What is medical reconciliation (MedRec), and why is it important within the acute care continuum? The Joint Commission (TJC) on Medication Management has stated in its 2012 list of goals that EDs must: “Maintain and communicate accurate patient medication information.” Dirk Stanley, MD, summarizes the medical reconciliation challenge nicely. He says it is obtaining from the patient the ‘home med list’ of what the patient usually takes, creating a current list of what the patient is taking at that moment, and then generating a new current med list of “what does the patient need to be on right now.” MedRec includes identifying omissions, duplications, contradictions, unclear information and changes and giving the new list to the patient when leaving the medical setting. Beyond its obvious value in patient care, MedRec is important to the ED because failure to adhere to a TJC National Patient Safety Goal can result in loss of accreditation.
Gaining a grasp of this workflow is inherently filled with uncertainty. For example, how can a provider even know for sure whether a patient takes the medications they state they take or if the patient is divulging all the medications they are taking? To meet the MedRec challenge, inter-department coordination and EMR utilization will be key parts of the solution. In a sense, the challenge and the accomplishments made in MedRec coordination can be seen as a microcosm of the future path towards breaking down department silos across the healthcare continuum to create efficiency and integration.
During a site survey, TJC is empowered to show up and request to see the medication reconciliation policy and procedure. TJC surveyors may even observe staff performing the MedRec process to ensure adherence to the written policy and procedure. To assess compliance, the surveyor may ask the nursing leader to provide ten open and ten closed medical records for review.
The results of this assessment can affect the survival of the hospital. Since 1965, CMS has required TJC (or equivalent) accreditation of US hospitals as a ‘Condition of Participation’ in order to receive Medicaid and Medicare reimbursements. Without this funding most hospitals would be forced to close their doors. A further source of financial risk to hospitals lies in the fact that failure to reconcile medications can result in harm to the patient. This morbidity may lead to hospital admission and/or readmission. Given the financial penalties for excessive readmission that hospitals will face beginning in October of 2012, ineffective MedRec will not only be injurious to patients but expensive for hospitals.
Despite these risks, and the fact that MedRec is a federal requirement for hospitals and outpatient settings, it is too often done sloppily, even at respected medical centers. We learned this the hard way. My husband’s mother was recently treated at a prestigious hospital ED for pneumonia and was provided an antibiotic for pneumonia. However, her doctor failed to screen for contraindications and failed to look for drug-to-drug interactions prior to prescribing the antibiotic. As a result of this lapse, my mother-in-law ended up with significantly increased neuropathy. When we looked at the reference sheets dispensed with the antibiotic, we saw that this antibiotic was contraindicated for anyone with a history of rheumatoid arthritis or diabetes, and was incompatible with oral diabetic medication. My mother-in-law suffered from both conditions and was using an oral diabetic medication. It took two additional hospital visits to stabilize her on a change in medications.
While MedRec is crucial both to patient care and to hospital finances, it is not necessarily an easy thing to do. Challenges include getting the home med list from patients who are often unclear about what they are taking, figuring out which providers are responsible for MedRec, and deciding at which points in the patient’s trajectory it is necessary to repeat the process. Acknowledging the difficulties, TJC states, “A good faith effort to obtain information from the patient and/or other sources will be considered as meeting the intent….”
The good faith effort may include questioning anyone accompanying the patient to gather documentation. Another idea has been put forth by William Cook, DO, chief of hospital medicine at Ohio Permanente Medical. He suggests a real-time discharge summary for each patient to identify and communicate with collaborators across care settings so that the “coaching baton” can be passed. When this baton is seamlessly passed within medical settings and medication adherence is improved, it really will be a tangible illustration of what hospital integration can accomplish.
There are also ways to pass the baton out to the expanding walls of the Acute Care Continuum. Karen Cheung-Larivee writes about engaging patients and family members, working with pharmacists and patients after discharge, and identifying high risk patients. Providers can encourage patients to take an active role in their health and work with pharmacy staff to address any discrepancies with medications that may cause inadvertent complications, and can ask pharmacists to communicate more with patients. Providers and nurses themselves can follow up with patients after discharge with a home visit, which is ideal, or with a telephone call between 24 to 72 hours after discharge.
While MedRec can be a logistical nightmare, adhering to TJC guidelines will not only improve patient care and protect hospital finances, but also improve communication through the acute care continuum. As we know, this is becoming increasingly important to survival with the changes brought on by the ACA and the expanding complexities of the Acute Care Continuum.