Building provider incentives around drug performance is one way health insurance plans can ensure optimal use
By Thomas Reinke
Medication reconciliation is a cornerstone of efforts to improve medication safety, yet widespread implementation of procedures that work has been a problem.
The Joint Commission, which accredits hospitals and other providers, established medication reconciliation as one of its national goals in 2005, but in 2009 it withdrew this requirement from its reviews because it was unworkable.
Many organizations, including the National Committee for Quality Assurance, the American Medical Association, and the National Quality Forum, either require or set standards for medication reconciliation, but their efforts stop short of steps that would actually boost performance.
An article in the November 2010 issue of the Joint Commission Journal on Quality and Patient Safety said that medication reconciliation standards must move beyond being an accreditation function to being a patient-centered function that improves safety.
One of the major problems is that medication reconciliation has largely focused on processing a medication list. CMS is an example: The Physician Reporting Program that pays bonuses to doctors for quality measures and the “meaningful use” incentive payments for adopting electronic health records only require providers to produce a medication list.
“Checking a list of medications is often seen as the major step in medication reconciliation, while the accuracy of the list and working with patients to understand their medications has not been emphasized,” says Mary Andrawis, PharmD, director of clinical guidelines and quality improvement at the American Society of Health-System Pharmacists.
Many reconciliation errors are the result of a poor medication history. At the University of Pennsylvania, 626 (37 percent) of 1,657 emergency room patients had errors in their medication lists. Nearly 10 percent of the errors were inclusion of discontinued medications, 27.9 percent were omission of prescription medications, and 38 percent were omissions of nonprescription medications.
At Northwestern Memorial Hospital, of 651 patients with 5,701 medications, 392 (60.2 percent) patients had 1,093 unexplained discrepancies between their medication histories and admission-order medications. Of the important instances, 200 patients required 309 changes in the medication orders because of discrepancies. Four errors (1.3 percent) had the potential to cause longer hospitalizations, 32 (10.4 percent) were rated as potentially causing temporary harm, and 162 (52.4 percent) were rated as potentially requiring monitoring or intervention to preclude harm. Multiple errors were also a problem: 47 patients had two errors, 21 had three, and 13 had four or more.
Andrawis says that medication reconciliation goes beyond simply matching previous medications with new orders. “It includes reconciling medications with no medical indication, diagnoses with no prescribed medication, and duplication of medications for the same condition.”
Wider, accountable implementation
In response to these shortcomings, the Joint Commission and the Leapfrog Group have recently taken steps to advance medication reconciliation through broader implementation and more accountability for its effectiveness.
On July 1, 2011 the Joint Commission will reinstitute medication reconciliation across the spectrum of its accreditation programs for hospitals, nursing homes, home care agencies, and ambulatory care providers.
The Joint Commission’s 2005 medication reconciliation standards attempted to “accurately and completely reconcile medications across the continuum of care.”
“But the original requirements … were found to be too prescriptive across all provider organizations,” says Maureen Carr, a project director at the Joint Commission. She explains that there was a requirement for the medication list to be transmitted to the next provider during transitions in care, but that was impossible because the next provider might not have been known.
The new performance elements require obtaining medication information at first contact with a patient, comparing previous medications to current orders to identify discrepancies, and emphasizing the patient’s involvement.
“The new standards focus on outcomes for patients, plus they recognize the diversity of organizations and provide latitude for them to design their own procedures,” says Carr.
In addition, the Leapfrog Group’s April 2011 hospital survey has a revised medication reconciliation standard that goes beyond paper compliance — a list — to ensuring accountability for improving medication reconciliation.
“Our safe practice is based on an NQF [National Quality Forum] standard. It has four elements: awareness, staff accountability, staff education, and action,” says Leah Binder, CEO of the Leapfrog Group.
She explains: “We measure activities that will improve medication safety — whether the organization has studied the number and severity of adverse drug events, whether a report has been sent to the board, and whether senior management is accountable for improvement.”
The survey also measures staff education efforts and the implementation of standardized procedures for medication reconciliation.
Binder says employers expect improvements in this measure — a point that health plans should understand in their dealings with plan sponsors. “Employers know that medication reconciliation is difficult, but they cannot understand why providers can’t fix this problem. Employers must deal with their own complex situations, and they believe providers should do the same.”
Binder has another important point for health plans. “Providers put the responsibility for coordinating care squarely on the shoulders of patients, and they may not always get it right. The fact that we don’t have the systems to properly track patient medications is a perfect example of our poorly organized health care system.”
The experts say health plans can play a role in improving medication reconciliation. “I’d like to see health plans work with employers to structure payment incentives around medication performance,” says Binder.
“It has been shown that pharmacists’ interventions are effective in ensuring that medications are not just reconciled but also used optimally, and health plans should support that,” says Andrawis. “On the technical side, this process will be much simpler if there is one reliable source of information about a patient’s medications.”
She says that pharmacy benefit managers could become that source. -
Stakeholders’ prescription for medication reconciliation
Medication reconciliation still has not been clearly defined. In 2009 the Society of Hospital Medicine convened a meeting of providers, accrediting agencies, employers, and CMS to clarify what this task is and how it should be implemented. Ten items were identified to improve medication reconciliation:
Writing a clear definition of what constitutes a medication, and of the process of reconciliation
Defining the role of providers, patients, and other participants
Employing clinically meaningful measures of the reconciliation process
Using a phased approach to reconciliation across the continuum of care
Establishing mechanisms to identify high-risk patients and situations
Funding research for best-practice research
Disseminating best practices
Using personal health records to facilitate access to information
Promoting medication safety outside of the clinician-provider relationship
Aligning payments with medication safety goals
Source: Greenwald JL, et al. Making Inpatient medication reconciliation patient centered, clinically relevant, and implementable: A consensus statement on key principles and necessary first steps. Joint Commission Journal on Quality and Patient Safety. November 2010. 36(11):504–513.
There’s more to medication reconciliation than matching previous medications to new orders, says Mary Andrawis, PharmD, director of clinical guidelines and quality improvement for ASHP.
“We don’t have the systems to properly track patient medications,” says Leah Binder of the Leapfrog Group.