Hospital Experiences Using EHRs to Support Medication

Transcription

1 Hospital Experiences Using EHRs to Support Medication Reconciliation Presentation for Academy Health Annual Research Meeting San Diego, CA June 9, 2014 Dori Cross Rebecca Gourevitch Joy Grossman, PhD Center for Studying Health System Change/ Mathematica Policy Research

2 Medication Reconciliation to Improve Care Transitions Medication discrepancies/errors common at hospital admission and discharge Absence of a gold standard medication list Poor information flow across care settings Difficult to implement standardized process for medication review upon admission/transfer/ discharge Increasing regulatory and political pressure to focus on medication reconciliation (med rec) The Joint Commission, Medicare reforms (Readmission penalties, ACOs) IT-specific: Meaningful Use Stage 2

3 What is Medication Reconciliation? Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. (Joint Commission 2005) Our working definition: 1) Develop best-possible pre-admission medication list (PAML) 2) Use PAML to write new medication orders at admission and discharge, resolving unintended discrepancies 3) Share new medication list with patient/family and next providers of care Hospitals have struggled with this process (Greenwald et al., 2010) Definitional disagreements Complicated workflows Lack of physician engagement

4 Study Motivation : IT to Support Med Rec IT has potential to address barriers to med rec practices relative to use of paper: Pre-admission Access to external medication list information sources (PAML) Linked processes (med hx, inpatient ordering, discharge planning) reduce retyping, opportunity for error Inpatient Medication Yet, limited research on List experiences using most recent commercial EHR products to support med rec Discharge Medication List

5 Research Questions How are hospitals with EHRs implementing medication reconciliation at admission i and discharge? How do EHRs address barriers to medication reconciliation? What are the challenges to using EHRs? What are the implications for efforts to promote medication reconciliation?

6 Research Design 36 telephone interviews conducted January-June hospitals/health systems across 10 (of 12) Community Tracking Study sites with highest EHR adoption minute interviews with: Hospital administration responsible for implementation Clinical users (physicians, NPs, nurses, pharmacists) Semi-structured interview protocols

7 Study Sites Seattle, WA Syracuse, NY Boston, MA Detroit, MI Indianapolis, IN Cleveland, OH Orange County, CA Little Rock, AR Phoenix, AZ G Greenville, ill SC Study conducted in the ten Community Track Study sites with the most EHR adoption. Twelve CTS sites were selected to be nationally representative of metropolitan areas with population >200,000.

8 Hospitals Vary By Size; EHR Vendor Mostly large, multisite health systems 2/3 teaching hospitals 15/19 achieved Stage 1 MU 1/2 using CPOE 3 years NUMBER OF HOSPITALS/HEALTH SYSTEMS (N=19) ELECTRONIC HEALTH RECORD VENDOR Epic 6 Cerner 4 AllScripts 3 Siemans 2 Internally-developed 2 MediTech 1 McKesson 1

9 Findings: Hospital IT Systems in Flux EHR capabilities to facilitate med rec processes highly varied Many hospitals awaiting product upgrades, EHR vendor changes Different implementation practices, customizations 1/3 of hospitals still supplementing med rec with 1/3 of hospitals still supplementing med rec with paper processes

10 E-Medication Reconciliation: Benefits Stage of Med Rec Creating the PAML Inpatient Medication List (IML) Discharge Medication List & Instructions Perceived EHR Benefits (1) Increased access to sources of medication history (2) Use of structured/codified fields (1) Direct conversion to inpatient orders (w/tools for formulary/route of administration changes) (2) Increased process compliance as part of workflow (1) Pulls PAML and IML in to discharge med rec module (2) Electronic DML facilitates: - E-prescribing - Communication to next provider of care - Generating patient-friendly instructions - Direct import into discharge summary

11 E-Medication Reconciliation: Challenges (1) Data Issues: Garbage in, garbage out At one time, we did give all staff access to...[our affiliated practices ambulatory] EHR but there was a lot of junk in there. Their [medication] lists were not clean or up to date everyone lost faith in it, so no one looks at it anymore.

12 E-Medication Reconciliation: Challenges (2) Technical Limitations: Outdated systems Interface design not matched to provider cognitive processing Echo effect ; Challenges with deduplication Difficult to enter/convert complicated medications i From a standards perspective there has to be an easy way to pull in structured data about medications.. without asking the physician to click six or seven times and re-enter dose, frequency, route and diagnosis. [With] a more standard way to make the sharing of that information consistent across platforms...that will bring us closer to having consistently accurate patient medication i lists.

13 E-Medication Reconciliation: Challenges (3) Workflows/Workarounds Non linear processes Difficult to impose standardized workflow, forced completion Use of free text fields Use of paper I did an audit of 100 reconciliations... About half had handwritten annotations that actually changed the content of the medication reconciliation, which to me means either the nurse or the doctor decided it was too cumbersome to keep a correct list in the computer... For some, the doctor just did the entire reconciliation on paper, p not at all in the system. That could be [lack of clinician] education, could be resistance

14 E-Medication Reconciliation: Challenges (4) Communication to patient, follow-up care provider Errors during med rec lead to confusing and/or incorrect patient t instructions Opportunities for hospital discharge summary patient discharge documents discharge documentation to follow-up care provider If you discontinue duplications or do anything to clean the list up, it automatically shows up on the patient s report. Then, the nurse has to go through and explain to the patient to not pay attention to several of the listings in their discharge instructions because they were the result of cleaning out junk.. It s because of how staff have to maintain the list that makes it confusing to the patient.

15 Policy/Practice Implications Increase quality of pre-admission medication lists Potential improvement with widespread EHR/HIE adoption Expedite federal-industry efforts on technical standards to support automated reconciliation of third-party data Address who is responsible for managing g medication list Enhance system design Support design research, usability studies, development of best practices across vendors (e.g. patient-friendly medication lists) Facilitate providing feedback from users to vendors More assessment of best practices Targeted hospital customization and user education/training

16 Study Limitations Qualitative results not statistically representative Respondent bias (large health systems, IT champions/super users, high-end EHRs) may under- represent challenges Substantial variation within systems across hospitals, within hospitals across units and among clinicians Can t measure impact on outcomes

17 Funding Acknowledgement This project was funded by the National Institute for Health Care Reform. The Institute is a 501(c)(3) ) nonprofit, nonpartisan organization established by the International Union, UAW; Chrysler Group LLC; Ford Motor Company; and General Motors. Questions? dacross@umich.edu Forthcoming Paper: Grossman, Joy M., Rebecca Gourevitch and Dori A. Cross. Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation, NIHCR Research Bi Brief fno. 17, National Institute for Health Care Reform, Washington, D.C. (forthcoming).