Medication Reconciliation and Pharmacy Technicians: Utilizing Pharmacy Technicians to Support the Medication Reconciliation Process Organized by the Section of Pharmacy Practice Managers ASHP Webinar Networking Session
Today s Presenters Janinah S. Barreto, PharmD, MS The Ohio State University Medical Center, OH Steve Ebert, Pharm.D. Drea Maier, Pharm.D Meriter Hospital, WI Teri Wooton, Pharm.D. Carolinas Medical Center Northeast, NC
The Joint Commission Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. This process comprises five steps: 1) develop a list of current medications; 2) develop a list of medications to be prescribed; 3) compare the medications on the two lists; 4) make clinical decisions based on the comparison; and 5) communicate the new list to appropriate caregivers and to the patient.
Role of Pharmacy Technician in Medication Reconciliation Janinah S. Barreto, PharmD, MS Medication Safety Pharmacist The Ohio State University Medical Center
The Ohio State University Medical Center Hospitals University Hospital Ross Heart Hospital James Cancer Center University Hospitals East Dodd Rehabilitation Facility 1,000+ beds 56,000+ patient admissions 15,700+ inpatient surgeries 1,000+ admitting physicians
OSUMC s Pre-Operative Assessment Center (OPAC) Simplifies the preoperative process for OSUMC patients Coordinates preoperative needs for the medically complex (ASA 3-4) Provides education for patients prior to surgery Anesthesia, sedation, risks and benefits, before the procedure (bring medications, what and not to wear the day of surgery, what meds to stop taking, diet Coordinates tests and assessments prior to surgery
OPAC Goals Increase patient satisfaction Decrease OR cancellations and delays 100% chart completion day of surgery
OPAC Staff Anesthesiologist and Residents Physician Assistants RN s Medical Assistants Pharmacy Technician
Typical Patient Visit Register for OPAC & Surgery Clinic Visit is ~1 hour and 15 minutes Weight and Vitals History and Physical Anesthesia Assessment & Q&A s Labs, EKG s and Type Screen/Cross Education for day of surgery... Medications, etc Medications Documented in CPOE
Sources of Information for Arrival Medications (i.e. home meds) Patient History Primary Care Physician Record Surgeon s H&P Internal Medicine Consult OSUMC Patient Database Other Outside Records
Medication List Source Documents
Electronic Documentation
Electronic Documentation
Single Visit Patient Home Medication List
Pharmacy Technician s Role 80% of time Review and document patient s arrival medication assuring appropriate dose, route, frequency and duration of therapy Review records for drug-drug interactions, duplication, drug-allergy interactions Assist with arrival medication order entry
Pharmacy Technician s Role 20% of time Cross-trained in IDX Medical records support Phone scheduling Participates in hospital and/or departmental committees relevant to practice area
Pharmacy Technician Qualifications and Role Qualifications CPht Retail Pharmacy Experience Prescription Receiver Refill Experience
Challenges Training/Competencies Limited Scope of Practice Staffing Level Nursing Perception
Future Steps Pilot Study Business Unit QA James Cancer Hospital Ambulatory Surgical Unit Data analysis pre- and post-implementation
Use of Technicians in the Medication Reconciliation Process Steven Ebert, PharmD, Clinical Professor of Pharmacy Clinical Supervisor Andrea Maier, PharmD Clinical Pharmacist Meriter Hospital Madison, WI
Meriter Hospital 448-bed non-profit community hospital 18000 Med-Surg admissions per year 16 pharmacist shifts/24 hours 11 clinical 11 central based technician shifts/24 hours 1000 RNs on staff!
Overview Decision process to utilize technicians Training and QA implemented Management/Road Blocks Implementation/logic Outcomes to date
Medication Reconciliation at Meriter, 2003 Nursing Medication History Patient Profile
Medication Reconciliation at Meriter, 2003 Pre-Admit Medications New Medications
Goals for Our Hospital Create a unified, accurate medication history Reconcile medications at transition points Provide an accurate medication list to patients on discharge
Med Reconciliation at Meriter Discrepancies of Various History Sources Compared to Reconciled Admission Medication List Total Discrepancies Omission Dose Frequency Formulation 350 # Discrepancies 300 250 200 150 100 50 N=50 patients 0 RN History Neville M, 2005 Outpt Rxy Clinic/H&P RPh History MD Admit Orders
History of Pharmacy Effort in Medication Reconciliation at Meriter 2004 RN & MD driven = no pharmacy involvement 2005 2006 9 min/pt 13 min/pt RN history verified & reconciled by RPh RPh enter medication histories into electronic health record 2007 13 min/pt Re-work of histories RPh generate discharge med list electronically 2008 More time spent on admit hx=less time downstream? Admissions Discharges Added ER & Pre-procedure patients
Discharge process Staffing Needs Update medications prior to admission in electronic record Benefit upon readmission, medication list would reflect changes from current admission 3000 hours = 1.5 FTE s Admission process 18000 admissions per year 30 minutes per admission 9000 hours = 4.3 FTE s additional work
Training Process for Technicians Developed formal training program Training sessions MR process overview & technician role Obtaining medication histories Created comprehensive training manual Provides multiple handouts for reference Mock patient interview scenarios Shadow pharmacists in ER Shadow MR technicians Lead technician is essential
Quality Assurance Written knowledge evaluation Multiple choice questionnaire Performance evaluation Pharmacist evaluates patient interview skills Continued evaluation & feedback Daily on-the-job feedback All work is reviewed & verified by a pharmacist
Roadblocks Hiring and retaining quality technicians Retraining RPhs to work with techs in clinical setting Keeping up with continued changes in responsibilities, new processes, etc.
Residency Project 2007 To evaluate whether the use of trained pharmacy technicians to assist pharmacists with MR tasks can: Increase efficiency with the MR process Decrease pharmacist workload Main endpoints Pharmacist time spent on MR tasks Pharmacist satisfaction with the process Measured by pharmacist surveys
Results: RPh Time Spent on Medication Reconciliation Baseline Post-Implementation 15 13 Time (min) 10 5 8.5 6.1 11 Exclusions: ER Shift ICU Shift Central Shift 0 Per Discharge Per Admission
Results: RPh Time Spent on Medication Reconciliation Time (min) 110 90 70 50 30 10-10 28 50.7 MR per shift baseline Projected 104.1 78.7 75.5 49.2 54.9 Admission 35.7 39.8 MR per shift Postimplementation Discharge Average admits per shift reported Baseline: 3.9 Post: 3.6 Average discharges per shift reported Baseline: 3.3 Post: 5.8
Survey Results Percent of RPhs that Agree or Strongly Agree 100 80 Baseline Post-implementation 81.8 77.2 72.7 89.5 100 Percent 60 40 20 5.3 27.3 21 45.5 35.3 0 MR allows time for other tasks MR is efficient MR done in timely manner Comfort with tech on admission Comfort with D/C tech
Results of Post-Implementation Survey "Amount of time spent by RPh on MR activities has decreased" Agree Strongly Agree 27% "Efficiency of MR process has improved" Agree Strongly Agree 73% 18% 100% either agree or strongly agree to both statements 82%
Progress to Date 4 FTE s 3 technician shifts M-F, 2 shifts Sat-Sun Duties: Discharge medication lists Medication histories Update medication allergies Manage medications brought in by patient and stored in pharmacy
Daily Pharmacy Workload Related to Med Reconciliation Obtain Hx Verify Hx PTA in Elect Record Tech Disch List RPh Check Disch List 7000 6000 Minutes/Day 5000 4000 3000 2000 1000 0 Pre-2005 Enter Inpt Med Hx into Epic- 2006 Admit and Discharge- Inpt/Cath/Amb Surg- 2008? Hx, Admit, Disch- Inpt/Cath/Amb Surg/OB/ER- 2009
Conclusion Incorporation of pharmacy technicians into MR process: Increases pharmacist satisfaction Pharmacists feel process is more efficient Decreases average pharmacist time spent per admission and discharge Allows for expanded pharmacy involvement in MR on a greater number of patients
Pharmacy Technicians in the Emergency Care Center Carolinas Medical Center Teri Wooton, PharmD, CDE Director of Pharmacy Services
Background Feb 07 JC Mock Survey with RFI for Med Rec & Pharmacy review of orders Mar 07 need for FTEs presented to Sr. Administration Apr 07 8 unbudgeted FTEs approved to fill for Pharmacy Services in ECC Jun 07 3 Pharmacists hired Sep 07 Technician selection begins
Technician Selection Formal interview process 1-2 days shadowing ECC Pharmacist Good communication skills Experience in pharmacy Good problem solving skills Able to withstand the environment
Background reading Technician Training 3 page competency checklist Observe pharmacist x 10 interviews Perform supervised interviews x 10 patients Pharmacist signs off competency
A day in the life Current hours 12:30PM 9:00PM 7 days/week Check status board for admission icon Collect med lists from various sources Perform patient interview Document current med list in computer Print out med rec list Review with Pharmacist Put list on chart for admitting MD to sign
A day in the life - continued Repeat x 15-20 patients Continue til 6:30PM 30 minute dinner break 7PM review the board with pharmacist 1-3 more patient interviews Retrieve Omnicell replenishment from Central Pharmacy Restock Omnicell cabinets Go Home
Overall Success Pharmacists couldn t do their job without them Review of orders Code participation C&S review MD Consults Tech career ladder, increased job satisfaction Positive feedback from MDs/RNs Minimized workload for admitting RN Assist with retrieval of stats
Lessons Learned Involve ECC staff in design of program Cross-train techs with central staff but maintain consistent core Must have a People person Constant opportunity to evaluate techs performance Standardized documentation methods Manage expectations
Future Plans Nov 08 expanded hours Tech: 7AM to 11PM Pharmacist: 7AM to 1AM Dec 08 Pilot PreOp interview OR Pharmacy Techs to perform Med Rec
Today s Presenters Janinah S. Barreto, PharmD, MS The Ohio State University Medical Center, OH Steve Ebert, Pharm.D. Drea Maier, Pharm.D Meriter Hospital, WI Teri Wooton, Pharm.D. Carolinas Medical Center Northeast, NC
Medication Reconciliation and Pharmacy Technicians: Utilizing Pharmacy Technicians to Support the Medication Reconciliation Process Janinah S. Barreto, PharmD, MS The Ohio State University Medical Center, OH Steve Ebert, Pharm.D. Drea Maier, Pharm.D Meriter Hospital, WI Teri Wooton, Pharm.D. Carolinas Medical Center Northeast, NC