This case study examines the implementation of a comprehensive medication reconciliation system at CentraState Medical Center, a 282-bed, not-for-profit, Magnet-designated community hospital in central New Jersey.
Accuracy of the home and discharge medication lists is critical to a patient-safety platform to reduce medication errors, avert potential allergy or drug-drug interactions and reduce readmission rates. The system solution is designed to accurately capture medication history on admission, reflect any changes in medication regimen as a patient moves through the hospital stay, and ensure patients receive clear instructions at discharge to improve their understanding of, and compliance with, medications to be taken post-discharge.
When a patient arrives at the emergency department, the triage nurse checks the system for medication history and allergies, all of which can be pulled forward from the most recent prior visit. The nurse validates the list with the patient to establish the ‘home medications list.' Any changes reported by the patient or family member are noted, along with the source of the information. If the patient is not aware of the actual name of a drug, a system tool permits the nurse to enter descriptors to help narrow the field to a possible medication. If the patient is new to the system, the information is captured for the first time, and then flows automatically to subsequent visits, providing a valuable longitudinal medication record.
On admission to the hospital, the admitting physician reviews the home medications in the system and compares this list to planned admission orders. The system allows the physician to continue or discontinue any home medications as part of the hospital stay. During changes in level of care, such as transfers to other units, the physician reviews the current medications and continues or discontinues as needed.
At discharge, the physician conducts a final medication review and discontinues any inpatient medications, providing the patient with a printed copy of medications to take after discharge. This list explains in layman's terms what each medication is used for and the dosing instructions. It gives patients clear direction on which medications to stop, restart or add to their regimen.
The hospital budgeted $150,000 for this solution. As a Web-based system, hardware requirements were minimal. The system was economically efficient, integrating with existing clinical and pharmacy systems.
An interdisciplinary team of clinicians and information technology staffers reviewed the existing process and re-engineered it where appropriate to best capitalize on the new system's functionality. The implementation team included five physicians, seven nurses, three pharmacy representatives and five IT and other staff. The vendor supplied a project manager and three technical resources to facilitate the implementation.
The medication reconciliation system was chosen with several objectives in mind. First, to ensure that CentraState leverages technology to provide the best care possible. Second, to provide clinicians with the tools required to ensure the effective continuity of care without adversely impacting workflow. Finally, to improve compliance with established requirements set forth by various regulatory and certification bodies.
The selected solution supports safe, quality care by ensuring clinicians have the most recent medication information available to them. It also provides:
- Customizable medication order sets
- Automated query to retail prescription data
- Formulary support
- Full clinical alerts for drug interactions, allergies, duplicate therapies and incomplete entries
- E-prescribing
Combined with embedded patient-safety tools, the system facilitates the rapid intake, and discharge, of patients. Patients are comforted that their caregivers know their home medications and take them into account when prescribing. When discharged, patients receive comprehensive, customized medication instructions, greatly enhancing their understanding and compliance as evidenced by follow-up patient discharge calls.
Providers must often navigate multiple computer systems and data sources, and deal with incomplete or uncertain data—all of which are time-consuming and detract from patient care. It was critical that the selected medication reconciliation system not impede provider workflow. Data show that the system, implemented last December, has drastically reduced the average physician documentation time for medication reconciliation, from over seven minutes prior to the system to 4 minutes and 35 seconds at go-live, and down to just 2 minutes and 55 seconds in March. Physician compliance has also increased dramatically, from 40% to above 90% in March.
The medication reconciliation system improves compliance with established requirements set forth by various regulatory and certification bodies. It integrates core measures into the medication reconciliation process, and provides comprehensive reporting functions and a full audit trail. The system provides added value by enhancing clinician communication across the continuum of care and improving patients' satisfaction with their medication education at discharge. While too early to document, it is anticipated that certain core measure indicators, such as congestive heart failure and acute myocardial infarction, will see improvement, demonstrated by reduced readmission rates, in part due to the quality of patient medications instructions at discharge.
Strategy for seeking funding for the health IT or system adopted from the American Recovery and Reinvestment Act of 2009, commonly known as the stimulus law.
Purchased prior to the stimulus law, the chosen vendor solution was in part selected for its exceptionally high physician adoption rates, but an unexpected benefit was that it met 17 of the 24 meaningful-use Criteria for 2011, including computerized physician order-entry adoption. Since approximately 50% of all orders are medication orders, and 90% of those orders are now completed electronically, this solution easily meets the 10% criteria for CPOE adoption through 2012.
Indranil (Neal) Ganguly is vice president and chief information officer at CentraState Healthcare System, Freehold, N.J.
