Identifying discrepancies in electronic medical records through pharmacist medication reconciliation

Research

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation Autumn L. Stewart and Kevin J. Lynch

Received August 27, 2010, and in revised form February 8, 2011. Accepted for publication February 19, 2011.

Abstract Objectives: To describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies. Design: Observational case series study. Setting: Indigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010. Patients: 219 adults presenting for follow-up medical visits and self-reporting medication use. Intervention: Medication reconciliation as part of patient interview and concurrent chart review. Main outcome measures: Frequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence. Results: Of 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies. Conclusion: Pharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them. Keywords: Medication reconciliation, medication therapy management, drug use review, ambulatory care, errors, medication safety, medication adherence. J Am Pharm Assoc. 2012;52:59–66. doi: 10.1331/JAPhA.2012.10123

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Autumn L. Stewart, PharmD, BCACP, is Assistant Professor of Pharmacy Practice, Division of Clinical, Social and Administrative Sciences, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA. Kevin J. Lynch, PharmD, BCPS, MBA, is Medical Outcomes Specialist, Pfizer, Pittsburgh, PA. Correspondence: Autumn L. Stewart, PharmD, BCACP, Mylan School of Pharmacy, Duquesne University, 209 Bayer Learning Center, 600 Forbes Ave., Pittsburgh, PA 15282. Fax: 412-396-2161. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. Acknowledgment: To Hildegarde J. Berdine, PharmD, BCPS, CDE, for general support. Previous presentations: American College of Clinical Pharmacy (ACCP) Annual Meeting, Anaheim, CA, October 18–21, 2009, and ACCP Annual Meeting, Charlotte, NC, April 23–27, 2010.

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edication reconciliation is a process of collecting an accurate list of all medications that a patient is taking, including name, dosage, frequency, and route of administration.1 Reconciliation involves comparing the patient’s self-reported current list of medications with physician orders, medication labels, or discharge orders from inpatient or long-term care and clarifying any discrepancies. Medication reconciliation continues to be a key initiative for improving patient care across all health care settings.2 An Institute of Medicine report cites that medication-related problems account for more than 2 million serious adverse events and as many as 7,000 deaths annually.3 The highest rates of medication errors occur at the “interfaces of care,” specifically when a patient changes practice settings or practitioners.1,2 Therefore, performing medication reconciliation at all transitions of care is critical. In 2005, the Joint Commission cited medication reconciliation as National Patient Safety Goal (NPSG) 8, which states that health care entities must accurately and completely reconcile medications across the continuum of care; this led inpatient care centers to begin implementing medication reconciliation processes.2 In 2009, the Joint Commission discontinued

At a Glance Synopsis: Through pharmacist medication reconciliation in an ambulatory care setting, the investigators sought to determine the types of and reasons for medication discrepancies between patient self-report and medications listed in electronic medical records (EMRs). A total of 219 patients were interviewed, 162 (74%) of whom had at least one discrepancy. Having an incorrect medication documented on the chart was the most common type of discrepancy. Use of OTC medications was the most common reason for discrepancies, followed by changes made by outside physicians without communication between providers and patients failing to report a medication that was listed as active in the EMR. Patients who were knowledgeable of the dosage for more than 75% of their medications had fewer discrepancies. Analysis: These results indicate that despite the potential for improvements with use of EMRs, medication discrepancies continue to exist. Considering the impact that pharmacists have previously demonstrated on improving the medication reconciliation process, they must continue to play an active role on the health care team despite the use of technology. Compared with other health care providers, pharmacists are better equipped to identify medication discrepancies during medication reviews in a primary care setting. This important medication reconciliation role is a potential means by which the pharmacy profession can continue to establish a role in the patient-centered medical home.

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factoring attainment of this goal into accreditation decisions; however, surveyors continue to evaluate and discuss these processes during on-site surveys.2 The decision was made, in part, because the organizations encountered difficulties in achieving the complex requirements under NPSG 8, and a period of time was necessary for further refinement of expectations.2,4 Although accredited ambulatory care centers have likely developed and implemented medication reconciliation processes as a result of NPSG 8, anecdotal evidence suggests and supports that many ambulatory care environments have not adopted the use of pharmacists in these processes and that implementation of medication reconciliation processes is not required for accreditation through the National Committee for Quality Assurance. The accuracy and consistency of medication reconciliation that occurs in these settings also is unclear. Although ambulatory care is a growing practice area for pharmacists, it can be expected that overall, in most practices, medication reconciliation is rarely conducted by pharmacists. Ketchum et al.5 emphasize the need for a multidisciplinary approach to medication reconciliation as a means to make the process more efficient and to provide for collaborative implementation. Research conducted by Varkey et al.6 demonstrated that involving nurses and pharmacists in the medication reconciliation process resulted in a significant reduction in the number of discrepancies upon admission and discharge. Other studies conducted in the inpatient setting have demonstrated that pharmacist involvement in medication reconciliation results in a reduction in medication errors, discrepancies, and costs.7,8 In addition, legislation allowing pharmacists to bill for medication therapy management (MTM) services further supports the drive for pharmacist-directed medication reconciliation programs. A medication therapy review is defined as “a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them.”9 This is an essential first step in the provision of MTM services. Milone et al.10 found the process of medication reconciliation effective for identifying patients as candidates for MTM; 40.7% of 122 medication reconciliation visits resulted in MTM services. Bayoumi et al.11 conducted a systematic review of all medication reconciliation studies performed in a primary care setting. Their results demonstrated a lack of quality evidence supporting the effectiveness of medication reconciliation and a need for additional research. In a study conducted by Bedell et al.,12 76% of patients in an outpatient practice had medication discrepancies, the majority of which involved medications not recorded as being taken by the patient. In this study, age and number of medications were both predictors of discrepancy. Peyton et al.13 described a pharmacist-led medication reconciliation intervention to improve medication accuracy. The number of records with medication discrepancies were only modestly improved by the intervention (85.6% before vs. 81.1% after). The authors suggested that use of technology such as electronic medical records (EMRs) as a potential solution for Journal of the American Pharmacists Association

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reducing medication discrepancies. In a meta-analysis of studies examining the role of information technology in facilitating the process of medication reconciliation, Bassi et al.14 found potential for information technology applications to be used in conducting medication reconciliation. Johnson et al.15 conducted a study examining the discrepancies existing between patients’ EMRs and community pharmacy medication lists. An average of six discrepancies per patient were identified, with inactive medications being most frequent. A limitation of the study was lack of direct communication with the patient to further clarify the cause or nature of discrepancies. In a study by Orrico et al.,16 medication discrepancies between EMRs and patient interviews were evaluated by nurses as patients used a nurse advice line. Although the investigators identified reasons for medication discrepancies similar to the previously mentioned studies, the context of the nurse interview presents several limitations. The findings from the study of Orrico et al. indicate a need to identify the frequency and causes of medication discrepancies between EMRs and patient interviews conducted in the medical home. Despite substantial review of medication reconciliation, a gap exists in descriptions of the nature of discrepancies in an ambulatory care setting using EMR documentation—a method that is becoming a standard of health records documentation. Further, a need exists to explore the causes of discrepancies that are unique to EMR systems.

Objectives The current study sought to describe the types of and reasons for discrepancies between patient-reported medications and medications listed in EMRs as identified by pharmacist medication reconciliation in an ambulatory care setting. The secondary objective was to identify patient characteristics associated with the presence of discrepancies between patient-reported medications and medications listed in EMRs.

Methods Following approval from the Duquesne University Institutional Review Board, patients from a primary care center (Catholic Charities Free Health Care Center) serving an indigent, uninsured population were recruited for participation in the study. The center, which is located in an urban setting, provides free medical and dental services to uninsured adults with household incomes less than 200% of the Federal Poverty Level. Patients eligible for care at the center cannot have private or government health insurance and must be between 18 and 65 years of age. Open approximately 40 hours per week, the center is under the direction of a physician and full-time nurse practitioner, with volunteer nurses and physicians providing the majority of care. The center provides primary and specialty care to eligible patients, including endocrinology, gynecology, cardiology, rheumatology, dermatology, otolaryngology, podiatry, psychiatry, urology, and ophthalmology. A combination of methods are used to obtain free and low-cost prescription drugs for patients. Prescribers are encouraged to use medications from local pharmacies’ discount generic drug programs Journal of the American Pharmacists Association

first line as appropriate. For medications not available from such programs, manufacturer prescription assistance programs are used. If a patient does not qualify for these programs or needs to initiate a therapy immediately, the center covers the expense of the medication minus a $4 cost sharing from the patient. For patients unable to afford the $4 cost at the pharmacy, donated gift cards are often available to assist them. The center was selected on the basis of having an established clinical pharmacy faculty member and pharmacy resident or fellow present daily. The center also serves as a teaching site for advanced pharmacy practice experiential rotations for doctor of pharmacy students. The implementation of medication reconciliation as a clinical pharmacy service was new to the site. Previously, medication review and reconciliation were conducted by center nurses and physicians. The center uses EMRs and computerized physician order entry (CPOE) exclusively for documentation and generation of prescriptions. The EMR divides the medication list into categories of current and discontinued medications. These lists are updated automatically through CPOE and can be manually updated by all providers within the center. The list from which medications can be selected includes prescription drugs, nonprescription drugs (over-the-counter [OTC] products), and dietary and herbal supplements. Patients were recruited through a verbal invitation to participate in the study before their scheduled physician visit. Results of medication reviews from encounters with patients refusing to provide informed consent were excluded from the study. In addition, patients presenting for their initial appointment at the center were excluded from data analysis because they lacked a charted medication record. Likewise, patients who denied the use of medications and had a blank medication list were excluded. Patients with previous visits that included pharmacist medication reconciliation also were excluded from the analysis. Medication review Pharmacists and student pharmacists involved in data collection were oriented using a 30-minute video created by the primary investigator for training purposes. The training video reviewed the process of medication reconciliation and methods for data collection. Approximately 25 students and 5 pharmacists completed the training. Pharmacists and student pharmacists conducting patient interviews were evaluated on technique and consistency by the primary investigator. Students were observed during patient interviews by a pharmacist until competency was established. If competent, students could interview patients independently, but they reported findings to a pharmacist before reporting to the physician. Reports to the physician and changes to the medication record were supervised by a pharmacist. All data were recorded using a medication reconciliation data collection form (Appendix 1 in the electronic version of this article, available online at www.japha.org), a scannable (Cardiff Teleform version 10; Autonomy Cardiff, Vista, VA) document that provides data entry directly into Microsoft Acwww. japh a. or g

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cess. The form was used to provide uniformity and consistency in patient interview and documentation of responses. Data collection occurred before the patient visit with the physician. Upon presenting for the physician visit, patients’ vital signs were measured by a nurse. Then, a pharmacist or student pharmacist collected patient medication history. All patients were interviewed to obtain the names, doses, regimens, and indications of the medications they were currently taking. The charted medication record was available to assist the pharmacist or student with obtaining a complete and accurate record and to facilitate assessment of patient knowledge. If needed, outside physicians or the patient’s community pharmacy were contacted to obtain additional needed information. The availability of multiple disciplines creates the opportunity for patients to receive the majority of their care at the clinic, if desired. When available, prescription drug labels were reviewed to ensure the accuracy of patient self-report. Patients also were asked to provide demographics, including age, gender, ethnicity, household size, and income. Patients were screened for medication adherence using the Morisky scale, which is a validated, four-item questionnaire that uses self-report to identify patients who may be nonadherent to maintenance medications.17 The Morisky scale provided an adherence score for each patient ranging from 0 to 4, with 4 being “adherent.” An assessment of patient knowledge was conducted by capturing the number of medications for which the patient was able to accurately recall the drug name, dose, regimen, and indication. This number was compared proportionally with the total number of reported medications. The thresholds of 0%, 25%, 50%, 75%, and 100% were selected arbitrarily for simplicity in data collection. Simultaneous to the patient interview, patient-reported medications were compared with charted medications from EMRs. Discrepancies between the lists were identified and categorized by discrepancy type and reason for discrepancy. Discrepancy types were used to describe the nature of the discrepancy (i.e., presence of drug on chart, use of medication by the patient, accuracy of drug, dose, or regimen). Various options were available for explaining the cause of the discrepancy and were documented as discrepancy reason and are listed in online Appendix 1. Each discrepancy was classified first by discrepancy type followed by discrepancy reason. Following the medication review, the interviewer verbally conveyed patientreported medications and discussed discrepancies and other medication-related problems with the physician. Corrections and clarifications to the medication record were subsequently performed. Of important note, patient knowledge was assessed independently of discrepancies. For example, a patient actually taking 10 mg of drug A who reported taking 20 mg of drug A and whose EMR listed 10 mg of drug A was identified as not being knowledgeable about their medication dose. Data analysis All data were entered into a Microsoft Access 2007 (Microsoft, Redmond, WA) database and analyzed using Minitab version 15 (Minitab, State College, PA). Descriptive statistics were used for all parameters and reported as mean (±SD) for nor62 • JAPhA • 5 2 : 1 • J a n / F e b 2012

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mally distributed continuous variables, median (range) for continuous variables that were nonnormally distributed, and count and/or percent for dichotomous variables. Inferential statistics were conducted using chi-square and Fisher’s exact tests for dichotomous variables. Mann-Whitney U test was used to compare the number of charted medications with the number of medications reported by patients. Multiple logistic regression analysis was used to assess for the association of one or more medication discrepancies, controlling for age, gender, race, and medication knowledge parameters. Patient variables included age, gender, race, number of medications, adherence, and medication knowledge. Results were considered statistically significant at P < 0.05.

Results A total of 219 patients who received a medication reconciliation intervention by a pharmacist or student pharmacist were included in the analysis. Patient interviews occurred during 2009–10 during a 13-month time frame. Baseline demographic characteristics are shown in Table 1. Reported medications A total of 1,499 medications were documented; 852 were recorded from patient interviews and 647 from medication lists in EMRs. Comparisons of medications from patient interviews and EMRs revealed 1,005 distinct medications. The difference between the number of medications reported by the patient (3.9 ± 2.54) and that documented in the EMR (3.15 ± 2.52) was found to be significant (P < 0.001). Medication discrepancies Of the 1,005 medications documented, 499 (49.7%) had a discrepancy present between patient-reported and charted medications. Discrepancies were identified in 162 (74%) patients, with 71 (32%) having two or more discrepancies. Types of medication discrepancies are shown in Table 2.

Table 1. Demographic characteristics of patients receiving a medication reconciliation intervention Variable n Age (years), mean ± SD (range) Female gender Race/ethnicity White Black Latino Other Unknown Medication adherence Morisky score, median (range) Forgetfulness with medications Careless with medications Take less when feeling better Take less when feeling worse

No. (%) 219 47.4 ± 11.9 (22–65) 136 (62) 125 (57) 78 (36) 6 (3) 9 (4) 1 (<1) 3 (0–44) 88 (40) 37 (17) 34 (15) 60 (27)

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Table 2. Most common medication discrepancy types Discrepancy type n Medication on chart (discrepancy with a medication listed in the chart)

No. (%) 219 167 (33.5)

Medication not charted (discrepancy with a reported medication not on the chart) Different dose (discrepancy between dose reported and dose charted)

257 (51.5)

Different regimen (discrepancy between regimen reported and regimen charted) Similar medication (patient reported medication similar to charted medication)

29 (5.8)

35 (7)

9 (1.8)

Discrepancy reason, no.(%) Patient did not report, 57 (34.1); medication with automatic stop date, 32 (19.2); patient stopped medication, 31 (18.6); change during recent office visit, 14 (8.4); discontinued medication during recent office visit, 11 (6.6); other reasons, 22 (13.2) OTC use, 137 (53.3); outside physician prescribed without communiqué, 68 (26.5); patient did not report medication correctly, 24 (9.3); initiated during a recent hospitalization, 7 (2.7); other reasons, 21 (8.2) Patient did not report medication correctly, 15 (42.9); change during recent office visit, 13 (37.1); outside physician prescribed without communiqué, 3 (8.6); other reasons, 4 (11.4) Patient changed medication, 20 (69); patient did not report medication correctly, 3 (10.3); other reasons, 6 (20.7) Changed during recent office visit, 2 (22.2); discontinued medication during recent office visit, 2 (22.2); initiation of new medication recently, 2 (22.2); other reasons, 3 (33.3)

Abbreviation used: OTC, over the counter.

Of the 499 medications with discrepancies, 257 (51.5%) were medications reported by patients that were not listed in the EMR. This was the most common type of discrepancy observed. The types of discrepancies were further characterized by reasons for the discrepancy (Table 3). Use of OTC medications was the most common reason for discrepancies, followed by changes made by outside physicians without communication between providers and patients not reporting a medication that was listed as active in the EMR. Relationships between the frequency of discrepancies and demographic variables also were analyzed (Table 4). Medication adherence (measured using the Morisky scale), gender, race, or age was not found to be associated with an increased prevalence of medication discrepancies. The presence of at least one discrepancy was associated with patients taking three or more medications. Patients who were knowledgeable of the dosage for more than 75% of their medications had fewer discrepancies, while patients who were able to report the name, indication, or regimen for more than 75% of their medications had no association with discrepancies (P < 0.01).

Discussion Discrepancies and inaccuracies in EMRs among outpatients occurred at an alarming rate in the current work—a finding that is similar to results from previous studies examining traditional documentation systems. These results indicate that despite the potential for improvements with use of EMRs, discrepancies continue to exist, suggesting that the method of documentation alone is not sufficient to have a considerable effect on the rate and types of discrepancies. Assuming that “usual care,” prior to the implementation of this service, included a regular review and update of patients’ current medications, it does not appear that other health care providers adequately identified and corrected discrepancies in the EMR. Journal of the American Pharmacists Association

Table 3. Overall medication discrepancy reasons, independent of type Discrepancy n OTC use Patient did not report Patient did not report correctly Outside physician prescribed without communiqué Patient changed/stopped medication Medication with automatic stop date Change during recent office visit Stopped during recent office visit Initiation of new medication, recent office visit Other

No. (%) 219 147 (30.2) 58 (11.9) 42 (8.6) 73 (15) 56 (11.5) 33 (6.8) 33 (6.8) 15 (3.1) 10 (2.1) 20 (4.1)

Abbreviation used: OTC, over the counter.

It appears that pharmacists can better identify medication discrepancies during medication reviews in a primary care setting previously providing usual care. Discrepancy types The most common type of discrepancy was a reported medication that was not documented in the EMR. We believe that this type of discrepancy has the most potential for patient safety issues in an outpatient setting because it could lead to drug interactions or unnecessary drug therapy, including duplicate therapy or medications used to treat the adverse effect(s) of another drug. Patients also may not receive timely monitoring and follow-up for therapies initiated elsewhere if their primary care provider is unaware of the treatment. This type of discrepancy also was common in previous studies examining discrepancies present using traditional documentation systems, suggesting that EMR documentation may not be more effective at www. japh a. or g

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Table 4. Patient characteristics and medication discrepancy prevalence Characteristic n Age (years), mean ± SD Gender (n = 219) Female Male Ethnicity (n = 200) White Black No. medications (n = 219), mean ± SD Knowledge (n = 205) Name ≥75% <75 Dose ≥75% <75 Regimen ≥75% <75 Indication ≥75% <75

Discrepancy No. (%) 162 47.4 ± 11.8 104 (76.5) 55 (66.3)

32 (23.5) 28 (33.7)

89 (71.8) 60 (79) 4.40 ± 2.64

35 (28.2) 16 (21) 2.91 ± 2.09

95% CI — 0.96–1.02 — — — — 1.07–1.52

P — 0.426 0.100

0.092 0.006

108 (72) 44 (80)

42 (28) 11 (20)

— —

0.246

66 (67) 89 (83)

32 (43) 18 (17)

— —

0.015

137 (74) 16 (80)

48 (26) 4 (20)

— —

0.553

139 (73) 14 (87.5)

50 (27) 2 (12.5)

— —

0.214

improving the frequency of this discrepancy type.12 The second most common type of discrepancy was medications listed in the EMR that were not actively being used by the patient. It was observed that medications often were not discontinued or changed in the chart when changes in therapy occurred. This confirms previous research and emphasizes the need, regardless of documentation system, for a thorough review of patient medication-taking behaviors at every visit.16 It is also consistent with reasons for medication discrepancies we observed, including patient changed or stopped medication, change during recent office visit, stopped during recent office visits, and initiation of new medication at recent office visit. Although many of these reasons are related to patient behavior, they also demonstrate the need for prescribers to update the EMR medication list to reflect changes made to current therapies. This type of discrepancy can lead to clinical decision making that assumes the presence of a therapy that may not be present. These chart inaccuracies also suggest the presence of therapies that may no longer be appropriate or applicable to the patient’s current status. Although the changes made verbally were much less frequent reasons for discrepancies, this lack of documentation may lead to confusion when patients or other health care providers (specifically, community pharmacies) request clarification of a drug, dose, or regimen and the listed medications are assumed to be accurate. Discrepancy reasons Use of OTC medications represented roughly one-half of the discrepancy reasons under “medication not charted” and was 64 • JAPhA • 5 2 : 1 • J a n / F e b 2012

No discrepancy reported No. (%) 57 47.3 ± 11.6

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the leading overall discrepancy reason. It can be assumed from this study that nonpharmacists were not documenting agents such as dietary supplements, vitamins, cough and cold preparations, OTC analgesics, or medications transitioned from prescription to OTC status. This suggests that pharmacist-led medication reconciliation may be better able to detect and document use of OTCs than medication reconciliation conducted by other providers. Although self-care products are intended for use without the supervision of a physician, potential drug interactions and duplicate therapies may not be recognized if these products are not clearly and accurately reported in the patient’s chart. Although the present study did not identify whether OTC products had been initiated following physician recommendation, inferring that prescribers who routinely use EMR document the recommendation of OTC products in a similar manner to that of prescription drugs is reasonable. In light of these results, the center began documenting recommendations for OTC products in the EMR by generating a prescription for the medication, thereby creating a record of the use of the OTC product in the EMR medication list. The second leading reason for overall discrepancies was “patient did not report.” Similar to the discussion above, drug therapy decisions based on a “presumably” accurate and complete charted medication list do not take into consideration the patient’s actual medications and accompanying medicationtaking behaviors. The impact of this disparity on patient safety, medication errors, and drug-related problems is unknown. Of note, medication nonadherence (as measured by the Morisky Journal of the American Pharmacists Association

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scale) was not associated with more discrepancies, suggesting that patient failure to report a medication is not related to adherence alone. The lower rate of medication nonadherence in the study population can be further explained by the variety of resources used to obtain free or discounted medications, alleviating medication access as a potential barrier to adherence. During data collection, it was observed and reported anecdotally that the initiation of unnecessary drug therapy and dose titrations were able to be avoided through a more accurately charted medication list. As the pharmacy profession explores opportunities to establish a role in the patient-centered medical home and primary care settings, medication reconciliation may be one such possibility. Our findings suggest that regardless of the method of documentation (i.e., EMR, paper record) discrepancies will occur and the system should not rely on technology alone. Considering the impact that pharmacists have previously demonstrated on improving the medication reconciliation process, they must continue to play an active role on the health care team despite the use of technology.6–8 During the intervention phase of the study, despite initial reluctance by some physicians and nurses, many began to take a more proactive approach in requesting pharmacist assistance before and after encounters with patients. Further research is needed to explore the impact of this service on economic and clinical outcomes. Based on number of medications, the rate of discrepancies appears to be consistent with previous research conducted among inpatients,7,8,16 suggesting that discrepancies at the outpatient level may contribute to or potentially cause discrepancies in the hospital setting. Whether pharmacist-led medication reconciliation in an outpatient setting affects the rates of discrepancies during the hospital admission or discharge process is unclear. Further research is needed to explore this and determine the impact of discrepancies on patient outcomes in all care settings. Additional research is needed to explore whether these findings can be generalized to other ambulatory care practice sites, including internal medicine and specialty. By identifying reasons for medication discrepancies, the current study can help target interventions to reduce specific types of discrepancies. For example, online patient medication record programs that interface with prescribers’ EMRs and allow patients to record medication changes or use of self-care therapies could have an impact on the rates and types of discrepancies. From the results of this study, patients reporting three or more medications or those unable to recall the doses of their medications have an increased likelihood of a discrepancy. Therefore, in a setting with limited resources, risk stratifying patients for particular interventions based on number of medications or ability to list drug dosages may be helpful.

Limitations One limitation of the current work was that the clinical importance of the discrepancies identified was not described beyond the discrepancy reason. This limits our ability to accurately predict the discrepancies’ effect on patient outcomes, includJournal of the American Pharmacists Association

ing relative risk of harm to the patient. Another limitation was the use of convenience sampling, as this population (indigent adults aged 18–65 years) may not be representative of patients in all primary care centers and may differ as a result of socioeconomic status and disease prevalence. Despite measures to improve interrater reliability, differences in documentation and judgment could have caused variation among interviewers.

Conclusion Medication reconciliation remains an important initiative for ensuring patient medication safety and is of concern in both outpatient and inpatient settings. Inaccuracies in charted medications remained a common occurrence in this setting, despite the use of an EMR system, and often are related to the use of OTC therapies and lack of communication and documentation during physician office visits. Patient-related factors such as number of medications and degree of medication-related knowledge are related to the frequency of discrepancies and may be reasonable predictors of such. As a result of their training and expertise, pharmacists have an opportunity to help lower the burden of medication discrepancies, which continue despite the use of technology such as EMRs. References 1. Midelfort L. Medication reconciliation review. Accessed at www. ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/Medi cation+Reconciliation+Review.htm, October 20, 2008. 2. The Joint Commission. Medication reconciliation National Patient Safety Goal to be reviewed, refined. Accessed at www. jointcommission.org/PatientSafety/NationalPatientSafetyGoals/ npsg8_review.htm, March 3, 2010. 3. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 2001. 4. The Joint Commission. Accreditation program: ambulatory health care National Patient Safety Goals. Accessed at www. jointcommission.org/PatientSafety/NationalPatientSafetyGoals, June 3, 2010. 5. Ketchum K, Grass CA, Padwojski A. Medication reconciliation. Am J Nurs. 2005;105(11):78–85. 6. Varkey P, Cunningham J, O’Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm. 2007;64:850–4. 7. Nester TM, Hale LS. Effectiveness of a pharmacist-acquired medication history in promoting patient safety. Am J Health Syst Pharm. 2002;59:2221–5. 8. Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61:1689– 95. 9. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc. 2008;48:341–53. 10. Milone AS, Harris IM, Philbrick AM. Pharmacist-performed medication reconciliation in an outpatient family medicine clinic. Presented at the American College of Clinical Pharmacy Annual Meeting, Anaheim, CA, October 18–21, 2009. www. japh a. or g

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11. Bayoumi I, Howard M, Holbrook AM, et al. Interventions to improve medication reconciliation in primary care. Ann Pharmacother. 2009;43:1667–75.

15. Johnson CM, Marcy TR, Harrison DL, et al. Medication reconciliation in a community pharmacy setting. J Am Pharm Assoc. 2010;50:523–6.

12. Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications. Arch Intern Med. 2000;160:2129–34.

16. Orrico K. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14:626–31.

13. Peyton L, Ramser K, Harmann G, et al. Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention. J Am Pharm Assoc. 2010;50:490–5. 14. Bassi J, Lau F, Bardal S. Use of information technology in medication reconciliation: a scoping review. Ann Pharmacother. 2010;44:885–97.

17. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24:67–74.

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Medication Reconciliation Data Collection Form 36934

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Today's Date:

Part 1 Chart #:

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Date of Birth #: Male

Gender:

Female

Household Size:

Ethnicity:

White

African American

<25k

$26 - 50k

Hospitalized within last 30 days

Yes

No

Income:

New Patient:

Yes

No

A. ICD 10

Follow - up Patient:

Yes

No

C. ICD 10

. .

Latino

$51-75k

B. ICD 10

Other $75 - 100k

>$100k

.

Part 2 Current Medications (per patient interview)

Discrepancies with the charted medication list?

Total Number =

Total number of charted meds =

Name

Dose

Regimen

Patient Medication Record provided?

Indication

Yes

No

Discrepancy Type

Patient brought Medication list?

Reason

Yes

No

Part 3

Adherence Assessment Score: 1. Do you ever forget to take your medications?

Yes

No

2. Are you careless at times about taking your medications?

Yes

No

3. When you feel better, do you sometimes stop taking your medications?

Yes

No

4. Sometimes if you feel worse when you take a medication, do you stop taking it?

Yes

No

Part 4 Patient Knowledge Assessment Number of Meds known (round to nearest %) Names

0%

25%

50%

75%

100%

Doses

0%

25%

50%

75%

100%

Regimen

0%

25%

50%

75%

100%

Indication

0%

25%

50%

75%

100%

Drug Related Problems Identified?

Yes

No

Category:

Medication Reconciliation Instructions and Scoring Guide

36934 Part 1

Collect patient demographics including chart number, Gender, DOB, and Ethnic Background. Part 2

Ask patient for the names, doses, regimens, and indications for all medications they are currently taking. Provide the total number of medications the patient currently takes. Compare the patient's reported meds with the charted meds. If a discrepancy is present, use the following discrepancy codes and reasons. Discrepancy Type

Discrepancy Reason

0

No discrepancy

A

Outside MD prescribed, communication sent

1

Not on med

B

Outside MD prescribed, no communication sent

2

Med not on chart

C

Changed during recent hospitalization

3

Similar med/class post discharge

D

Changed during recent office visit

4

Similar med/class per MD change

E

Initiation of new med during recent office visit

5

Different dose

F

Discontinuation of med during recent office visit

6

Different regimen

G

Change over telephone/verbal recommendation

7

Different Indication

H

OTC use of medication

8

Medication on Chart

J

Samples given

K

Patient changed/stopped med

L

Patient cannot afford med

M

Other MD changed

N

Changed after hospital discharge

O

Initiate over telephone/verbal recommendation

P

Initiated during hospital visit

Q

Formulary/Therapeutic Switch

R

Patient did not report

S

Automatic Stop Date

Part 3

Ask the patient each of the Adherence Assessment questions. Each "No" response is 1 point. Add the total to provide an Adherence Score. If a Drug Related Problem is identified, use the following codes to document the category. 1- Unnecessary Drug Therapy 2- Wrong Drug 3- Dosage too low 4- Adverse Drug Reaction 5- Dosage too high 6- Inappropriate compliance

7- Needs additional therapy 8- Drug interaction, no adverse reaction occurred 9- Drug interaction, adverse reaction occurred