VA Medication Reconciliation

1. VA Medication Reconciliation More than just a patient safety goal!

2. Goals for Today • Medication Reconciliation (MedRecon) • At the VA • The Challenges • The Opportunities • What you can do

3. Simple Definition “Know what a patient may be taking before prescribing medication” (Trettin, 2009)

4. Cases • 78yo male receives Toprol XL samples from non VA PCP, then receives metoprolol as VA refill in the mail, takes both, falls, and breaks his hip. Discharged to nursing home. • 55yo male admitted for ankle surgery has non VA Synthroid entered incorrectly (off by one decimal point) by nurse. Intern imports this to inpatient and later discharge medication list. Wife inquired why dose has changed.

5. Cases • 89yo male discharged after being admitted for syncope, extensive work-up negative, “MedRecon completed” at every interface. Wife queries PCP if its because he takes all of his 3X daily Isosorbide Dinitrate at once in the morning. • 36yo female with PMH + for opiate addiction, s/p shoulder surgery in remote VA, is getting opiates from home VA as well. Relapses.

6. Why MedRecon? • Prevent Adverse Drug Events • Coordinate Care • Address Compliance • Promote Shared Decision Making • Cost Avoidance

7. “Accurately and completely reconcile medications across the continuum of care.” NPSG.08.01.01: A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. NPSG.08.02.01: When a patient is referred or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service and the communication is documented. Alternatively, when a patient leaves the organization’s care directly to his or her home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, or the original referring provider, or a known next provider of service. NPSG.08.03.01: When a patient leaves the organization’s care, a complete and reconciled list of the patient’s medications is provided directly to the patient, and the patient’s family as needed, and the list is explained to the patient and/or family. NPSG.08.04.01: In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. The JC 2009 National Patient Safety Goal #8

8. “Maintain and communicate accurate patient medication information.” Obtain and Document information on the medications the patient is currently taking when he or she is admitted to the hospital, or at each outpatient encounter. Provide updated medication and hospital contact information to the patient (or family as needed) when he or she is discharged from the hospital or at the end of an outpatient encounter. Providing the patient with updated medication information is necessary only when medications are deleted or added or doses are changed during the encounter or stay within the hospital. Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpatient encounter. Draft JC 2011National Patient Safety Goal # 3

9. THE VA MEDRECON DEFINITION: MedRecon is a process to ensure maintenance of accurate, safe, effective, and above all patient centered medication information, By

10. THE VA MEDRECON DEFINITION: • Obtaining medication information from Patient, caregiver, and/family. • Comparing this to the medication information available on CPRS/VistA including current medications, non VA medications, and medications given at other VA facilities (remote data) for the purpose of identifying and addressing discrepancies. • Assembling and documenting the updated medication information. • Communicating with and providing education to Patient, caregiver, and/or family regarding this information. • Communicating this medication information with the appropriate members of the VA and non VA healthcare team.

11. Non VA Meds • Non VA Provider prescribed Medications • VA Provider prescribed medication filled at Non VA pharmacies • Herbals, OTCs, Nutraceuticals, & Alternative Medications

12. Why is it so hard?

13. Barriers to MedReconSurvey 11/2008-1/2009 & Field Reports • Time • Tools • Staff

14. Our Colleagues say: “I thought we had a list for patients.” “If the patient wants to get care in the private sector, let him/her bring the list.” “I am not changing the meds tab, my patient has enough meds at home and he can’t afford the co-pay.” “Its not my job to take responsibility for the psych meds!” “My patients will never get their meds right, ever!”

15. Bob’s List • Furosemide 40 2 pills in the morning, 3 if my ankles are up, take in the afternoon if going to church • Simvistatin 40 ½ pill in the morning, take it at bedtime on bridge nights • Metoprolol 25 1 pill in morning one at night, skip Friday night if OK with wife • Can’t take Sertraline (dizzy) –still down • Take Ambien 10 rarely for sleep- once a month

16. “Our List” from CPRS/VistA • Furosemide 40mg 3 pills daily • Simvistatin 40mg ½ Tab daily • Metoprolol 25mg 1 tab twice daily • Sertraline 100mg 1 tab daily • Ambien 10mg 1 tab at bedtime as needed for sleep • Aspirin 325mg 1 tab daily

17. The Difference is the Discrepancy Rate CPRS/VistA List “Medications we recommend you take” Patient List: “Medications I am willing and able to take” Discrepancy Rate

18. VA Medication Reconciliation Initiative“Our mission is to support safe, effective, and patient centered medication reconciliation across the VHA system” • Providers, Pharmacists, Nurses, Administrators, & Information Technologists from every level of the VHA, and OIT CACs • Grew out of a grass roots workgroup focusing on sharing best practice, developing metrics, tools, and educational materials • Share Point Usage Data: Up to 1,117 visits monthly from every VISN and VACO representing 226 unique visitors • Events: Virtual Summit in March 2009, VA 5 Million Lives Conference in August 2009, Documentation and Monitoring Face to Face September 200, & VA MedRecon: Soldiering On! In May 2010

20. VA Medication Reconciliation Initiative“Our mission is to support safe, effective, and patient centered medication reconciliation across the VHA system” Priorities Challenges Accomplishments VA MedRecon Toolkit VA MedRecon EPRP & Monitor VA MedRecon Initiative Coordination of VA MedRecon Ability to manage remote medications Ability to change medication order without dispensing medication or issuing co-pay • JC prolonged reevaluation of NPSG #8 • Delayed and uncoordinated software development • Involvement of all stakeholders in software development

22. VA Medication Reconciliation Performance Monitor At the post-discharge phone call: • “Did you receive an updated medication list upon discharge?” • “Do you know where to call if you have questions?” Target: 60% in all facilities Start: FY2009Q3

23. VA Medication Reconciliation External Peer Review Program (EPRP) Did the organization document • the patient list of medications in the medical record? • a comparison of the list in the medical record? • that the list was reviewed with the patient? • that the list of medications was given to the next provider?

24. VA National Medication Reconciliation Task Force Charter • Insure that this process is patient centered. • Establish a collaborative, integrated, and multidisciplinary team approach. • Support continuous quality improvement of development and implementation of tools and change strategies.

25. VA National Medication Reconciliation Task Force-Products • VA MedRecon Policy • Integrated tool development • Ongoing forum for improvement • Ultimately, Medication Reconciliation will be so imbedded in our daily routine and consistent with the expectations of our Patients that the campaign will become obsolete and the terms forgotten.

26. Innovations on the Horizon

27. Automated Patient HistoryIntake Device (APHID) Portland Patient Center of Inquiry Electronic kiosk accessed by veteran prior to clinic appointment or admission Security ensured by allowing access only via Veterans Identification Card or other unique identifiers Deliver a structured and automated history form Distribute data to members of health care team for action 27

28. Integrated Medication Manager

29. Medications: Play it Safe! My HealtheVet Healthy Living Center

30. VA MedRecon • It’s what we all want • To be on “the same page” as patient and healthcare team member and • Deliver Healthcare • Safely, with the highest quality, efficient, and cost effective • Imbedded in our daily routines • Including Patient and healthcare team

31. What can you do to help? • Encourage Patients to keep their medication information current • Encourage Healthcare Team to ask Patients what they are taking at home • Share this information with Patient and HeathcareTeam • Leave a “trail” in the chart

32. Help your colleagues understand: • It is difficult to obtain patient data • Maintaining an accurate medication list means amending orders • Remote data is a problem • Non VA list must be updated • Communication with the Non VA Provider requires ROI, storing demographics, and having a method of data transfer

33. Questions? Medication Reconciliation Will fundamentally change how we practice medicine by systemizing the management of the medical treatment plan, placing checks and balances at every interface, and instituting an ongoing dialogue with the patient and his/her healthcare team. Maureen Layden, MD, MPH Director VA Medication Reconciliation Initiative Phone: (617) 302-3591 Maureen.Layden@VA.gov National VA Medication Reconciliation Share Point