Using a Health Information Exchange (HIE), clinicians across multidisciplinary care teams can access a patient’s medications, reconcile the list and monitor their progress, thereby reducing medication errors and future costs from preventable hospital admissions.
Multiple factors combine to make the prescribing, supplying and taking of medications a perilous and costly issue for patients and the healthcare sector. Prescription medication use is by far the most common health intervention. Unsurprisingly, medication errors are also common.
According to the Agency for Healthcare Research and Quality (AHRQ), a medication error may occur at any point in the medication management process. The process begins when a clinician prescribes a medication, continues while the patient receives the medication and ends when the patient has completed the prescribed supply of medication.
Ongoing monitoring of the patient and their medication experience is essential in all but the most trivial of circumstances. Most medication pathways rely on sound communication between providers to ensure the pathway is followed and errors are avoided. Even so, medication errors are common and may cause unnecessary patient harm, hospitalization, and even fatality.
An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication. ADEs have multiple causes including medication errors, drug and allergic reactions, and overdoses. Adverse drug events are not necessarily an indication of clinician error. For instance, a patient developing a cough while taking an ACE inhibitor for the first time is experiencing an ADE, however, if the patient was prescribed the medication for a sound clinical reason, it may not represent a medication error. The Office of Disease Prevention and Health Promotion estimates the rate of ADEs is 2 million per year in the United States. Most experts agree that about half of all ADEs are preventable.
Terms Relevant to Drug-Related Harm
Between 5 and 10 percent of hospital admissions in the U.S. are medication-related. The general consensus is that ADEs are more likely to occur during transitions of care, such as discharge from the hospital. At points of transition, it is common for information not to be transferred accurately and completely. It is estimated that ADEs comprise one-third of hospital adverse events, affect approximately 2 million hospital stays annually and prolong hospital length of stay by between 1.7 to 4.6 days. Surveillance data indicate that ADEs account for more than 3.5 million physician office visits, 1 million emergency department visits and approximately 125,000 hospital admissions each year.
Care Coordination and Medication Management
With respect to medications, care coordination focuses on the organization and sharing of medication information between the different roles caring for the patient. The circle of care, defined as the group of healthcare providers treating a patient who needs the information to provide that care, is a key component. All caregivers in the circle are entitled to access the patient’s healthcare record, including their medication record as they are all involved in the treatment of the patient and need that information to provide that care.
A mechanism of action transmitting a request for medication-related information between a pharmacist and a family physician helps coordinate the patient’s medication management. Care coordination activities have the potential to be taken for granted and therefore neglected in the design of IT systems.
The cornerstone for successful medication reconciliation is creating the best possible medication list by using a systematic approach based on a patient/carer interview and reviewing all other medication sources such as prescription bottles, discharge medication orders or pharmacy records. Numerous studies have shown that no single source of medication use is fully accurate and reliable, hence the need to use a variety of data sources.
The evidence base supporting the benefits of reconciling medications is poor. While many studies have been performed, they have generally been on small sample sizes with widely varying approaches and definitions. Even so, there is agreement that medication reconciliation should be performed at points of care transition, especially admission and discharge from the hospital.
Medicine reconciliation is considered a strong driver of the interoperability agenda and is a missing link to improving health information exchange. A recent survey of hospitals by the American Hospital Association found a strong correlation between medication reconciliation and interoperability and recommended policymakers focus on the adoption of medication reconciliation to help advance interoperability and health information exchange.
Access to complete information pulled from multiple sources and presented in a concise way is an essential part of all medication management. Electronically available information can supplement and help interpret the medication history taken from the patient. This should include information from electronic medical records (EMRs), pharmacies and claims data, as well as patient, contributed information via systems like patient portals.
There is a process to medication management, from the initiation by a prescriber (typically but not always a physician) through to dispensing (typically by a pharmacist), administration (either by a nurse, the patient themselves or a care worker) and ongoing, regular monitoring.
The latest medication list should be identified as such, including the provenance of that medication list, such as who it was performed by, their name and date, and available at all points of care where medications are involved.
The ability to perform medication reconciliation at all points of care with the output of the final medication list is essential. Physicians may prefer to use their EMR while community pharmacists may prefer to use an HIE. The point is that information needs to be messaged between all modalities, hence the concern for interoperability between systems.
It is highly likely that in the future pharmacists will be tasked with an enhanced role in patient care, meaning they will take their rightful place in the patient’s multi-disciplinary care team. Pharmacists will need access to technologies that fully interoperate with both EMRs and regional HIEs. This will enable them to readily access the relevant information drawn from all possible sources so they can more quickly and accurately make decisions based on complete information about the patient. Having medication information available across the circle of care and across the health economy will be essential to improvements to the safety of patients as they are prescribed and use medications across the entire health system.
About the Author
Dr. Chris Hobson, MD MBA is the Chief Medical Officer with Orion Health, a global healthcare platform advancing Population Health Management and Precision Medicine solutions in the health community. He is responsible for the clinical direction of Orion Health products and solutions and ensures the protection of patient safety and privacy in everything Orion Health does.