Pharmacy Informatics: “There’s a VA App for That!”

Pleasanton, CA.August 2 – 5, 2011

VA MedRecon Share point VA MedRecon Yammer Group

Maureen.Layden@VA.govRosemary.Grealish@VA.gov

VA Medication Reconciliation Initiative

First, Thank you!

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MedRecon Journal Club: Adams, Shawn M (Portland); Amarshi, Rahemat; Ashworth, Joann Y.; Bockhold, Colleen R.; Church, Victoria L (Portland); Davis, Lisa G; Doten, Amy E; Ducharme, Elizabeth A.; Golterman, Lori (VHACO); Hoeksema, Laura J. (NCPS); Kazi, Salahuddin; Kinnaird, Daniel E. ASHVAMC; Layden, Maureen Q.; Lesselroth, Blake J (Portland); Lyle, Diane M.; Ondeck, Deborah A.; Perry, Arlene A.; Rayburn, Larry D.; Rayburn, Virginia (Columbus); Reiss, Alexander I.; Rogers, Delories Jean (ATG); Stainbrook, Renotta G.; Toy, Shawn; vhapbh Burke-Bebee, Suzie

MedRecon Documentation and Monitoring Group: Adames, Irene; Adams, Shawn M (Portland); Amarshi, Rahemat; Anderson, Jacquelyn D.; Baruch-Bienen, Deborah L; Bockhold, Colleen R.; Boockvar, Kenneth S.; Cagle, Stephen W.; Chavalitanonda, Nann N.; Cho, Richard; Cohen, Emily; Conrad, Chester; Curtis, Van; Cusack, Caitlin M. (BITS); Davila, Yvonne B.; Davis, Lisa G; Delgado, Ailsa M.; Deltoro-Borrero, Yolanda; Dierker, Susan E; Doten, Amy E; Durkin, Rob; Farrell-Holtan, Jean M.; Gillon, Joseph; Grealish, Rosemary; Group Review VHAMASTER; Heitman, Edgar R.; Hughes, Lina R (SPO); Kaboli, Peter J.; Kazi, Salahuddin; Khan, Shaiza FHCC Lovell; Layden, Maureen Q.; Lesselroth, Blake J (Portland); Lin, David; McConnell, Mark E.; Mewton, Joel; Michaud, Dana L. VHAIRO; Ochs, Leslie A.; Ondeck, Deborah A.; Pickard, Marcia (Ann Arbor); Plourd, Kimberly M.; Profit, Lori; Reiss, Alexander I.; Silverman, Robert; Stadler, John B.; Stein-Gocken, Julie; Stimson, Jean M.; Taylor, Suzanne; Toy, Shawn; Tubbs, Traviss A.; VHASYRBROWND3; Washington, Myron J.; Wittenberg, Geri FHCC Lovell

MedRecon Staff and Patient Education: Amarshi, Rahemat; Bockhold, Colleen R.; Charters, Kathleen (CCSI); Chavalitanonda, Nann N.; Echt, Katharina; Gill, Rosemary; Gill, Rosemary (Palo Alto); Golterman, Lori (VHACO); Grealish, Rosemary; Heitman, Edgar R.; Hoeksema, Laura J. (NCPS); Horvath, Kathy; Kazi, Salahuddin; Layden, Maureen Q.; Lyle, Diane M.; McConnell, Mark E.; Mehta, Sima N.; Ondeck, Deborah A.; Painter, Kathleen; Plourd, Kimberly M.; Pries, Rose Mary NCP; Probst, Maria (White City/VISN20/); Rayburn, Virginia (Columbus); Rayford-Outsey, Faye L CAVHCS; Trudeau, Paulette; Trudeau, Scott; vhapbh Burke-Bebee, Suzie

MedRecon Task Force: Adams, Shawn M (Portland); Connolly, Karin S.; Connolly; Cusack, Caitlin M. (BITS); Ducharme, Elizabeth A.; Grealish, Rosemary; Heller, Thomas; Layden, Maureen Q.; Lesselroth, Blake J (Portland); Lin, David; Lucas, Joe (VHA OHI); Ondeck, Deborah A.; Pickard, Marcia (Ann Arbor); Rayford-Outsey, Faye L CAVHCS; Silverman, Robert; Vasquez, Luz; Watson, Kimberly R.

Goals

Understand Medication ReconciliationIn the VA

In your facilityAnd your important role

First Thanks!!

VA Pharmacy InformaticsTaking the Lead

Conservative Estimations, compliments of Dr. Lesselroth

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• Estimate 4.5 discrepancies per patient encounter, 30% clinically relevant1-3

• Each discrepancy has a positive predictive value for an ADE of 0.0234

• 4.5 x 0.023 = 0.1 ADE/Encounter• If we conservatively estimate that 13% of those ADEs result in

temporary disability, hospitalization, or death4 • O.1 X 0.13 = 0.013 Events/Encounter

• If we estimate a facility manages 415,000 encounters per year • 415,000 X 0.013 X 5, 395 Events every year

1. Kaboli et al., Am J Mgd Care, 2004 ; 2.Lesselroth et al., JC Qual Pt Saf, 2009; 3.Pippins et al., JGIM, 20084. Boockvar et al., Qual Saf Heath Car, 2009

Medication ReconciliationWhat it is NOT

• Just about a list• Pharmacy’s problem, alone• Useless• Being phased out in Joint Commission• Impossible, BUT

• IT IS: • Hard to do

VA Medication

Reconciliation DirectiveDefinition

1.Obtaining medication information from patient, caregiver, and/family.

2.Comparing this to the medication information available

3.Communicating with and providing education to patient, caregiver, and/or family regarding this information.

4.Communicating this with the

healthcare team(s).

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The Joint CommissionReconciliation Revised Patient

Safety Goals*

1. NPSG.03.06.01 EP1: Obtain information on the medications the patient is currently taking.

2. NPSG.03.06.01EP3: Compare the medication information.

3. NPSG.03.06.01EP4: Provide the patient (or family as needed) with written information.

4. PC.04.02.01: Information about treatment is provided to other service providers

Minimum MedRecon Documentation Requirements

• Patient provided medication information obtained at the episode of care must be represented in the electronic medical record (EMR)

• Comparison of this to the medication information available on the EMR*

• Final updated medication list highlights the added, changed, and discontinued medications

• Discharge instructions = discharge medication information in the EMR

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MedRecon Documentation: Lessons Learned

• Avoid Duplicate Documentation • Make your templates consistent with workflow in the

clinical setting• Consider that all the minimum documentation

requirements do not have to be captured in the template but must exist somewhere in the note

• Engage the end-users in developing tools• Must essentially help us help the patient, “What did the

patient come in on, what did she leave with, and why• Don’t put Remote Meds in Non VA Meds-Use the Software

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VA MedRecon Directive• Assign a VISN and Facility MedRecon Point of

Contact to disseminate timely info• Update your facility MedRecon policy, if

necessary– Establish MedRecon processes– Assign roles and responsibilities– Measure the effectiveness of your facilities MedRecon

• Participate in the MedRecon EPRP & Discharge Call Monitor or PACT equivalent

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VA MedRecon Directive

• In the MedRecon Goody Bag (Toolkit) regarding the MedRecon Directive– MedRecon FAQs– Directive and Facility MedRecon Policy Gaps Analysis

Tool– Please email us if you have questions

• Directive and Joint Commission Crosswalk

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Post-Discharge Call Monitor (Voluntary)

• Discharge patients to home– Did you get an updated

Medication List?– FY2010 Quarter 4,

Average 95% Yes!– 183, 182 Veterans were

called

*Guidance Deb Ondeck, RN, OQP 13

1 & 2 Review the patient’s list of medications

3. Identify medication discrepancies

4. Address medication discrepancies

5. Provide a written list6. Refer to or follow-up

medication management?

External Peer Review Process (Pilot)*:

Metrics

• Patient Activation: “Did you bring your medications or your med list to this appointment?”

• Terminal Process Metric: “Did you receive an updated med list at the end of the encounter?

• Outcome:• Discrepancy Rates• ADEs• ED/Urgent Care visits• Re-admission

MedRecon Metrics: Local

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MedRecon Software

• Let’s get to work• Where are you doing “MedRecon”?• Who is doing what tasks?• How are you measuring the process?• Are there opportunities for change?

• Completion of the MedRecon/PCMIM NSR– Focus on existing projects– Take into account organizational history

• PBM Patient Centered Care Liaison– Support Shared Decision Making– Medication Use Crisis

• Standardizing Medication Information– Display– Content

• Continue to promote pharmacy as key player in this multidisciplinary process

Patient Centered Medication Information Management

Ultimately, Medication Reconciliation will be so imbedded in our daily routine and consistent with the expectations of

our patients that the campaign will become obsolete and the terms

forgotten.

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Patient Centered

Medication Information Management

VA Medication Reconciliation: and Patient Centered Med Info Mgt

• MedRecon NSR, incollaboration with:

– VPS Kiosk– MHV– The Daily Plan– Ask a Pharmacist– Greenfields– Health Risk Assessment– Local Innovations– New Functionalities

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The Top 3 VA MedRecon Barriers• MedRecon software works only if clinicians update the Medication Orders in

pharmacy packageVulnerabilities:

1) Co-pays are generated 2) Patients are dispensed extra or excess medication [a safety and financial liability]

• Our Medication Lists are generated from many sources with variable/inconsistent output display– Active & Expired– Outpatient & Inpatient– Local & Remote (Other VAMCs & DoD)

• Remote med conflicts have caused sentinel events

– VA & non VA• It is difficult to obtain, document, and store in the chart patient-derived

medication information [the Veteran’s voice]

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