SummaryPeaceHealth, a nonprofit integrated system, established a process to allow patients and providers in physician offices to reconcile two medication lists—one maintained by patients either manually or on a Web-based personal health record and one maintained by providers on an electronic medical record. The new process resulted in more accurate medication lists, an enhanced culture of medication safety, and high levels of patient and provider satisfaction.Moderate: The evidence consists of before-and-after comparisons of medication discrepancies, along with post-implementation provider and patient survey data on their experiences with the reconciliation process.
Date First Implemented2004
Problem AddressedAdverse drug events are common in the outpatient setting, driven in part by inconsistencies between the lists of drugs and dosages maintained by providers and what is reported by the patient. Established systems and processes to ensure that providers have an accurate medication list can help reduce adverse drug events, but relatively few providers have access to such resources.
- A common problem: Medication errors that lead to adverse drug events are as common in the ambulatory setting as they are in hospitals.1 A recent survey found that between 2.5 and 3.7 of every 1,000 physician visits was prompted by an adverse drug event, above the comparable figures for hospital outpatient visits (between 1.8 and 3.4 of every 1,000 visits).2
- List discrepancies often to blame: One study found that 76 percent of patients have discrepancies between the medications recorded in the physician’s office and what the patient reported. Discrepancies included patients taking medications that were not recorded, patients not taking a recorded medication, and differences in dosage.3
- Lack of systems to ensure accuracy: Many adverse drug events can be prevented by developing and maintaining medication tracking systems; establishing strong clinician–patient relationships based on thorough and accurate communication; improving patient medication self-management and information availability; developing a culture of medication safety; and using information technology to improve medication management.1 Although accurate medication lists can result in fewer medication errors and adverse drug events, few clinicians in the outpatient setting have immediate access to such lists.4
Description of the Innovative ActivityPeaceHealth creates a single medication list that integrates the patient-reported medications (collected manually or entered into the Shared Care Plan, a Web-based personal health record) with the medication list maintained by clinicians using an electronic medical record (EMR). After a defined process for evaluating medication usage, providers and patients review the two lists during office visits and reconcile the differences. Key elements of the revamped process are outlined below:
- Obtaining medication lists: When a clinician accesses a patient’s record during an office visit, a popup screen on the clinic’s EMR alerts the clinician if the patient uses the personal health record. If so, the nurse uses a separate Internet site (called “Meds on Record”) to create a list of all medications included on the personal health record and EMR. For those patients who do not use a personal health record, the nurse asks for a list of all current medications (including prescription drugs, over-the-counter medications, herbals, and nutraceuticals). Because a majority of patients do not use the personal health record, this process is generally handled through discussions with patients.
- Reviewing and reconciling medication lists: Clinic personnel review the medication lists with the patient or the patient’s representative. Most clinics use licensed nurses or medical office assistants for this step, with the nurse alerting the physician to any discrepancies found. Some clinics use physicians—for example, a geriatric clinic that commonly cares for frail, complex patients routinely has a physician handle this review. The patient’s medication list and the EMR medication list are reconciled so that the lists match, with any changes documented in RxPad, the EMR's prescription writing software. For example, prescriptions prescribed by non-PeaceHealth physicians may be added, while discontinued prescriptions are removed from the list. The time required to complete the review/reconciliation process varies, depending primarily on the complexity of the patient’s condition(s). The average reconciliation process in a PeaceHealth geriatric clinic takes about 5 minutes, but it could take twice that long for a patient on 10 to 12 medications, and only 1 minute for a patient on 2 to 3 medications. These medication review processes now occur in all ambulatory clinics, both primary care and specialty care, across the organization.
- Checking safety of new prescriptions: Staff check the updated, reconciled medication list to ensure that any new medication orders do not create the potential for drug–drug interactions or other potential safety problems or issues.
- Accessing and maintaining the list: All providers in the PeaceHealth system have access to the most recent, accurate list, which is entered into the EMR. The patient can access the updated list through the personal health record, and/or receive a paper copy at the end of each encounter. Patients who use the personal health record are responsible for adding and deleting medications in that system. Clinicians update the medication list by adding new prescriptions and deleting old ones in the EMR. Clinicians can also enter an “end date” so that medications are deleted automatically at the end of the prescribed course. In addition to the personal health record, patients who receive care can sign up for a patient portal called Patient Connection, which allows them to see labs, x-rays, other reports and medication lists that are found in the patients' EMR. The patient can review the list and if the list is inaccurate or would like to add a medication to the list, they can send an e-mail directly to the physician to update the list or ask questions about their medications.
Context of the InnovationPeaceHealth, a nonprofit integrated health system that operates hospitals and clinics in Washington, Oregon, and Alaska, has been using an EMR since 1996. In 2002, PeaceHealth was awarded a Robert Wood Johnson Foundation Pursuing Perfection Initiative grant to create chronic care services that strengthen patients' self-management skills. One outcome of that project was the development of the Shared Care Plan, an online personal health record owned and maintained by patients that includes a medication list. PeaceHealth leaders believed that comparing the Shared Care Plan medication list with the medication list on the health system’s EMR could help to improve medication safety by reducing adverse events.
ResultsThe new process resulted in more accurate medication lists, an enhanced culture of medication safety, and high levels of patient and provider satisfaction.
Moderate: The evidence consists of before-and-after comparisons of medication discrepancies, along with post-implementation provider and patient survey data on their experiences with the reconciliation process.
- Fewer medication discrepancies: Before the intervention, only 20 percent of medication lists examined in the three clinics had no discrepancies (i.e., the personal health record medication list was identical to the EMR medication list). Three months after initiating the intervention, more than 50 percent of the lists had no discrepancies. In addition, the number of significant discrepancies declined considerably.
- Enhanced culture of medication safety: Clinicians from all three pilot sites completed a 16-item PeaceHealth Ambulatory Medication Safety Culture Survey before and after program implementation. Results show that two of the three clinics experienced significant increases in their culture of medication safety score.
- Positive patient experience: Patient surveys have shown high levels of satisfaction with the program.
- Easy to use: Patients using the Shared Care Plan find it easy to access and the medication list easy to use (100 percent), read (100 percent), and print (94 percent).
- Useful and empowering information: Almost all patients (96 percent) think the medication list contains all the information they need to understand what medications they are taking and when and how to take them. A similar percentage (97 percent) find that having the medication list makes it easier for them to take an active role in their health care.
- Greater confidence and less fear: A majority of patients (83 percent) report that having a medication list made them more aware of the possibility of medication errors and the same percentage report that the list reduced their fear of a medication mistake. More than three-fourths (78 percent) of patients find that having a medication list makes them confident that wherever they go for care, providers will know what medications they are taking and that they will not be given a medication they should avoid. A similar percentage believe that having a medication list makes them more confident they are taking their medications correctly. Finally, 96 percent believe that their primary physician knows what medications they are taking, while 93 percent believe that other providers know this information.
- Improved communication: Most patients (90 percent) believe that having a medication list improves communication with their health care provider.
- Positive physician reports: Anecdotal reports suggest that physicians believe that their conversations with patients about medications and medication safety have been much more robust since implementation of the medication review process.
Planning and Development ProcessKey steps included the following:
- Development of new process and technology: The mapping of a new clinic medication review process and the technical development of EMR tools occurred simultaneously.
- Technical component: Technical assessment addressed how existing technology could support the medication reconciliation process and how medication data could be shared. The solution was to develop an interface to allow medication lists maintained on the personal health record and the EMR to be presented on a single Web page called Meds on Record.
- Process component: A suggested process was developed for providers to review the medication lists, reconcile the lists with patients, and generate a single, accurate list.
- Selection of pilot sites: PeaceHealth selected three ambulatory care clinics (Senior Health and Wellness Center, Eugene, OR; Center for Senior Health, Bellingham, WA; and Health Associates at Peace Harbor, Florence, OR) to participate in the pilot project based on their interest in improving medication safety and their experiences in implementing successful quality improvement projects.
- Securing clinician buy-in: Physicians and other caregivers at the three sites received briefings on the rationale for the new system and offered their suggestions on how the program could be incorporated into existing care processes. Clinicians agreed on a standardized set of process steps to be adopted by every clinic.
- Clinician and patient training: A quality improvement coordinator taught caregivers at the three participating clinics how to implement the medication reconciliation process and taught patients how to use the medication list function within the personal health record.
- Program expansion: The revised medication review process was adopted by all PeaceHealth ambulatory medical practices in Alaska, Washington, and Oregon in 2005.
Resources Used and Skills Needed
- Staffing: The program required no new frontline staff, as the revamped approach to medication reconciliation was built into existing work processes. PeaceHealth did hire a quality improvement coordinator to conduct training on the new process. Since the end of the pilot phase, existing quality improvement managers in each PeaceHealth region have provided ongoing support related to improving the medication reconciliation process.
- Costs: Total project costs have not been tracked.
Funding SourcesAgency for Healthcare Research and Quality; PeaceHealth
The PeaceHealth Community-wide Electronic Shared Medication List Study was funded by the Agency for Healthcare Research and Quality under the Safe Practices Implementation Challenge Grants Program (Grant Award Number: UC1HS14315-02). This grant also funded the work of the newly hired quality improvement coordinator for 1 year. PeaceHealth provided matching fund contributions to the study.
Tools and Other ResourcesInformation on the Shared Care Plan can be found at: http://www.sharedcareplan.org.
Getting Started with This Innovation
- Understand limitations of electronic tools: Many patients, particularly older ones, are not accustomed to or comfortable with using a computer. As a result, the medication review process should be established first, after which providers can determine whether and how to use electronic tools to supplement or support the process.
- Provide patient education: Involve patients in the process, including explaining the rationale for maintaining an accurate medication list and for pursuing medication reconciliation.
- Ensure interpersonal interaction with patients: At some point, the provider must have a one-on-one conversation with the patient to generate an accurate medication list. Relying solely on electronic tools will not work.
Sustaining This Innovation
- Be cognizant of the impact of health system features on process adoption: As an integrated system, PeaceHealth has one EMR system and a homebuilt personal health record and can generally institute system-sponsored process changes across all system providers. A less integrated group of clinics and/or hospitals might find it significantly more difficult to institute a similar type of medication review process.
- Hire dedicated coordinator: The quality improvement coordinator helps to ensure that physicians and patients support the new process and know how to maximize its effectiveness.
- Measure and report compliance with new process to stimulate improvement: Using a simple survey of a random sample of patients as they leave the office, PeaceHealth measures and reports on clinic adherence to each of the key components of the revised medication reconciliation process. When measurement began several years ago, compliance rates ranged from 60 to 70 percent, with the failure to offer or give patients a copy of their updated medication list being the most common omission. After reviewing these performance reports, clinic leaders began working with physicians and staff to examine and discuss internal processes, with the goal of identifying corrective actions to improve compliance. In most cases, the solution was to assign responsibility for the step to one or more individuals, including physicians and nurses (who were encouraged to make offering the list a part of their standard script) and receptionists (who sometimes see patients just before they leave). The approach worked, as adherence rates have consistently been above 90 percent. PeaceHealth currently includes adherence to the medication review process as a standard quality measure for all clinics, and continues to provide performance reports to the clinics (monthly) and PeaceHealth executives (quarterly).
- Create annual competency-based training: The organization implemented an annual competency-based training for all medical office assistants and nurses participating in ambulatory medication management processes. A video was produced for this training to assist in the standardization of the process across offices and to ensure that all nursing staff are adequately trained to participate in the same process regardless of where they will be working.
- Engage patients: A Patient Advisory Council has been formed in PeaceHealth Medical Group to provide feedback and guidance to the medical group. One of their focus areas is patient safety, which includes medication management. This group has developed a video for patients, informing them about how they can partner with their providers to make care safer. One of the chapters of the video is dedicated to medication safety and the process that the medical group is engaged in as well as what the patients can do to keep their medication list accurate.
References/Related ArticlesMahoney E. The Patient Experience with the Shared Medication List (PESML) Survey. Bellevue, WA: PeaceHealth Survey, Research, and Development Division; 2005.
Stock RD, Mahoney E. The Medication List Discrepancy Tool. Bellevue, WA: PeaceHealth Survey, Research, and Development Division; 2003.
Stock R, Mahoney E, Gauthier D, et al. Developing a community-wide electronic shared medication list. In: Henriksen K, et al: Advances in Patient Safety: New directions and alternative approaches. Vol. 4. Technology and Medication Safety. AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
Stock R, Mahoney E. The PeaceHealth ambulatory medication safety culture survey. In: Henriksen K, et al: Advances in Patient Safety: New directions and alternative approaches. Vol. 2. Technology and Medication Safety. AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
Stock RD, Scott J, Gurtel S. Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group. Joint Comm J Qual Patient Saf. 2009;35(5):271-7. [PubMed]
Zhan C, Arispe I, Kelley E, et al. Ambulatory care visits for treating adverse drug effects in the United States, 1995-2001. Jt Comm J Qual Patient Saf. 2005;31(7):372-8. [PubMed]
Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med. 2000;160(14):2129-34. [PubMed]
4 Stock R. Developing a Community-Wide Shared Medication List. (Draft report supplied by innovator)
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Original publication: August 04, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 12, 2011.
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