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Medication Reconciliation—A Field of Onions (Part 2)

November 10, 2011
by Joe Bormel
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There is enough variation with medication reconciliation that developing a "one size fits all" model won't work

Part II: Medication Reconciliation – A Field of Onions

In Part I ( link) of this blog, I presented some background pertaining to medication reconciliation (MedRec), and a series of assumptions about this topic I gleaned from attending the AMIA conference. As promised, here in Part 2, I’m presenting my thoughts for moving forward.

My conclusions, based on what I learned at AMIA and captured in the list of assumptions, are there exist several concrete and useful ways to approach medication reconciliation that are not in common practice today:

A. Separate out and professionally design the user interface:

Usability: There were multiple examples provided at the conference demonstrating highly usable user interfaces. The opposite was also true; awful displays of what not to do. Hire professionals to do this; analysts, engineers, and end-users are often weak in usability methods, practice and evaluation skills.

Mobility: In addition, it was clear that the time is now to design the user interface to work concurrently on mobile devices, including tablets and Smartphones. That means the ability to drag and drop a medication list, and to be able to simply press on a trashcan or device appropriate method to remove an item from a list. On an iPhone for example, that may mean sliding your finger over a drug name from left to right to bring up a large, red, “delete” button. An iPhone user would expect that to be available and work accordingly.

Data-to-Ink Ratio: Aggressively work to achieve a high data-to-ink ratio. We need to develop ways to remove redundant text so the displays are simpler, clearer, and require less time to absorb wherever possible.

Order and Sequence: The order and grouping of medications on a list is critical. It should be possible to group drugs together in ways that help clinicians do their work.

B. Separate out the medication semantics issues:

Clarity: Brands and generic names, clinical indications, and so forth should be available for display and shown consistently. Drug information can be confusing; design should seek to reduce the chance of errors. One method of doing this is, for example, TALLMAN lettering such as "predniSONE" and "prednisoLONE" ( ).

Decision Support: There were multiple examples provided that made it clear identification of therapeutic duplication requires clinical decision support systems. For example, if two different drugs both contain morphine or act as a beta blocker, this needs to be apparent to a busy clinician by the design of the user experience.

NLP: Natural Language Processing will clearly be required since medications, even codified ones coming through an interoperable Continuity of Care Document (CCD), will need to be semantically reasoned over to be presented effectively to a clinician. So, for example, if a patient’s visit note references a drug that doesn’t appear on the medication list, the clinician should be given the opportunity to add it or record that it is being discontinued.

C. Separate out ambulatory medication reconciliation from that of inpatient hospitalization:

- Ambulatory MedRec can often be accomplished with a two list model. It tends to be concerned only with ePrescribing.

- Ambulatory MedRec is far less concerned with acute issues like response to newly initiated intravenous medications.

- Medication reconciliation for inpatient hospitalization is a different animal in many, many respects. Probably the biggest difference is the profound and tight integration requirements with hospital processes such as clinical assessment and medication administration.

- Unlike ambulatory medication reconciliation, it is unrealistic to expect being able to decouple the reconciliation process from ordering, ePrescribing, or documentation for inpatients.

- Inpatient MedRec requires a different sort of dynamic conversation with the patient and any home care providers who may be involved, both when being admitted, as well as when being discharged. Poor hand-offs at admission and during discharge are significant problems that the MedRec process needs to address.


In summation, medication reconciliation is like working in a field of onions. There is enough variation that developing a one size fits all model won't work. Peeling back the layers in MedRec is critical.




Dr. Bormel,
I can see from your blog where the industry is definitely making inroads to making MedRec more useable. And may I way that it's about time if we are to significantly raise the bar for patient safety.

What is not clear to me is the when of all this. Is there any time frame available that will at least tell us when we'll see a light at the end of this tunnel?

Doc Benjamin

"The work that our team demonstrated at AMIA shows how experts in information visualization and user-centered design working in conjunction with clinicians can bring innovative advances to EHRs. To bring these advances to clinicians and patients we are now looking for vendors to team up with us to adapt our ideas to their existing systems. Vendors that choose to work with us can gain a competitive advantage by developing and deploying advanced user-centered interfaces that decrease errors and increase clinician efficiency."

Eliz Markowitz MS
Elmer V. Bernstam MD, MSE
Jorge Herskovic MD, PhD
Jiajie Zhang PhD
Ben Shneiderman PhD,
Catherine Plaisant PhD
Todd R. Johnson PhD

Editors note: 
Readers might find value in this background article by the same team,
/Media/BlogReplies/2011-07 Eliz Markowitz, Todd R. Johnson, PhD et al.pdf
additional details and graphics on Improving Medication Reconciliation,

Other project-related artifacts and videos from SharpC at Maryland are available here.

Thanks Dr Cusack for your insights. I especially liked the idea of a "truth" filter. One of my clients did a chart review of their own medication reconciliation at time of discharge and compared that to the patient discharge instructions and the discharge note. They were in agreement about half of the time. I think that speaks to your point.

Per your elaboration of lists and my prior "Kayaks and Perspectives on Meaningful Use" blog post, perhaps we should expect our pursuit of truth to end with something more than identical lists.

While I was one of the attendees in the audience when the MedRec prototypes were demonstrated at AMIA, I did not applaud.  

It is disappointing that we in healthcare have been conditioned to not expect much from the technology being developed for us, other than to have it replicate the paper record.  Yes, the prototypes did a great job at combining two lists, but the issues of MedRec, as you so articulately point out, go way beyond the ability to merely combine two lists together.   

In addition to the items you list, our MedRec tools must be able to track the discrepancy between what we have asked the patient to do and what they are actually doing over time, a, ‘discrepancy rate’. As well, we must have the ability to indicate how the patient is truly taking or not taking a medication.

Not discussed in your article is the issue of quality/performance measures which force us as clinicians to regularly prescribe medications to patients, even when we know they will never take them.  We need the ability to have our medication list reflect that we have attempted to meet those measures, either allowing us to receive credit for attempting to do the ‘right’ thing, or removing those patients from our denominators of these measurements.

Finally, missing is the patient’s voice, and the ability to integrate patient entered data on what their understanding is around the medications they are taking, as well as their understanding about their allergies, side effects, and medication preferences.  

I wonder if ultimately we will settle on three lists: one that is patient managed and patient entered, representing the ‘truth’ as the patient experiences it; the second being a record of medications that have been prescribed, the ‘truth’ as care guidelines would dictate; the third a reconciliation representing the overall ‘truth’.  In taking into account the challenges we face in MedRec, the ability to combine two lists into one seems almost primitive. 

When a prototype is developed that addresses the real needs in MedRecon, I too will be applauding.

Doc Benjamin,
Thanks for your comment.

We can already see the light at the end of the tunnel. A few years ago, the majority of hospitals began printing a multi-column, multi-section paper report for physicians. It was common for the analysts and designers involved to be confident that version one would handle every contingency. On the patient care floors and clinics, these were usually evolved to version seventy-three (or there abouts!.)

And that was only a semi-automated solution. It's best to appreciate, as Frank Poggio commented in part one, that the systems of care are getting more usable and safer. That should comfort us as we live through perpetual intermediate solutions. We have reached our destination for straight-forward reconciliation. The rest will improve with time, energy, focus, and commitment.

"Moving parts in rubbing contact require lubrication to avoid
excessive wear. Honorifics and formal politeness provide lubrication
where people rub together.

Often the very young, the untraveled, the

naive, the unsophisticated deplore these formalities as 'empty',
'meaningless' or 'dishonest' and scorn to use them. No matter how 'pure'
their motives, they thereby throw sand into machinery that does not work
well at best."

- Time enough for love: the lives of Lazarus Long
By Robert Anson Heinlein

Frank,  Thanks for your comment.  I am in violent agreement with your premise of guarded optimism.  As you and Eliz and many others have noted, medication reconciliation didn't work well in the manual systems that we are trying to make paperless.  And, of course, making paperless can be a far cry short of automation.  I chose the Heinlein quote above, one of my long time favorites, because it points out two shared human problems of both communication and, more specifically Med Rec.

First is that the system (machinery) does not work well at best.  That true of both confrontational communication which Heinlein is addressing in the quote.  It's also true of Med Rec, which, prior to our current efforts to make it paperless, and automate it didn't work well.  In the process of computerizing it, the assumption is that we can and should strive to make it perfect.

Second, most of the readers of this post have run into folks who are angry about the state of Med Rec.  They share the vision that most of us have in healthcare IT, which is that computers ought to be able to make medication reconciliation, neat, clean, perfect and flawless.  Their anger falls into a category my psychiatrist friends refer to as a blind rage.  Leave out the word "blind" and these psychiatrists will correct you, because the blindness is a distinct attribute is not reduced or eliminated with training, education, glasses or more light!

All of this is why I deeply appreciate Eliz Markowitz's comment and linked work, especially "Improving Medication Reconciliation."  I'm especially appreciative of the comment from her and her team.  Why?  First of all, the framing of the problem, ie to improve medication reconciliation is critical.  Presenting a med rec solution in any other way than steps toward improvement is rage inducing!  Second, her and their approach and examples of deconstructing medication reconciliation constitute one of the best and most complete frameworks.  It's certainly very pragmatic.  I especially appreciate the timeline displays!  And lastly, the appeal to collaboration in her comment is very telling.  Vendors, academics and provider organizations struggle with the deep challenges of innovation.  The work we do together is almost always the best work possible.

Joe & Ben,
Boy you guys are way to opimistic for me. I agree we have made great progress in all this over the last decade, but as I said in part 1, just when you think you've got it knocked- BANG! they change the rules on you.

I really do not want to sound pessimistic just realistic. One of the reasons why I stayed in the HIT world for 35 years is I came to the conclusion long ago that since we (the HIT professionals) are chasing a ever moving target this will be a very challenging career. No chance to get bored.

As I noted in part one there are millions of "medical onions" out there and we are a long way from the pot.
Keep up the good work, more people (particualrly the regulators) need to better understand these complexities and dynamics