Last week, I attended the American Medical Informatics Association (AMIA) conference in Washington, DC. This conference is the largest U.S. gathering of practitioners, researchers, academics, and government/policy professionals working in informatics. The social networking alone is worth the price of admission. There are dozens upon dozens of published experts in every dimension of medical informatics, and nearly all of them have real world experience from one or more healthcare systems that have completed productive and innovative projects.
In this post I want to focus on a single topic from the conference —medication reconciliation (MedRec). It is broadly recognized that medication reconciliation is a fundamental part of patient safety and has challenged commercial and noncommercial designers, developers, and implementers for years. Like working in a field of onions, you need to peel back the layers of several different onions to see what is really going on.
By necessity, this is a two-part blog so I can present the necessary details. MedRec is a topic of central importance to Meaningful Use and patient safety, and medication reconciliation in general is poorly understood, as you’ll see as you read on. In this, Part I, I’ve included some background and a series of MedRec assumptions. In Part II, I’ll present my thoughts on the way forward.
It's generally accepted that MedRec is at best challenging without electronic enablement. Although medication reconciliation was named by The Joint Commission as an accreditation requirement in 2006, the requirement was dropped (technically re-designated so that it was no longer scored) in 2009 in recognition of the lack of proven strategies for accomplishing it.
When technology is brought into the picture, there is tremendous potential to improve on safety, as well as possibly worsen it. Arguably, the biggest challenges are displaying available information and interacting with that display. These are popularly referred to as usability issues. Not surprisingly, they received a lot of treatment at AMIA, as were the related usability requirement definitions for Stage Two of Meaningful Use.
In my experience, a central recurring flaw is how the MedRec problem is defined and, therefore, what the requirements are for a solution. What follows is a list of assumptions that lie beneath the problem.
1. The "two list" assumption, i.e. reconciliation is all about one list before reconciliation and one list after completing a reconciliation. That's true at a very high level for ambulatory MedRec; however, that assumption rapidly breaks down in other areas. There are often effectively more than two “lists” and they are just as often likely to be wrong and incomplete.
2. Setting and context of care dramatically influence and/or change the problem. An example here is that sub-specialists in an ambulatory delivery setting do not feel trained or comfortable reconciling drugs outside of their practice area. So, for instance, it’s difficult for a non-rheumatologist to tell a patient to continue taking their dangerous rheumatic drugs. The non-rheumatologist will say to the patient, "Continue as you were directed," not knowing with confidence what those directions were!
3. The assumption that it is possible to separate reconciliation from ordering and ePrescribing is often made by non-clinical solution designers. The notion is that you start and complete the MedRec process after ordering and ePrescribing are complete is a potentially dangerous assumption. What happens if, during the reconciliation, you notice that a drug should have been continued but wasn’t? You order it (inpatient) or prescribe it (ambulatory). If the reconciliation software doesn’t support this, those medication list displays are blind to the changes being made. That’s very bad, because the reconciliation report won’t reflect what actually happened or accurately reflect which drugs the patient was told to take.
4. The wishful design assumption that the medication list display can contain only the list of medication names, and ignore the explicit reason, aka intent, behind the use of the medications:
- The therapeutic intent (indication) for each drug, e.g. Zoloft for panic attacks. The indication can impact dose and other prescribing details like frequency of use.
- The contextual intent, e.g. hold Coumadin before surgery and restart after follow-up per your surgeon.
- The experience-based intent, e.g. discontinued because of allergy, inadequate affect, side effects, etc. If a physician doesn’t know that another physician deliberately discontinued a medication and why, they will not be able to reason adequately on what to do for the patient.
- The unintended intent, e.g. stop taking the medication because I ran out of visit time, or forgot to consider asking the patient or myself whether to continue or discontinue it.
5. The assumption that our current practices around medication documentation prior to instituting medication reconciliation are adequate. Medication reconciliation often presupposes that a patient, doctor and nurse can pull together and write down what medications a patient is taking. This isn’t always the case. Patients and their families aren’t necessarily competent historians. I certainly don’t remember when I started and stopped medications in the past.
Prior notes don’t necessarily help either. For example, several presenters at AMIA shared that in a recent review, the majority (81%) of ambulatory clinical notes did not have the patients’ medications listed. Said differently, our current state is often inferior to what we had thought or hoped it had been.
6. The assumption that reconciliation is simply a matter that independent drugs A, B and C all appear in each of two lists is often the basis of MedRec. That’s too simplistic.
The basic model is that a drug name, the drug’s dose, and frequency (e.g. once a day, or with meals) is generally sufficient to describe a medication on a list is only one simple case. An often cited exception is that for a patient taking the drug Coumadin at the dose of 7 mg at bedtime.
Unfortunately, the patient and the doctor need to deal with the fact that there isn’t a 7 mg tablet. The medication will probably be taken as two pills, say a Coumadin 5 mg tablet and Coumadin 2 mg tablet at bedtime. The effective dose is then seven milligrams.
If the medication reconciliation solution does not model this, confusion, poor usability, unintended consequences, and patient harm are likely. In this case, the display should reflect the total intended dose, i.e. 7 mg, and the fulfillment by a 5 mg and 2 mg tablet.
Similar confusions occur related to splitting scored pills and tracking the impact on quantities, waste, and refills. Again, said differently, we want the reconciliation to reflect the medication dose prescribed, and, if needed, the product detail sufficient to safely describe the situation.
7. The failure to recognize or adequately model the difference between what the doctor asks the patient to take and what they're truly taking. And it's probably more complicated than that. There's an adage that "what people say they do, think they do, and actually do are often three different things." It is common for a patient to tell a doctor what they think the doctor wants to hear, either to please them, or to avoid an argument!
8. The incorrect assumption that MedRec has one major workflow that doesn't vary in significant ways across care settings, clinical domains, and drug-specific use cases. Simple and compelling user interfaces can be built and tested around specific use cases and practice workflows. Unless they've been modeled to generalize other major scenarios, they often don't generalize and cannot be re-used if the medication doesn’t match the supported pattern. That's not necessarily bad; it simply needs to be factored into our expectations.
There you have them, the assumptions as I noted them from multiple presenters at AMIA. I invite your comments and thoughts, and I’ll present my conclusions in Part II. I'll also provide links to two of the best prototype demonstrations which really delighted many physicians.
Joe Bormel, M.D., MPH
CMO & VP
the only profession that labors incessantly
to destroy the reason for its existence.
- James Bryce