Prescribing of new medications

Implementation of a pharmacy technician centered medication reconciliation program at an urban teaching medical center Sanchita Sen, Laura Siemianowski, Michelle Murphy, and Susan Coutinho McAllister Prescribing of new medications and adjustments of existing outpatient medication regimens occur frequently in patients admitted to the hospital. Such fluctuations in medication regimens place patients at high risk for unintentional medication errors and subsequent adverse drug events (ADEs). 1 Reported rates of inpatient medication errors have ranged from 45% to 76%, 2-9 with most errors occurring on admission 2,3 due to inaccuracies in medication histories and reconciliation. 1,2,4 Since these inaccuracies have been associated with ADEs, the Joint Commission has designated inpatient medication reconciliation (MR) as a National Patient Safety Goal since 2005. 10 MR is defined as the process of compiling the most accurate medication list for a patient and providing the correct medications for the patient anywhere within the health care system using this list. 11 Despite experimentation with various approaches, there have been significant difficulties Purpose. An inpatient medication reconciliation (MR) program emphasizing pharmacy technicians role in the MR process is described. Summary. As part of quality-improvement (QI) efforts focused on MR-related adverse drug events, an urban academic medical center in New Jersey implemented a pharmacy technician centered MR (PTMR) program targeting patients on its internal medicine, oncology, and clinical decision units. The program is staffed by five full- or part-time technicians who are trained in MR methods and work under direct pharmacist supervision, interviewing newly admitted patients and using other information sources (e.g., community pharmacies, physician offices, nursing facilities) to compile an accurate and complete medication list. About 30% of all patients admitted to the hospital are served by the PTMR program, which averages more than 500 cases each month. During one three-month in determining the most optimal method for performing MR. 10 Pharmacy-led MR processes have been shown to significantly decrease period, 1748 discrepancies on preadmission medication lists were identified, most of which involved the omission of drugs (65.7% of cases) and incorrect information on dose and frequency of use (14.4%). Efforts to overcome resource constraints and other program challenges (e.g., privacy concerns, delays in community pharmacy transmittal of prescription refill lists) are ongoing. To date, most research on PTMR has been conducted in emergency departments or perioperative settings; experience with the PTMR program suggests that this approach can be applied in other hospital areas to improve MR processes and, ultimately, enhance pharmacotherapy safety and effectiveness across transitions of care. Conclusion. Based on experience, providers perspectives, and QI data, the PTMR program is an effective method to obtain, document, and communicate accurate MR data for patients at this institution. Am J Health-Syst Pharm. 2014; 71:51-6 the rate of medication errors. 5-8,12-17 More specifically, it has been identified that relative to other MR processes, a pharmacy-led process signifi- Sanchita Sen, Pharm.D., BCPS, is Clinical Pharmacy Specialist Internal Medicine and Assistant Professor of Clinical Pharmacy; and Laura Siemianowski, Pharm.D., is Postgraduate Year 2 Critical Care Resident and Clinical Instructor of Pharmacy, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, PA. Susan Coutinho McAllister, M.D., is Director of Quality, Division of Hospital Medicine, and Assistant Professor of Medicine, Cooper Medical School of Rowan University, Camden, NJ. Michelle Murphy, Pharm.D., BCPS, is Pharmacist, Cooper University Hospital, Camden, NJ. Address correspondence to Dr. Sen (s.sen@usp.edu). The authors have declared no potential conflicts of interest. Copyright 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0101-0051$06.00. DOI 10.2146/ajhp130073 Am J Health-Syst Pharm Vol 71 Jan 1, 2014 51

cantly decreases medication-related readmissions, the number of inappropriately prescribed medications at hospital discharge, and the number of missed doses during hospital stays. 5,7,8,12,14 Such processes, however, have not been shown to decrease hospital length of stay. 12 Most studies investigating pharmacy involvement in MR have described pharmacist-acquired medication histories and reconciliation. Most have targeted patients at high risk for medication errors 7,14 in very specific hospital settings or locations. 5,7,12 In one study conducted in the perioperative setting, the rate of medication discrepancies and the number of missed doses during patients hospital stays were significantly reduced when MR tasks were performed by pharmacists instead of physicians. 12 In the emergency department (ED) setting, pharmacist-conducted MR has been shown to significantly decrease the rate of medication discrepancies. 5,7 In a study involving a general medicine population, medication discrepancies were significantly decreased through the use of pharmacist-led MR rather than a nurse-driven process. 1 Multiple studies have shown that pharmacists are effective at decreasing medication errors. 1,5-8,12-14 However, issues of availability and cost associated with implementing an additional role for pharmacists leave many hospitals without the capability to ensure that medication-related problems are promptly identified and resolved through a pharmacydriven MR process. In recent years, the involvement of pharmacy technicians in efforts to provide accurate MR has been discussed, but few studies have investigated its value. Some evidence suggests that technicians, with minimal pharmacist supervision, can play a role in performing MR in the ED and in the perioperative setting, potentially reducing medication errors by more than half. 15-17 A pharmacy technician centered MR (PTMR) program, directly supervised by a pharmacist, is an important innovation and provides the pharmacist with the opportunity to resolve errors by making clinical interventions through direct communication with physicians. A PTMR program with full pharmacist supervision was implemented at Cooper University Hospital (CUH) in January 2011. This article describes the components of the PTMR program, including the development of tools and the training of staff. A synopsis of qualityimprovement (QI) data is also included to quantify the program s impact. Since those data are collected daily as a QI measure, the CUH institutional review board waived the review process. Background CUH is a 550-bed urban academic medical center located in Camden, New Jersey. Over 700 physicians in more than 75 specialties practice within the CUH health system. The pharmacy department is structured under a hybrid model using teams of centralized and decentralized pharmacists comprising staff, patient care, and clinical pharmacists. The department consists of over 90 pharmacy employees, including 32 pharmacist full-time equivalents (FTEs), 27 pharmacy technician FTEs, and management staff. Dispensing pharmacy service is provided 24 hours a day, seven days a week. Staff pharmacist responsibilities include all routine clinical functions such as assessing and verifying medication orders, providing drug information, and education. Patient care and clinical pharmacists provide direct patient care services, drug level monitoring, clinical support, and protocol development. Technician responsibilities include medication filling, delivery, and inventory control. Prior to 2011, MR was a multidisciplinary process, in which preadmission medication histories were obtained by physicians and nurses in the ED or inpatient units and directly documented in the electronic health record (EHR). Oftentimes, medication verification and reconciliation did not involve the utilization of objective data sources such as retail pharmacies and physician practices. This resulted in incomplete, outdated, and inaccurate medication lists, which led to inaccurate continuation, discontinuation, and modification of outpatient medications while the patient was hospitalized. The PTMR program was an offshoot of the hospital s transition to an EHR system. In September 2009, CUH converted from a paper chart with computerized physician order entry to an EHR. After some experience with the newly implemented EHR and an informal chart review, it was identified that patient-reported preadmission medication lists were not verified appropriately and, consequently, patients were being discharged with inaccurate medication lists. With the EHR serving as the central location for patient information, inconsistent and unreliable entry of preadmission medications was an unacceptable practice. After this information was presented to administrators at CUH, it was determined that the process of admission MR required significant improvement. As a result of these findings, the institution financially supported a high-quality, cost-effective model for MR. This new MR model incorporates pharmacy technicians working under pharmacist supervision. Since CUH is a participant in the Centers for Medicare and Medicaid Services EHR Incentive Program to improve patient care, optimizing the EHR was an institutional goal. The PTMR program was designed to utilize the EHR to capture a single medication list, shared by all disciplines, for documenting the patient s current medications. The new PTMR model was designed and implemented by a team 52 Am J Health-Syst Pharm Vol 71 Jan 1, 2014

of two pharmacists and one physician (the development team). Although the physician had been involved in prior QI initiatives throughout the hospital, neither of the pharmacists had experience in developing a new program. Both pharmacists had an interest and experience in transitionsof-care projects, including MR. Program components and operation In January 2011, the PTMR program was launched. One newly hired full-time pharmacy technician and one pharmacist started the process. The program has since been expanded to include three full-time and two part-time technicians, who are supervised by one or two pharmacists. The MR staff currently works Monday through Friday from 7:00 a.m. to 3:30 p.m. The program serves all patients admitted and transferred to the internal medicine, oncology, and clinical decision unit (CDU) services within 72 hours. The internal medicine service consists of 10 teams, each of which cares for up to 15 patients per day. The CDU is a 20-bed post- ED unit with rapid turnover where inpatient admission and discharge determinations are made. Finally, the oncology service provides care for up to 15 patients per day. The PTMR process is a structured and standardized process that is continuously evaluated and improved. Currently, patients are assigned to pharmacy technicians by clinical service according to acuity level and logistics considerations. Each morning, the technicians print their respective patient lists, document the preadmission medications obtained from the EHR on an MR form (appendix), and review patient information in preparation for the patient interview. Next, the technicians interview each patient to obtain a list of home prescriptions, nonprescription medications, nutritional supplements, and allergy information. In addition, the technician inquires about the patient s outpatient pharmacies (community and mail-order pharmacies) and obtains health care provider information (name, phone number, address). After the patient interview, the technician is responsible for calling the appropriate pharmacies, physician offices, and skilled-nursing or long-term care facilities to verify all outpatient medication information (e.g., name, dose, schedule, last refill). Technicians compare this finalized list with the patient-reported list and the preadmission list in the EHR and reconcile any discrepancies. The resulting updated preadmission list is manually documented on the MR form, updated in the EHR by the technician, and handed off to the MR pharmacist. The pharmacist is available during the technician interview and reconciliation process to address questions or concerns that may arise. The MR pharmacist uses information from the MR form, the updated preadmission medication list, and any additional discussion with the technician to document an MR pharmacy note in the patient s EHR. This note is viewable by all CUH-affiliated health care providers who access the EHR; in the event of urgent clinical issues, the pharmacist orally communicates recommendations to the physicians. To retain patient confidentiality, all completed MR sheets are kept in locked cabinets accessible only by MR pharmacists and technicians. Depending on the complexity of a patient case, the full MR process can range from 30 minutes to several days. On average, it takes the MR technician 30 40 minutes per patient to complete the medication history interview, verify the interview information, and make the appropriate changes to the electronic preadmission medication list. As part of the QI process, pharmacists also document the quantity and types of medication discrepancies on the MR form. Types of medication discrepancies are categorized as follows: medication omission, error of commission (i.e., a medication that the patient was not on prior to admission is prescribed due to incorrect information), incorrect dose or frequency, incorrect formulation, ordering of nonformulary medications, accurate allergy information missing, duplicate therapy, and drug drug interaction. MR procedures and tools. The successful initiation and implementation of the PTMR program required four major components: the development of program tools, utilization of technicians in the MR process, training of pharmacists in their MR role, and staff education. The development team created the tools for the PTMR program, which include an MR form, training manuals for pharmacy technicians and pharmacists, an electronic Medication Reconciliation Pharmacist progress note template for the EHR, and materials for onsite education for all health care providers. Currently, the technicians use the MR form to document all the appropriate information, and pharmacists assist them in completing the reconciliation process. A manual was developed to assist in the training process and is provided to each of the technicians and pharmacists during training. This manual outlines the steps of appropriate MR, the roles of MR technicians and pharmacists, the process for identifying patients who are at a higher risk for medication errors, and guidelines for formulary conversions, including appropriate dose equivalents. Materials to improve the training manual are added as needed. Pharmacists started documenting a standardized MR progress note in the EHR three months after the PTMR program was implemented. The MR progress note template the first pharmacy note added to the EHR at CUH mimics the format of the MR form, providing clinicians with all the information gathered Am J Health-Syst Pharm Vol 71 Jan 1, 2014 53

during the MR process, as well as the MR pharmacist s recommendations and contact telephone number. Finally, formal PTMR program didactic materials were created to provide onsite education for health care providers as appropriate. Didactic training focuses on the PTMR process and the roles of the multidisciplinary team in making the program successful. Clinicians are educated on the importance of documenting an accurate preadmission medication list in order to ensure the accuracy of inpatient medication orders and the discharge medication list. Members of the development team demonstrate how to best utilize the electronic MR pharmacist note and where to find PTMR staff contact information. The didactic materials were created by the development team and reviewed by the pharmacy director and chief of medicine. Pharmacy technician training. Pharmacists, pharmacy management, and physicians formally interview all MR technicians during the hiring process. The interview consists of standardized open-ended and case-based questions developed by the pharmacists on the development team; the desired technician skills include strong communication, attention to detail, self-motivation, and hospital work experience. In addition, the interviewers have discovered that retail pharmacy experience contributes to strong communication skills and an increased knowledge of commonly prescribed outpatient medications. The training process for all MR technicians involves one-on-one supervision by an MR technician mentor. The first technician to serve in that role was trained by the lead MR pharmacist. Training begins with a two-day orientation to the MR program and EHR computer training with the MR pharmacist. For the remainder of the first month of training, the technician participates in role observation, responsibilities and procedures review, and instruction in patient interview techniques and EHR documentation. It is at the discretion of the mentoring MR technician and the MR pharmacist to decide when the new technician is competent to work independently. Pharmacist training. As a developer of the PTMR program, the lead MR pharmacist serves an additional key role by training all pharmacists new to the PTMR process. Currently, all staff pharmacists are undergoing training in PTMR procedures in order to ensure adequate pharmacist supervision; most have completed the two-week training program, which includes studying the training manual, observing the MR pharmacist role, documenting an MR progress note in the EHR, and communicating recommendations to the clinicians when appropriate. The pharmacist-in-training initially performs these roles with supervision and then, when deemed competent by the mentoring MR pharmacist, independently. Staff education. During the first year of the program, there were monthly meetings between the pharmacists and physicians to discuss concerns and progress. The first of those meetings included formal didactic instruction delivered by the development team. Patient care and clinical pharmacists were educated on how to discuss MR recommendations with CUH medical residents and provide ad hoc small-group or individual reeducation about the program as needed. Members of the hospital administration and nurses were also educated through formal and informal processes. The development team continues to provide an annual didactic program for medical residents and attending physicians who are new to the hospital. Additional education is provided as requested by clinicians. Experience with the program A retrospective review of information on patients who received PTMR services between August 2011 and August 2012 was performed in order to determine the number of MRs per month. The number of MRs completed in August 2011 was 433; that figure increased to 710 in August 2012, with a yearly average of 522 MRs per month. Additionally, specific types of discrepancies were quantified for the period June August 2012. A total of 1748 medication discrepancies were identified in 1797 MR encounters during that period. The most frequent type of discrepancy was medication omission (65.7% of encounters). The omission rate far exceeded the rates of other types of discrepancies identified: incorrect dose or frequency (14.4%), ordering of nonformulary medications (10.9%), errors of commission (3.9%), incorrect formulation (2.7%), missing allergy information (1%), duplicate therapy (0.7%), and drug drug interactions (0.5%). MR pharmacists and technicians were surveyed with a written questionnaire on their perspective of the PTMR program. Physicians were also informally surveyed for their thoughts and perceptions. The surveyed technicians stated that most hospital pharmacy technicians traditionally have minimal patient contact and interaction, but all indicated that as MR technicians, they felt relieved of repetitive filling responsibilities and were able to provide patients with a higher, more personal level of care. MR pharmacists expressed that the PTMR program shifts a hospital pharmacist s thought process from focusing on current inpatient medical decisions to thinking about the integration and connection between a hospital stay and the patient s care as an outpatient. They expressed their view that the program bridges the care between the inpatient and outpatient realms of pharmacy and physician services. All of the MR pharmacists agreed that they serve 54 Am J Health-Syst Pharm Vol 71 Jan 1, 2014

as a valuable resource to the medical team by providing recommendations to optimize medication regimens through MR interventions. Internal medicine residents and attending physicians were informally surveyed about the PTMR program. The surveyed residents felt that the program was helpful and allowed them to focus on patient care activities other than the time-consuming medication history-taking process. Attending physicians who were surveyed indicated that they appreciated the time saved and that the program enhanced their patients experiences by improving the quality of bedside care, improved their own efficiency in delivering high-quality outcomes by enabling the use of electronic MR information across care transitions, and changed the culture between pharmacists and physicians at CUH to one of collaboration. Discussion The optimal process for MR in a health care system has not been determined, but MR is necessary for appropriate patient care. Historically, nurses and medical residents at CUH performed MR; the PTMR program was developed as a processimprovement initiative. Currently, the program serves about 30% of patients admitted to CUH. An average of 522 MRs per month are completed by three fulltime and two part-time pharmacy technicians supervised by one or two pharmacists. A total of 1748 medication discrepancies in 1797 patient cases were identified over a threemonth period, and 65.7% of those discrepancies involved medication omissions. This finding is consistent with published study data indicating that, when medication histories were obtained by a pharmacist, 60% of medication discrepancies identified involved omissions. 1 The reasons for the high frequency of medication discrepancies identified through MR initiatives are multifactorial and complex. Within the current structure of the U.S. health care system, obtaining an accurate medication history is very difficult due to the numerous avenues by which patients obtain medications. Inpatient practitioners are concerned with primary acute medical conditions and may not assess the appropriateness of individual medications within the patient s complete list of medications and supplements. This can ultimately lead to inaccurate medication lists upon discharge from the hospital. Inadequate time dedicated to taking medication histories, inadequate communication among health care providers, incomplete information, and poor health literacy further add to the increased risk of discrepancies. 15,16 Several outpatient health care providers may prescribe particular medications for a patient, but all providers may not take action to ensure each medication s appropriateness within the patient s entire drug regimen; this may contribute to the lengthy medication lists compiled for some patients. Outpatient pharmacists review the appropriateness of a single or a set of prescriptions for a patient, but they may not review or even have access to the patient s entire medication profile, especially in the setting of polypharmacy. The PTMR program at CUH focuses its efforts on obtaining the most accurate medication list by using a variety of sources, including direct patient interviews, outpatient health care providers, long-term care facilities, and pharmacies. The PTMR program has been widely accepted and utilized among the services it currently covers, and it is in demand by other disciplines. Despite the program s successes, there were many challenges during the implementation process. Due to the thorough process involved in conducting a single MR episode, technicians and pharmacists must be specifically trained for the PTMR program; initially, that required significant time, effort, and the development of a standardized process. Another challenge for the PTMR program was the high volume of calls to retail pharmacies that were needed to verify medication lists. There was initial resistance from local pharmacies. In an effort to decrease the number of calls to outpatient pharmacies, the pharmacy created a written agreement that pharmacies contacted during the MR process are asked to sign. The agreement cites the federal rule authorizing consultations between health care providers regarding a patient as necessary for patient treatment (the HIPAA Privacy Rule, 45 CFR 164.501, promulgated under the Health Insurance Portability and Accountability Act of 1996). Most local pharmacies have agreed to fax medication-refill histories when requested to do so. Typically, technicians receive medication lists from retail pharmacies immediately upon request, but there can be delays of up to 24 hours in certain circumstances. To mitigate this issue and to increase efficiency, efforts are underway to obtain software for the secure storage of medication information for patients with certain types of health insurance that is received from retail pharmacies. The most encouraging aspect of this program is that almost all of the disciplines in the hospital (e.g., surgery, cardiology, pediatrics) are now insisting that PTMR services be provided for their patients. The goal is to eventually provide hospitalwide daily coverage; however, that is not possible with current program resources. The biggest barriers faced are (1) a lack of funding to enable consistent participation by a second MR pharmacist and (2) suboptimal interaction with some retail pharmacies that do not have the staff to provide appropriate medication information for patients served by the PTMR program. The development team continues to brainstorm methods to overcome these barriers Am J Health-Syst Pharm Vol 71 Jan 1, 2014 55

in order to move toward full coverage of the hospital. At the time of writing, CUH was moving forward with plans to provide PTMR services to the cardiology service. Conclusion Based on experience, providers perspectives, and QI data, the PTMR program is an effective method to obtain, document, and communicate accurate MR data for patients at this institution. References 1. Pippins JR, Gandhi TK, Hamann C et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008; 23:1414-22. 2. Bell CM, Brener SS, Gunraj N et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011; 306:840-7. 3. Cornish PL, Knowles SR, Marchesano R et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005; 165:424-9. 4. Snyder AM, Klinker K, Orrick JJ et al. An in-depth analysis of medication errors in hospitalized patients with HIV. Ann Pharmacother. 2011; 45:459-68. 5. Vasileff HM, Whitten LE, Pink JA et al. The effect of medication errors of pharmacists charting medication in an emergency department. Pharm World Sci. 2009; 31:373-9. 6. Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admission. Emerg Med J. 2010; 27:911-45. 7. Hellstrom LM, Bondesson A, Hoglund P et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011; 67:741-52. 8. Walker PC, Bernstein SJ, Tucker Jones JN et al. Impact of a pharmacist-facilitated hospital discharge program. Arch Intern Med. 2009; 169:2003-10. 9. Feldman LS, Costa LL, Feroli R et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012; 7:396-401. 10. Joint Commission. 2011 hospitals National Patient Safety Goals. www.joint commission.org/assets/1/18/2011-2012_ NPSG_Presentation_FINAL_8-4-11.pdf (accessed 2011 Nov 7). 11. Resar R, for the Institute for Healthcare Improvement. Medication reconciliation review. www.p4communitycare.org/ media/files/medicationreconciliation review_luthermidelfort.pdf (accessed 2012 Nov 13). 12. Marotti SB, Kerridge RK, Grimer MD. A randomized controlled trial of pharmacist medication histories and supplementary prescribing on medication errors in postoperative medication. Anaesth Intensive Care. 2011; 39:1064-70. Appendix Condensed version of Cooper University Hospital medication reconciliation form a Patient Name: MRN: Room: Admit Date: Admission Medication Reconciliation PATIENT INTERVIEW 13. Eggink RN, Lenderink AW, Widdershoven JW et al. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure. Pharm World Sci. 2010; 32:759-66. 14. Lisby M, Thomsen A, Nielsen LP et al. The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine. Basic Clin Pharmacol Toxicol. 2010; 106:422-7. 15. Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health-Syst Pharm. 2003; 60:1982-6. 16. Van Den Bemt P, van Den Broek S, van Nunen AK et al. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. Ann Pharmacother. 2009; 43:868-74. 17. Johnston R, Saulnier L, Gould O. Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists. Can J Hosp Pharm. 2010; 63:359-65. NKDA/Allergies (Reaction): Pharmacy Name: Pharmacy Location: Phone #: Primary Physician (PCP): Physician Location: Phone #: Verified by Medication Dose Route Frequency Current order RPh Reconciling Patient/ Name in EPIC b Notes Family/ Physician/ Pharmacy a MRN = medical record number, NKDA = no known drug allergies, PCP = primary care physician. b Pharmacy information system (manufactured by Epic Systems Corporation, Verona, WI). 56 Am J Health-Syst Pharm Vol 71 Jan 1, 2014