Improving Medication Reconciliation in Care Transitions Using Health Information Exchange (HIE) Presenters: Joe Litsey, Pharm.D. Candy Hanson, BSN, PHN, LHIT-HP Date:

June 17, 2015

Objectives •

• •

Learn about the Prospective Medication Review (PMR) pilot that was implemented in a Stratis Health Special Innovation Project Hear strategies to improve medication reconciliation in care transitions Understand the role of pharmacy in care transitions and how it is improving care

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Stratis Health • Independent, nonprofit, Minnesota-based organization founded in 1971 – Mission: Lead collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities

• Working at the intersection of research, policy, and practice

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The Problem • • • • • •

Current workflow Current documentation methods Incomplete/inaccurate medication histories Incomplete/inaccurate medication lists Transcription errors that follow the patient Poor/incomplete communication

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Health Information Technology for Post Acute Care (HITPAC)

Centers for Medicare & Medicaid Services' Special Innovation Project: Health Information Technology for Post-Acute Care Providers (HITPAC)

Collaboration between three Fairview Hospitals and 10 skilled nursing facilities

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Minnesota HITPAC Communities Community 1A Fairview Ridges Hospital Fairview Southdale Hospital Augustana Minneapolis BHC Innsbruck Ebenezer Ridges Martin Luther St. Gertrude's The Colony of Eden Prairie

Community 1B Fairview Lakes Hospital Birchwood Health Care Ecumen North Branch GoldenLiving Rush City Margaret S. Parmly Thrifty White Long Term Care Pharmacy

Fairview Long Term Care Pharmacy

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Two Main Focus Areas

Transitions of Care

Improving Medication Management

Electronic Health Record/EHR towards Health Information Exchange/HIE

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Prospective Medication Review (PMR) Pilot • Implemented in our project • Workflow redesign which will improve patient safety and will impact skilled nursing facility staff time, hospital staff time, dispensing pharmacy staff time • Medication reconciliation and evaluation done at “preadmission” once SNF staff inform hospital that they can accept a resident • Dispensing pharmacy will screen for 7+ items • Data Collection

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Prospective Medication Review (PMR) Pilot Screening process 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Duplication of therapy Drug-Disease interaction Drug-Drug interaction Incorrect dose or duration Drug-Allergy interaction Evidence abuse/misuse Incomplete orders (see adjacent) Diagnosis errors Dose ranges PIM Other (ex: cost)

Incomplete Orders a. Dosage form b. Dose c. Frequency d. Strength e. Diagnosis

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PMR Rationale • Medication management is one of the most significant factors contributing to unnecessary hospital readmissions. • The majority of medication errors occur during times of transitions • Approximately half of hospital related medication errors and 20 percent of adverse drug events are due to poor communication at transitions.

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PMR Rationale • Our experiment: • Implement a Prospective Medication Review (PMR) • Goal: • Through PMR: Improve medication management through medication reconciliation and medication evaluation during transitions of care between hospital and LTC-PAC facility 10

Health Information Exchange Results • • • •

42 SNF to hospital test exchanges 2 hospital to SNF test exchanges 2 SNF to pharmacy test exchanges Actual health information exchanged achieved with PMR pilot participants

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PMR Results PMR Results 90 80 70 60 50 40 30 20 10 0

Most frequent problems IDed

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Lessons Learned  There need to be stops across the health care continuum for medications that are prescribed without an indication or diagnosis  Current hybrid processes have many potential opportunities for improvement  Medication reconciliation is a different activity than medication evaluation  Pharmacy needs to play a bigger role in medication reconciliation 13

Lessons Learned (Continued) Medication reconciliation needs to be a “shared responsibility” going forward Limited use/availability of e-Mar, e-Rx, CPOE Need more understanding of the role of EHR in improving medication management

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Lessons Learned (continued) The value of interoperability still needs to be realized Privacy and security practices in an EHR/HIE environment will continue to need much attention Workflow issues will need solutions quickly to advance health information exchange across the industry 15

PMR Pilot White Paper “Understanding and Improving Medication Reconciliation Between Hospitals and Nursing Homes” http://www.stratishealth.org/documents/stratis-healthmedication-reconciliation-white-paper-2014.pdf

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The Role of Pharmacy in Care Transitions •

Medication reconciliation vs. Medication evaluation •

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Medication Reconciliation -- The process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. (Institute for Healthcare Improvement) Drug use evaluation (DUE) is a system of ongoing, systematic, criteria-based evaluation of drug use that will help ensure that medicines are used appropriately (at the individual patient level). (WHO) Medication use evaluation (MUE) is similar to DUE but emphasizes improving patient outcomes and individual quality of life; it is, therefore, highly dependent on a multidisciplinary approach involving all professionals dealing with drug therapy. (WHO)

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Understanding Medication Management During Transitions Med Rec

Home

Med Rec

Hospital

Med Rec

Long Term Care

Home

Ongoing Medication Evaluation

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Medication Reconciliation and Medication Evaluation Med Rec

Hospital

Long Term Care

Home

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Prospective Medication Review: Jane Doe Medication

Dose/route

Frequency

Indication

Glyburide

5mg PO

BID

DM

Diphenhydramine

25mg

PRN

Isosorbide

30mg PO

BID

Diazepam (Valium)

5mg PO

BID PRN

Anxiety

Lantus

15u SQ

QHS

DM

Xalatan Ophthalmic

1 gtt

QHS

Glaucoma

Celexa

30mg PO

QD

Depression

Norvasc

10mg PO

QD

CV insufficiency

Simvastatin (Zocor)

40mg PO

QD

Hyperlipidemia

Metoprolol

100mg PO

QD

HTN

Hydrocodone/APAP

1-2 tabs PO

Q4-6hrs PRN

Pain

Oxycodone

5-10mg PO

Q4-6hrs PRN

Pain

Zantac

150mg PO

BID

Combivent

Inhaler

QID PRN

20 COPD

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Consulting: Medication Review Jane Doe (BD: 5/33; Weight: 125 lbs.) • BP: 100/50 • Serum Creatinine: 2.1 • History of falls • Confusion • Dementia Can further medication related problems be identified?

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Jane Doe (BD: 5/33; Weight: 125lbs) [BP: 100/50; Serum Creat: 2.1; HX falls, confusion] Medication

Dose/route

Frequency

Indication

Glyburide

5mg PO

BID

DM

Diphenhydramine

25mg

Q6hrs PRN

Allergy/reaction

Isosorbide mono.

30mg PO

BID

Angina - CAD

Diazepam (Valium)

5mg PO

BID PRN

Anxiety

Lantus

15u SQ

QHS

DM

Xalatan Ophthalmic

1 gtt OU

QHS

Glaucoma

Celexa

30mg PO

QD

Depression

Norvasc

10mg PO

QD

HTN

Atorvastatin (Lipitor)

10mg

QD

Hyperlipidemia

Metoprolol Succinate

100mg PO

QD

HTN

Hydrocodone/APAP

5/325 - 1 tab PO

Q4hrs PRN

Pain

Acetaminophen

650mg PO

Q6hrs PRN

Pain

Zantac

150mg PO

BID

GERD

Spiriva

1 puff

QD

22 COPD

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Demonstration Project: Connecticut • Nine pharmacists • 88 Medicaid patients • July 2009-May 2010

Ref: Health Affairs. In Connecticut: Improving Medication Management in Primary Care. April 2011

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Demonstration Project: Connecticut • Identified 917 drug therapy problems • Resolved 80% after four encounters • Annual savings: $1,123 per patient on medication claims $472 per patient on medical, hospital and education expenses

• More than covered the expense of the pharmacists Ref: Health Affairs. In Connecticut: Improving Medication Management in Primary Care. April 2011

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To Really Make a Difference • Medication reconciliation should not be viewed as an accreditation function • Must be viewed as an important element of patient safety • Move from information transfer to information exchange in health care Ref: Journal of Hospital Medicine. Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant, and Implementable, October 2010.

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Summary

Readmission prevention strategies are based on common sense… the hard part is creating integration across different healthcare professionals, institutions and organizations.

Pharmacy

LTC Facility

Hospital

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Summary Sound medication management can reduce overall healthcare expenditures and reduce unnecessary hospital readmissions. Allowing the patient to age in place and thus increasing marketability and attractiveness of facility as a preferred provider and referral center. One Intervention made by a pharmacist can result in tens of thousands of dollars of savings in total health care expenditure ― Preventing a COPD exacerbation > $10,000 ― Preventing a bowel obstruction > $38,000 ― Preventing a hip fracture > $40,000

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Questions? Joe Litsey Director of Consulting Services [email protected] Candy Hanson Program Manager [email protected] www.lsqin.org

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This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C3-15-128 060115