Getting on the Same Page:

1. Getting on the Same Page: Challenges in Medication Reconciliation Across Settings for Older Adults Heather Young, GNP, PhD, Paul Gorman, MD, Valerie King, MD, Karl Ordelheide, MD, Dale Kraemer, PhD, Misha Pavel, PhD, Terri Bianco, PharmD Samaritan North Lincoln Hospital Oregon Rural Practice Research Network Oregon Health & Sciences University Oregon State University Funded by the Agency for Healthcare Research & Quality

2. RxSafe in Lincoln City Oregon • 4 Local Pharmacies • 6 Clinics • Rural hospital • SNF/REHAB • 3 Assisted Living

3. Basic Steps in Medication UseEach with different information and different technology Dispensing Pharmacists Proprietary Software Administering ALF/SNF staff Paper Med Admin Record Fax Prescribing Primary Care Clinician Fax/Paper record Electronic Medical Record Monitoring Facility, pharmacy, and clinic staff

4. Population at risk: adults with multiple health problems, advanced age, frailty, multiple providers Overmedication duplications within class, between class discontinued medications Undermedication errors of omission Wrong medications amaryl~reminyl; foradil~toradol Interactions Clinical Problem Everyone has different information

5. It is easier to move the patients SNF Clinic Home health Hospital Assisted Living Communication: fax, foot, phone

6. Different Source Documents Different Needs Different Conventions

7. Prescribing Primary Care Clinician Monitoring Facility and pharmacy staff RxSafe Dispensing Pharmacists Administering Facility Goal of RxSafe:Get to everyone on the same page

8. Single Medication List Accurate Complete Current Available Secure access for Prescribing Dispensing Administering Monitoring Benefits Reconcile lists and terminology Eliminate duplication Improve adherence Reduce interactions Improve effectiveness of decision support Provide platform for practice improvement Early detection of anomalies RxSafe: Overall Goals of Project

9. Evaluation Priorities • Valid, reliable measure of differences among lists • Describe the extent and nature of the differences • Determine clinical significance of the difference • Identify priority areas for intervention

10. Existing Measures • Limited to counting events: • Frequency by patient • Total number of events • Events per patient • May or may not include counts by subcategories (drug name, dose, frequency, etc.) • Usually have a gold-standard list (may be physician reviewing records)

11. Limitations of Existing Measures • Not designed to compare across >2 lists • Based on event-driven reconciliation (e.g., hospital discharge) rather than ongoing reconciliation process as occurs in long term care settings • Do not combine dimensions (e.g. discrepancies and harm likelihood / severity) but tabulate these separately

12. RxSafe Functionality • Collect information from all existing lists • Pharmacy • Clinic • Residential Facility • Render the lists as similar as possible • Order the lists to maximize similarity • Identify potential spelling and translation errors • Provide interface for efficient and easy comparisons of the medication lists

13. Record Comparison

14. RxSafe List Comparison Mary Jones Dr. Smith DOB 12/12/12 SNF/Rehab Pharmacy Hospital Clinic Temazepam Aricept Warfarin Oxybutinin Lisinopril Ferrous sulfate Dyazide Augmentin Atenolol Augmentin Oxybutinin Aricept Lisinopril Coumadin Atenolol Dyazide Phenergan Temazepam Oxybutinin Coumadin Dyazide Atenolol Lisinopril Donepezil Augmentin Temazepam Fe Gluconate Lisinopril Augmentin Donezepil Coumadin Atenolol Oxybutinin Diazide Phenergan Temazepam

15. Proposed Metrics for Evaluation • Disorder • Sorting, spelling, sameness - Assessment is based on the number of operations required for reconciliation • Discrepancy • Magnitude of difference • Hazard Probability • Hazard Severity • Combined

16. Human Reconciliation Process:Task Summary • Within list cleanup – organize entries (making sense of spelling mistakes, remove duplicates) • Select one list as the reference list • Sort the other lists to match as closely as possible the reference list • For each item • Find the closest potential match • If correspondence is not found • Find transformations that would minimize differences • Determine if the best transformation is feasible • If possible transform to equivalent (translate, calculate) • If not possible to transform, note the discordance

17. Pilot Study: Empirical Evaluation • Lists for 23 residents were collected from: • Facility • Clinic • Pharmacy • Lists were transcribed and reordered by a trained pharmacy technician • 3 experienced clinicians coded the lists

18. Evaluation of Discordance • Reorder lists to maximize similarity • Judge the correspondence for each item • I – Identical • E – Equivalent • M – Missing • N – Not the same • D – Duplicate • Hazard likelihood scale • Hazard severity scale

19. Results • The average number of items per list was 14.5 • The total number of prescription items was approximately 334

20. Differences in ListsClinic vs. Facility/Pharmacy vs. Facility # # I = Identical; E = Equivalent; M = Missing; N = Not the Same

21. Proportion of Differences

22. Methodological issues • Unable to find suitable existing method to reconcile multiple medication list sources • Time intensive to review due to • Different order of medications on lists • Inconsistent brand vs. generic name use • Dosage calculations (e.g., 2 – 20 mg tablets vs. 40 mg) • Timing issues (synchronizing information) – “dirty MAR” vs. monthly reviews vs. clinic records

23. Additional Methodological Issues • Medication records serve different purposes in different places (e.g., billing, organizing tasks, providing reminders for non-medication activities) • In addition to the number of discrepancies, the potential clinical significance is important – hazard risk and potential severity. Cannot evaluate severity using standard schema due to lack of required data (e.g., assessment of adverse effect)

24. Next steps • Fine tune the quantitative approach for describing number, type and severity of discrepancies • Complete data analysis for baseline, then data over time and post-intervention • Add observations at key times of reconciliation (monthly review, clinic visit, etc.) to describe process and to quantify time and human resources for this task