Study: Medication reconciliation still a work in process

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 - patient record, EHR, EMR

While the use of medical reconciliation has long been part of the Joint Commission’s hospital accreditation program, as well as part of the Stage 2 Meaningful Use requirements, the transition to EHR-based medication reconciliation is still a work in process, according to a study by the National Institute for Healthcare Reform.

The study, which looked at how 19 hospitals across the U.S. used EHRs to support medication reconciliation, found that EHR-supported medication reconciliation implementation efforts “are in flux” with vendors adding or enhancing these capabilities, and with hospitals upgrading their EHRs or changing vendors.

But, despite the fact that vendors have been adding or enhancing medication reconciliation functionality, some hospitals are still dissatisfied with the medication reconciliation tools provided by their EHR vendors. For example, about one-third of the hospitals in the study use a system that at some point in the admission/discharge process is still paper-based. Additionally, many of the hospitals studied had access to external electronic sources of medication histories to help them generate more accurate pre-admission medication lists, but questions remained about whether the added information was reliable enough to be worth adding to the medical record.

Hospitals with more advanced EHR-based medication reconciliation functionality, however, have been able to integrate medication reconciliation with electronic admission and discharge ordering, enabling them to improve legibility, reduce data re-entry and support more patient-friendly discharge instructions. 

A key point, the researchers said, is that these medication reconciliation functions are still evolving, with some vendors only just recently introducing medication reconciliation function modules or upgrading that functionality. The hospitals that are still using paper for some of the medication reconciliation process still plan to move to a completely electronic process.

But, even hospitals that have implemented an EHR medication reconciliation module have had different levels of success because of differences in vendors, product lines and software versions, as well as how hospitals implemented the process.

Other barriers to successful medication reconciliation efforts include the problem of physician engagement and the question of whether some clinicians believe that medication reconciliation is more complicated and time consuming when supported by the EHR. “There is likely wide variation among clinicians within and across hospital systems in attitudes about the value of medication reconciliation itself and experiences using EHR-based medication reconciliation tools in delivering care,” the researchers wrote. “Ultimately, effective EHR-based medication reconciliation will rest on clinician engagement with the process.”

There’s also the problem of having access to accurate, complete and up-to-date pre-admission medication lists, which the researchers referred to as the “garbage in/garbage out” phenomenon, and which can be a further deterrent to physician engagement. In the long run, the report suggests, pre-admission medication lists could improve, but in the short-term the use of clinical decision support tools could help clinicians identify the relevant medication history information. “Federally funded research is underway in this area to help develop such tools, and enhancing ways for key stakeholders—patient safety advocates, policymakers, researchers, EHR vendors, hospitals and physicians—to share best design practices would be beneficial,” the researchers wrote.

The researchers also pointed out that while these EHR-supported medication reconciliation tools are increasingly being incorporated into physician practices and hospitals, more research needs to be done on how they are impacting patient outcomes—i.e., adverse drug events and medication discrepancies—as well as related healthcare spending. Research will also be needed to determine what kind of EHR designs and hospital implementation strategies result in the best outcomes.

This kind of research can, the researchers concluded, “help guide hospitals, and increasingly, post-acute facilities and large physician organizations, in assessing the overall value of electronic medication reconciliation and provide guidance about customizing their EHRs, adopting appropriate medication reconciliation processes and policies, and developing performance monitoring to help improve clinician compliance and medication reconciliation quality."