Thanks to everyone in Pharmacy Informatics! Goals for today is to discuss

1. Patient Centered Medication Information Management &Medication Reconciliation InitiativeUpdateMaureen Layden, MD, MPHRosemary Grealish, RPhMarch 7, 2013

2. Thanks to everyone in Pharmacy Informatics!Goals for today is to discuss • Medication Reconciliation • Patient Medication Information • What is new • How you can help

3. Medication Reconciliation: The Same Page Medication Reconciliation is a process to ensure maintenance of accurate, safe, effective, and, above all, patient centered medication information by

4. 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) *These are in alignment, they do not take precedence over each other

5. Highlights from the VA MedRecon Directive • MedRecon is initiated at every episode or transition in level of care where medications will be administered, prescribed, modified, or may influence the care given • The medication history • Is iatrogenic disease/harm on the differential diagnosis? • Facilities must • Define the processes to be used when medications are outside of the scope of the health care team member performing components of MedRecon • NOTE: Addressing a discrepancy does not always require managing a medication or changing the medication order • Assign a Facility and VISN Point of Contact for MedRecon information dissemination • Define the roles, tasks, and steps of the MedRecon that work for their facility

6. What is new • More Non traditional care • Non Face-to-Face Encounters • Secure Messaging • Asynchronous Communication with Patient Generated Data • Increased focus on team approach • Pharmacy plays a critical role as leader and subject matter expert (ASHP, 2013) • But, this must be done as a team to be successful • The Essential Medication Information Addendum

7. Essential Medication Information: Patient’s Medication Lists

8. MEDICATION RECONCILIATION DIRECTIVE ADDENDUM 2013Essential Medication Information  • Purpose: To define the minimal or essential elements necessary to share and review medication information between healthcare teams, patients and caregivers. • Name/strength of drug • Instructions/Directions • Notes Section to allow patients write any information they need to help them manage their meds (Indication, description of medication, etc.) • Medications • Active Medication List • Remote, non VA, and Patient Generated Data • For the purpose of reviewing medications with patients, the following: Recently Discontinued, Expired, Pending Status are important in determining what medications a patient may be taking.

9. Not Only Joint Commission: Meaningful Use • Meaningful Use Stage 2 (2014) • Use computerized provider order entry (CPOE) • Use clinical decision support • Provide patients the ability to view online, download and transmit their health information within 36 hours after discharge. • Use certified EHR technology to identify and provide patient-specific education • Perform medication reconciliation • Provide summary of care record for each transition of care or referral • Automatically track medications with an electronic medication administration record (eMAR) • Generate and transmit permissible discharge prescriptions electronically (eRx) Use secure electronic messaging to communicate with patients on relevant health information • Meaning ful Use Stage 3 (2016) • Bidirectional communication using Patient Generated Data • Active Medication List is formed by Medication Reconciliation

10. Meaningful Use:To promote the spread of electronic health records to improve health care in the United States Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. For details about the incentive programs, visit the CMS website. VA is mandated to comply despite receiving no incentive payments

11. VA’s Hospital Comparehttp://www.hospitalcompare.va.gov/

12. The Patient Protection and Affordable Care Act of 2010 (ACA), • Shift from volume-based to results-based payments • Focus is on keeping patients out of the hospital • HHS estimates that ACOs could save Medicare up to $960 million in the first three years • Hospital Based or Outpatient based metrics include: • Patient Experience of Care • Communication about medications • Staff Communication and responsiveness • Communication about Meds • Pain Management • Discharge Info • Clinical Processes • Medication Reconciliation • Medication Treatmen t Management • Transitions in Care • Medication Information Hand -Offs • VA is not mandated to participate in ACA

13. VA MedRecon External Peer Review Pilot Program (EPRP)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 an updated list? Discharge Info=Patients Med List Did the team explain the importance of managing meds to the patient/caregiver? 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).

14. VA Medication Reconciliation EPRP 2013Q1 Facilities

15. 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 for EPRP • 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)

16. 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. MedReconDirective FAQs

18. Medication Use Crisis Virtual Conference • Joint effort VHA Program Offices, DoD, and Indian Health • Kick Off 16 hours of CE Programming over 4 Tuesdays in May 2012 • Continues Quarterly 4 Hours “The fifth Tuesday’ • Tracks: • Information Management* • Teams and Transitions • Optimizing Resources • Veteran and Caregiver • In January, the theme was “Medication Challenges faced by Transitioning Servicemembers” • In April, “On their own: Helping Veterans with their medications in between visits, at home, and in the non VA healthcare systems

19. 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

20. Workgroup Tuesdays Your Meds Your Life Play it Safe! Talk to me • 1st Tuesday 1PM East Office Hours Open Forum • 2ndTuesday 1PM East Documentation and Monitoring • 3rd Tuesday 1PM East Patient and Staff Education • 4th Tuesday 1PM East MedRecon Series

21. Other Workgroups • Emergency Department and Urgent Care Medication Management Workgroup • Interprofessional Medication Information Management Education Module • Pharmacists leading here! • National Alliance for Patient Medication Information Standardization • EPRP Analysis Group • Medication Use Crisis Conference Planning Committee From our newest video: Take as Directed: MedReconChampions”

22. 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?

23. What is “Medication Information”? • Patient Medication List • Medication Data • Content and Display • Use Cases: Self Management, Care Coordination, Reconciliation, etc. • Context: • Healthcare Team: Allergies/Adverse Reaction, Adherence Data, Drug-Drug, Drug-Disease Interaction, Past Medication History • Patient/Caregiver: Barriers to taking medications, Preference, Caregiver involvement • 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!

24. How do we use this information? • Pharmacy • Order Pharmacy Processing  Dispensing or Administration • J.D. Power & Associates 2012 Customer Service Champion • Care Coordination • Clinical and Shared Decision Making • Education • Adverse Drug Event reporting and management • Adherence Detection and Management • Quality Improvement & Management • Research

25. National Alliance for Patient Medication Information Standardization (NAPMIS) BACKGROUND: There are more than 15 different VA funded projects addressing patient-facing medication information. There is no system in place to ensure consistency: • Content • Display • Source and Data management of Medication Information • Development, deployment, evaluation, usability, and convergence across platforms • NAPMIS: Field Staff, Administrators, Multi-program Office, PCS, Innovations, OIA, NCPS, Care Coordination, OIT, DoD, and Indian Health NAPMIS White Paper Recommended setting up a Multi-program Office Interdisciplinary Task Force to write guidance to ensure consistency NAPMIS took part in the eConnected/Digital Health Tasks Force reinforced those recommendations

26. PBM Patient Medication Information Issue Brief 2, 2013 • Guidelines do not yet exist for Patient Medication Information • Business Rules: Content, Display, Use Cases: Review of Medication Information, Sharing Medication Information, and Managing Medication Information, Management of Data, Oversight/Analysis of Data. • IT Rules: Database Management, Naming Conventions, Sharing, Synchronization, etc. • Patient Medication Information Projects include but are not limited to; • Patient MedRecon/PatientCentered Medication Information Management New Service Request: Funded, but monies have not and may be be released FY2013 • VA Point of Service Kiosk • MyHealtheVet • My Recovery Program on MyHealtheVet • h12 non VA Mobile Application • h12 Medication Reconciliation Project • Innovations, Research, and Program Office Projects (No national OIT support)

27. PBM Patient Medication Information Issue Brief 2, 2013Recommendations • PBM, as a program office, provide foundational guidance and multi-program office coordination to: • Create the standards necessary for consistent patient medication information • Design a unified approach to make certain that this consistency is upheld in current and future medication lists, tools, applications, and/or innovations • Release MedRecon Directive Essential Med Info Addendum • PBM will publish standards in patient medication information in collaboration with OIA and OIT • PBM provide SMEs on applications which employs medication information • OIA-Health Systems, OIA-h12, and PBM will complete a crosswalk of all patient medication information projects to identify gaps and overlaps • OIA, Patient Care Services (PCS), and National Center for Patient Safety (NCPS) collaboratively will engage leadership to support this endeavor

28. How you can help • Share your MedRecon or Patient Med Info Management Process/Lessons Learned with us on one of the Workgroups or Share Point • Let us know of any new MedReconor Patient Med Info Management application so we can continue to build community, raise awareness, and support innovators • Let your facilities know about the About the resources and barriers in VistA/CPRS

29. Barriers Short Term Solutions More than half the discrepancies are related to inaccuracies in our medication information • 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: Use the MedRecon Software! • 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

30. Interim Solution Medication Reconciliation Tool Comparison Chart MedRecon Share Point Documentation Folder

31. Barrier Short Term Solutions Patient Medication Discrepancies are complex • 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

32. Barriers Short Term Solutions The updated med list barriers • Communicating with the Healthcare Team • Between Departments • Settings • Facilities • Non VA • No 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

33. 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

34. VA MedRecon IT Projects • VA Point of Service Kiosk • Medication Image Library • MedRecon NSR • Park Meds Innovation • 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

35. 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.

36. 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 Chart

37. Consider helping your facility • 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 • Recognize that ultimately patients are in charge of their information and need to manage it

38. The Same Page

39. Thanks! • Please feel free to email Maureen.Layden@VA.gov or Rosemary.Grealish@VA.gov for any questions From “Bob’s Med Wreck”