In the first two parts of this series we reviewed the fact that although medication reconciliation is recognized as being extremely challenging, there was progress being made in 2011. Some of that progress, the prototype user experience, earned a standing ovation from physician leadership in HCIT.
In this post, we will wrap up the topic by discussing the provider organizational process issues, where the many critical contexts of medication reconciliation (MR or Med Rec) come together. We’ll draw heavily from a presentation by Vickie Kamataris of Novaces in which she effectively peeled back the layers of the MR onion with great clarity. Titled “Medication Reconciliation: Putting a Dent in One of Healthcare’s Toughest Problems,” and delivered in August 2011, you’ll find it here.
Kamataris has the talent, skills and experience stemming from her nursing and Six Sigma master black belt training to make some very intelligent points. What follows are the fundamental dimensions and implications for action from her presentation.
A. Unreliable Med Rec is recurrently identifiable as the root cause of every major inpatient process failure. That’s true for preventable readmissions, attainment of quality goals, personal time and energy management of healthcare providers (especially nurses and doctors). Also included are avoidable waste such as non-value-added activities, and the effective management of transitions of care (admission and discharge being the granddaddies). 
Implication: The Med Rec process must be understood and addressed as a prerequisite to any inpatient improvement project. This requires the correct use of tools, as shown in the figure above.
B. A systems approach, using a toolset and skillful talent set like Lean Six Sigma, is a required discipline. Although Med Rec failures always produce the obvious end result, the degree to which a specific component contributes is not necessarily obvious. Therefore, measurement, careful observation, and assumption testing that aren’t free and often require uncommon analytical skills are necessities. One approach, the DMAIC Roadmap described in the linked presentation, is shown here:
Implication: Implementing a “solution” to a poorly characterized problem is an inefficient, often ineffective, and usually costly way to deal with it.
C. Clinical Transformation is critical and unavoidable. As we race to demonstrate Meaningful Use of certified solutions, it’s understandable that many of us strive to change as little as possible. What we’ve learned is that the requisite workflows, such as those to accomplish MR, maintain an up-to-date problem list, or do quality measurement as a by-product of care, must be implemented electronically, not by manual abstraction. This requires careful attention to process design. Translating those transforming processes to operations requires them to be repetitive by design.
Implication: Points A and B above define the strategic critical work. The first step is to understand your current processes and recurrent types of failures. That requires resource planning starting with “buy, rent or growing those resources.” Parts of your problem are probably not adequately understood to pick the right tool to fix them. If you don’t have Pareto diagrams that characterize your inputs and failures, such as in the above example, you won’t understand your problem(s).
D. The future is reconciliation, and it’s not simply medications. A core dimension to MR is the input of information by care providers. None of us do that perfectly 100 percent of the time. Another dimension is patients who present with no medication lists, long lists, or a Ziploc bag of medications, some of which may be high risk meds. Add them both together and it is not surprising that the pre-automation Med Rec success rate is never higher than 50 percent when carefully studied. It’s clear there is a cousin to Med Rec – problem reconciliation.
Many of the required solution elements, like grouping by category (examined in Part 2 of this series) are the same. This also is true with designs that scale up when the number of list elements exceeds a dozen. In this case, those elements need the same kinds of treatment we saw in TwinList. There is tremendous overlap, of course, with clinical documentation improvement (CDI) initiatives, which similarly focus on establishing clarity in areas that have a high gap rate. 
Implication: Current state assessment of your organization, such as that needed for phase one ICD-10 preparation, is vital and will need to be on-going. As demonstrated in the graphic above, the “Med Rec process is universally broken.” We are already beginning to find the same conclusion for problem list management and its reconciliation. However, the approaches shown in the video dramatically improved MR and are essential to process improvement.
To fully understand these points and their implications, I strongly recommend watching the Kamataris-Novaces Medication Reconciliation video presentation.
As challenging as MR can be, the field of onions we’ve been discussing is manageable. In some cases, simply collecting these metaphorical onions in baskets and counting them is more than sufficient for our operations. In others, peeling, slicing, boiling, sautéing and caramelizing will be essential. And, ultimately, some repackaging, such as French Onion Soup or onion rings, will be critical to delivering better care for patients.
What do you think?
Joseph I. Bormel MD, MPH
CMO, Vice President
QuadraMed Corporation
Clarity affords focus.
Thomas Leonard