Taking Control

TMA Develops Medication Reconciliation Tool

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Quality Feature – July 2013

Tex Med. 2013;109(7):49-52.

 By Amy Lynn Sorrel 
Associate Editor

When Garland family physician Clifford T. Fullerton, MD, gave one of his elderly patients a printed summary of her visit that included a list of all of the medications she needed to manage various conditions, her reaction took him by surprise. Tears welled up in the woman's eyes.

"She felt so much more in control to have that information – what she was taking and why she was taking it," he said. "Having that list relieved a lot of confusion she had. We [physicians] forget how second nature this is to us and how foreign it is to patients."

The approach may be simple. But with more patients managing chronic diseases and a broad push to improve care coordination and reduce health care costs, medication reconciliation is that much more critical, physician leaders say.

According to a study by the Agency for Healthcare Research and Quality, drug-related adverse outcomes were recorded in 838,000 emergency department visits (1 percent of all visits) and 1.9 million hospitalizations (5 percent of all stays) in 2008, costing roughly $2.6 billion. Medication reconciliation also is a recognized component of patient safety the Joint Commission incorporated into its National Patient Safety Goals.

Yet, until today's health care system is fully integrated, primary care physicians, specialists, and pharmacists aren't always able to talk to each other in real time, nor can electronic medical record (EMR) systems communicate with one another. Dr. Fullerton knows physicians could use a tool to stand in the gap. He leads the Patient-Centered Medical Home Initiative at HealthTexas, a multispecialty physician network at Baylor Health Care System in Dallas, where he also is vice president of the Chronic Disease Institute.

Dr. Fullerton says a medication list "is probably the single most helpful piece of information a patient and physician can have because it frequently indicates the active problems the patient has." It's important because of the potential risks of medication interactions and because patients may land in the emergency department, hospital, or a physician's office without a primary care history.

To help avoid those risks and encourage patients to get involved in their own care, Dr. Fullerton and fellow members of the Texas Medical Association Council on Health Care Quality created a medication reconciliation tool with support from the Texas Medical Liability Trust. The tool is the latest in a suite of quality improvement resources the council is developing. (See "Investing in Prevention," June 2013 Texas Medicine, pages 39-42.)

The "Personal Emergency and Medication Record" is a standardized, paper-based form a physician office can use to help patients track their medicines and record their primary care and emergency contacts in one place. Physicians can keep a record on file, patients can fold it up to fit in their wallet, and parents can give it to their children's schools.

"The form is a patient engagement and patient safety tool all in one," said TMA Director for Clinical Quality Joseph Y. Gave.

The tool is free and downloadable from the TMA website.

Getting Patients Involved

Patients' health status can frequently change, and so can their medications, which is why the form has a place for patients to record not only the type of drugs they take, but also the dosage, frequency, and reason.

As with Dr. Fullerton's elderly patient, that last piece of information can be especially helpful in getting patients to comply with doctors' orders if they fully understand why they are taking a drug.

"It turns the focus to the patients and helps keep them at the center of what we are doing," he said. Armed with the information, patients can better evaluate whether they really need a particular pain medication, for example, or remind themselves to discuss their cholesterol at their next primary care visit.

The tool targets any patients taking multiple medications who do not otherwise have a way to track them.

But it particularly can benefit those with chronic conditions, whose health status can frequently change and for whom a drug regimen is critical to improving care, says San Antonio infectious disease specialist Jan Ellen Patterson, MD, also a member of TMA's Council on Health Care Quality. Patients receive a similar form upon discharge from the hospitals and veterans clinics affiliated with The University of Texas Health Science Center at San Antonio, where she is associate dean for quality and lifelong learning.

"This helps patients become more literate about their own health, and a lack of health literacy is very expensive," she said. "If people don't understand why they are taking a medication and the dose, they end up coming back [to the hospital] within 30 days of leaving, and care becomes inefficient and expensive. That's especially true for patients with chronic conditions like heart and lung disease, who are at high risk" for complications.

Such a tool can also better equip physicians to manage their patients' care and foster patient safety.

More often than not, patients show up in the emergency department or are admitted to the hospital without a record of the medications they take. If a patient's medications change upon release, "that information doesn't always get back to the primary care physician," Dr. Patterson said, adding that a written list of patients' current medications could prevent that information from falling through the cracks and help avoid unintended drug interactions.

On top of that, some medications have multiple purposes. Wellbutrin (bupropion), for instance, can be prescribed for depression or for smoking cessation, so physicians might think a patient is depressed, when he or she is trying to quit smoking. Certain seizure medications can be used to treat chronic pain.

Knowing why a patient is taking a particular drug "can make a big difference in how you manage that patient," Dr. Fullerton said.

Filling the Gaps

While the form is designed largely for practices that rely on a paper-based chart system, even those using EMRs can benefit.

Unless practices are hooked up to a formal health information exchange, such as through a medical home collaborative or accountable care organization (ACO), the digital records can't "talk" to each other, i.e., share information among different practices or hospitals.

Dr. Fullerton uses his EMR to record his patients' medications. But if a patient seeks care from a specialist, such as a cardiologist or a surgeon, that specialist can't see his notes.

Nor is communication among various care settings completely streamlined.

Patients may see a subspecialist without notifying the physician of their current medications or without alerting their primary care physician to any additional prescriptions, for example. Ideally, the subspecialist writes a letter to the primary care physician explaining the treatment, Dr. Patterson says. But if that particular primary care physician did not refer the patient, he or she may not get that notice.

TMA leaders emphasize the importance of having patients regularly update the medication reconciliation form. Doses may change, for example. And physicians may have a record in the chart of what they prescribed, but patients may not actually be taking that drug if they didn't follow through on filling a prescription or if the pharmacy filled the order with something else.

Dr. Patterson also recommends doctors instruct patients to record any nonprescription drugs they use, as well. These days, more patients are taking herbs and vitamins, for instance, "which can interfere with certain medications, and patients don't always think about those being important to mention."

The tool also can help prepare physician practices for a health care system moving toward population-based health care, which requires not only increased care coordination and patient involvement, but also physician engagement, Dr. Fullerton says.

HealthTexas physicians used a similar paper-based form before adopting an EMR system and before becoming a recognized medical home.

"One idea behind the medical home and ACOs is [patient] self-management, and [medication reconciliation] is a step along the way," he said. In addition, "care coordination is a lot of things, but part of it is knowing more about your patients when they walk in that door, and this [tool] provides that additional information."

Whereas traditional medical training largely taught physicians to diagnose a problem, give patients a recommendation, and send them on their way, Dr. Fullerton says physicians now have a greater role in helping patients engage in their own care.

A study published in May in the Journal of the American Medical Association highlights a number of patient behaviors and barriers that contribute to medication noncompliance. For example, patients may not understand the relevance of medication adherence to their continued health and well-being; they conclude the benefits of taking medications do not outweigh the costs; the complexity of medication management can be challenging or patients are not vigilant enough; or patients do not perceive medications to be effective.

"We're now beginning to understand there are a multitude of reasons why patients are not following through [on their care], whether they forgot or didn't understand," Dr. Fullerton said. "Physicians do care about patients and this is another tool to help them." 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.  

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