed at every visit • Inquire about how your patient manages there meds, who helps, what we can do to help • Foster an understanding that meds are hard to take, that sometimes things go wrong, and the most important thing is to communicate concerns before changes are made to meds • Ultimately patients are in charge of their information and need to manage it

48. Seamless • “My son Mike is a 30yo Veteran, he has TBI, and is confined to a wheelchair. There are a lot of things to keep track of, meds, appointments, you name it.” His care giver requires support

49. Seamless His care is customized • “I have a team working for me and my son, home health aid, visiting nurses, my pharmacist, case manager, and PA—not to mention my great PACT team and specialists.”

50. Seamless She is connected virtually • “I rely on my caregiver support coordinator Renee. In the beginning, when Mike came home from Bethesda, I SM’d her everyday. She set me up with telehealthso I am connected with the team ‘realtime’. • Yesterday, I showed them a rash on the video phone”