- Email: [email protected]
Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic
EXPERIENCE
Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic Anna S. Milone, Ann M. Philbrick, Ila M. Harris, and Christopher J. Fallert
Received November 27, 2012, and in revised form July 11, 2013. Accepted for publication September 15, 2013.
Abstract Objectives: To evaluate the incidence of medication discrepancies in electronic health record (EHR) medication lists in an outpatient family medicine clinic where clinical pharmacists perform medication reconciliation, to classify and resolve the discrepancies, to identify the most common medication classes involved, and to assess the clinical importance of the discrepancies. Methods: This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, with data collected from February 2009 to February 2010. To be included, patients had to be 18 years or older and have at least 10 medications listed in the EHR. The clinical pharmacist saw each patient before the physician, reviewed the medication list with the patient, and made corrections to the EHR medication list. When possible, comprehensive medication management (CMM) also was conducted. Results: During 1 year, 327 patients were seen for medication reconciliation. A total of 2,167 discrepancies were identified and resolved, with a mean (±SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies per patient. The range of total discrepancies per patient was 0 to 26. The most common discrepancy category was “patient not taking medication on list” (54.1%). Overall, the source of the discrepancy usually was the patient, but it varied according to discrepancy category. The most common medication classes involved were pain medications, gastrointestinal medications, and topical medications. Of the 2,167 discrepancies, 51.1% were determined to be clinically important by the pharmacist. The pharmacist conducted CMM in 48% of patients.
Anna S. Milone, PharmD, is Professional Education Teaching Specialist; and Ann M. Philbrick, PharmD, BCPS, is Assistant Professor, College of Pharmacy, University of Minnesota, Twin Cities, Minneapolis. Ila M. Harris, PharmD, FCCP, BCPS, is Associate Professor; and Christopher J. Fallert, MD, is Assistant Professor, Medical School, University of Minnesota, Twin Cities, Minneapolis. Correspondence: Ann M. Philbrick, PharmD, BCPS, Bethesda Family Medicine Clinic, 580 Rice St., Saint Paul, MN 55103. Fax: 651-665-0684. Email: [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. Published online ahead of print at www. japha.org on February 11, 2014.
Conclusion: Outpatient medication reconciliation by a pharmacist identified and resolved a large number of medication discrepancies and improved the accuracy of EHR medication lists. Because more than 50% of the discrepancies were thought to be clinically important, improving the accuracy of medication lists could affect patient care. Keywords: Medication reconciliation, outpatient setting, pharmacists. J Am Pharm Assoc. 2014;54:181–187. doi: 10.1331/JAPhA.2014.12230
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edication reconciliation is a frequently discussed topic in pharmaceutical care. In 2007, the American Pharmacists Association and the American Society of Health-System Pharmacists collaborated to provide the following definition for medication reconciliation: “the comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well to observe compliance and adherence patterns. This process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are rewritten or adjusted, or if the patient has added nonprescription medications to (his or her) self-care.”1 The use of medication reconciliation has been promoted by many national organizations, including The Joint Commission, as a means to reduce medication er-
At a Glance Synopsis: Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic identified and resolved 2,164 medication discrepancies in 1 year, resulting in improved accuracy of electronic health record (EHR) medication lists. The most common discrepancy category was “patient not taking medication on list” (54.1%). Overall, patients typically were the source of medication discrepancies, but this varied according to discrepancy category. More than 50% of the discrepancies were thought to be clinically important; therefore, improving the accuracy of medication lists could have a positive effect on patient care. Analysis: Some of the discrepancies identified in this study could have been easily prevented. For example, approximately 13% of discrepancies were caused by short-term medications remaining on the EHR medication list, which could have been prevented by adding an end date to the electronic prescription, thereby automatically removing the medications from the medication list when the course of therapy was complete. Although predicting discrepancies would be ideal, these data demonstrate the difficulty of such a possibility. Given that the most common medication implicated in discrepancies (albuterol) only garnered 3.1% of all discrepancies, identifying high-risk medications that may indicate the presence of discrepancies would not be feasible. Considering that patients averaged three clinically important discrepancies, the lack of ability to predict discrepancies highlights the importance of regular medication reconciliation in the outpatient setting.
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rors and prevent adverse drug events (ADEs). Medication reconciliation first came to the forefront of health care initiatives in 2005 when National Patient Safety Goal (NPSG) 8 was introduced; it sought to “accurately and completely reconcile medications across the continuum of care.”2 This goal, originally aimed at improving medication errors in the hospital setting, has since been expanded to ambulatory care. Effective January 1, 2013, The Joint Commission introduced NPSG 03.06.01: “Maintain and communicate patient medication information.”3 This safety goal stresses five areas of success: (1) obtaining and/or updating information on the medications that patients are currently taking, (2) defining the types of medication information to be collected (i.e., name, dose, strength, frequency, purpose), (3) comparing the medication information the patient brought with the medications ordered to identify and resolve discrepancies, (4) providing patients with written information on the medications that they should be taking following completion of the care episode, and (5) explaining the importance of managing medication information to patients at the end of care episode.3 The National Committee for Quality Assurance (NCQA) stressed medication management and specifically medication reconciliation in its 2011 standards for patient-centered medical homes (PCMHs).4 In addition, medication reconciliation is a core measurement in the Centers for Medicare and Medicaid ServicesGuidelines for Accountable Care Organizations (ACOs). ACOs are measured based on the percentage of patients 65 years or older discharged from any inpatient facility who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record.5 Although much of the information surrounding medication reconciliation is based in the hospital setting, ADEs also are a major problem in ambulatory care. Approximately one-third of ADEs happen in the ambulatory setting.6 The rate of ADEs in older patients in the ambulatory care setting has been reported as 50.1 per 1,000 person-years, with 38% of ADEs categorized as serious and 27.6% considered preventable.7 Pharmacists can play a major role in managing patient medications and decreasing ADEs. Many studies have shown decreased medication errors and decreased ADEs when pharmacists perform medication reconciliation in an inpatient setting.8–13 However, studies are just beginning to show the benefit of pharmacistled medication reconciliation in the ambulatory care setting. Thus far, only one study has been published regarding pharmacist-led medication reconciliation in an outpatient setting. Stewart and Lynch14 studied medication discrepancies through pharmacist-conducted medication reconciliation in a free ambulatory care clinic with several specialty services for indigent, uninsured patients. Their study objectives included describing discrepanJournal of the American Pharmacists Association
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cies and identifying patient characteristics related to the presence of discrepancies. There was no requirement for the minimum number of medications patients were taking. Data were collected over 13 months and included a total of 219 patients, among whom 499 medication discrepancies were found. The most common type of discrepancy found was medication reported by patients not listed on the electronic health record (EHR; 51.5%). Stewart and Lynch also found that the presence of at least one discrepancy was associated with taking three or more medications.
Objectives The primary objective of the current work was to evaluate the incidence of medication discrepancies in EHR medication lists. The secondary objectives were to classify discrepancies, identify the most common medication classes involved, estimate the clinical importance of the discrepancies, and determine whether medication reconciliation was an effective means to identify patients in whom comprehensive medication management (CMM) should be conducted. Previous studies have not looked at whether medication reconciliation is an effective method to identify patients for CMM. This is applicable to pharmacy practice structures and viability because CMM is a billable service, whereas medication reconciliation alone in an ambulatory setting is not billable. The overall goal of this process improvement was to improve accuracy of patient medication lists and increase collaboration between physicians and pharmacists through pharmacist-performed medication reconciliation.
Methods This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, and data were collected from February 2009 to February 2010. Bethesda Family Medicine Clinic is a training site for University of Minnesota Family Medicine residents and serves as a rotation site for advanced practice experiences of medical students and student pharmacists. It serves a low-income population, and the majority of patients have medication insurance from the State of Minnesota, which provides medications for a low copay. St. Paul is a U.S. designated resettlement city, so Bethesda Family Medicine Clinic has a large population of refugees from Southeast Asia. Bethesda Family Medicine Clinic is now a statedesignated health care home, though it was not at the time of this study. Two clinical pharmacists each spend 2 days per week at the clinic, providing 4 days per week of clinical pharmacy services. One of the clinical pharmacists is funded by the college of pharmacy, and one is funded by the medical school/clinic site. Practice obligations include conducting CMM, serving as consultants to physicians, and educating medical residents and student pharmacists. Pharmacists perform CMM Journal of the American Pharmacists Association
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and provide pharmacist-managed anticoagulation and smoking cessation services. This study was given exempt status by the Institutional Review Board at the University of Minnesota, Twin Cities. Eligibility criteria were age 18 years or older, scheduled for an appointment with a physician, and 10 or more medications listed in the EHR. This number was used because it indicated polypharmacy and was an easily identified number of medications on our rooming notes by patient care staff. Although polypharmacy commonly is defined in the literature as five or more drugs, the number of patients meeting this criteria in a clinic day would far exceed the acceptable number of patients that one clinical pharmacist could see. Although medication reconciliation was performed for patients every 6 months, after transitions of care, or as requested by the primary physician, only the data from the first medication reconciliation were included in this study. Process Patient care staff identified eligible patients based on the EHR medication list as part of the rooming process and paged the clinical pharmacist to the exam room. The clinical pharmacist saw the patient for medication reconciliation immediately before the physician visit. Because the clinical pharmacist has many clinical duties other than medication reconciliation and approximately 96 patients are seen daily in the clinic, only a portion of eligible patients could be seen. When a clinical pharmacist was unable to see a patient, it was the provider’s responsibility to ensure that the medication list was accurate. For patients taking fewer than 10 medications, the patient care staff performed medication reconciliation. During medication reconciliation, the clinical pharmacist reviewed the medication list with the patient and/or caregiver and made corrections to the EHR medication list. The final medication list was updated to reflect what the patient was actually taking. If the patient was not knowledgeable about their medications and did not have their medications or a written medication list with them, their pharmacy was called and dispensing records were reviewed. The clinical pharmacist verbally communicated any important omissions, changes, and/or drug therapy recommendations to the provider when possible. When verbal comments were not possible, a written note was left at the provider’s workstation. At the end of the visit, the patient was provided with an updated printed medication list. Each visit was documented in the EHR using a standard template (Appendix 1 in the electronic version of this article, available online at www.japha.org). Demographic information and a subjective assessment of patient knowledge of medications were collected. Patients were determined to be knowledgeable if they could j apha.org
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name and describe how they were taking most of their medications, somewhat knowledgeable if they required prompting by the pharmacist, and not knowledgeable if they were unable to state the medications they were taking, even after prompting by the pharmacist. Medication discrepancies were recorded and classified in the categories “current medication not on list,” “patient no longer taking medication on list,” “dosage listed differently than how patient is taking,” “frequency listed differently than how patient is taking,” and “duplicate medication on list.” From there, they were further classified into subcategories, by who was responsible for the discrepancy: a provider at the clinic, a provider outside of the clinic (labeled as specialty provider), or the patient. When a hospital discharge or home health/ nursing home medication list was involved, discrepancies between that list and the clinic EHR medication list also were recorded. Finally, the actual medications involved in each discrepancy were recorded for each patient. If time permitted, CMM was performed. The definition of CMM was from the Patient-Centered Primary Care Collaborative and was defined as the standard of care that ensures that all of a patient’s medications are appropriate, effective, safe, and able to be taken by the patient as directed. It includes a care plan to achieve goals of therapy and a follow-up plan.15 Pharmacists had scheduled CMM visits during the day but also performed CMM as needed in response to medication reconciliation. The pharmacists purposefully do not have a fully scheduled day of patient visits because they also need to be available for physician consults, anticoagulation management, and seeing patients per physician request. Although clinical pharmacists cannot bill for medication reconciliation, medication management by pharmacists in a clinical setting is a billable service in Minnesota for medical assistance recipients, even when the patient also is seeing a physician on the same day. The codes used are 99605, 99606, and 99607, and the level of service is dependent on the number of medications, medical conditions, and drug therapy problems identified.16 The number of patients seen for medication reconciliation who then received CMM was documented to determine whether medication reconciliation was an effective method to identify appropriate patients for CMM. The clinical importance of each discrepancy was determined based on the pharmacist’s clinical judgment, but each clinical pharmacist followed general guidelines. For example, discrepancies from short-term medications still on the list (e.g., antibiotics) and overthe-counter (OTC) medications (e.g., multivitamins, docusate) generally were not considered clinically important. Dose discrepancies of important prescription medications (e.g., patient’s metoprolol dose was increased by cardiologist), the omission of physician184 JAPhA | 5 4 :2 | M AR/AP R 2014
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Table 1. Characteristics of patients receiving medication reconciliation at the clinic Characteristic n Age (years), mean ± SD Gender Women Men Race/ethnicity White Black Hmong Other Asian Somali Hispanic Other Interpreter needed Had medications with them Had medication list Has a home health nurse Has a patient care assistant
% 327 55.9 ± 14.9 67.3 32.7 45.3 35.2 10.1 4.0 3.1 1.5 0.9 15.5 23.2 25.4 16.5 10.1
prescribed medications (e.g., new medication started in hospital), and prescribed medications discontinued by the patient (e.g., patient stopped metformin because of adverse effects but did not inform their physician) were deemed clinically important. The clinical pharmacists may have deviated from the categories based on clinical judgment. For example, OTC medications may have been considered clinically important if a patient on warfarin was taking OTC aspirin or ibuprofen. Likewise, a prescribed medication discontinued by the patient may not have been clinically important (e.g., discontinuation of seasonal allergy medication that was no longer needed). Data collection and analysis Each patient was assigned an anonymous identifier. A spreadsheet linking patient identifiers with actual patients was maintained on a password-protected computer by the clinical pharmacists. After each visit, the EHR documentation note was printed with all patient identifiers removed. The anonymous identifier was recorded on the printed note. These notes were collected for data entry and analysis by the primary investigator. Descriptive statistics were used to report the results.
Results Medication reconciliation was performed for a total of 327 patients during a 1-year period. Patient characteristics are summarized in Table 1 and reflect the population seen at the clinic. At least one discrepancy was found in 322 (98.5%) patients. A total of 2,164 discrepancies were identified, with more than one-half (51.1%) Journal of the American Pharmacists Association
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considered clinically important. All medication discrepancies were resolved, and all medication lists in the EHR were updated to reflect the medications that the patient was actually taking. Means (± SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies were found per patient. The range of total discrepancies per patient was 0 to 26. Overall, medication reconciliation shortened patients’ total number of medications (15.4 ± 6.1 before the visit, 12.5 ± 5.6 after medication reconciliation). Overall, 59.3% of patients were considered knowledgeable, 24.2% somewhat knowledgeable, and 16.5% not knowledgeable. Regarding medication discrepancies, the category of discrepancy type with the highest frequency of discrepancies was “patient no longer taking medication on list” (54.1%) and, overall, a majority of discrepancies resulted from patients making changes to their medications (Figure 1). However, when discrepancies were evaluated within individual categories, the cause varied. For example, in the categories “current medication not on list” and “dosage listed differently than how patient is taking,” almost one-half of the discrepancies occurred because a specialist prescribed or changed the medication. However, in the categories “frequency listed differently than how patient is taking” and “patient no longer taking medication on list,” the patient was the source of approximately one-half of the discrepancies. Medication discrepancies also were organized by medication category. Among the top three were pain medications (11.4%), gastrointestinal medications (9.9%), and topical preparations (7.1%; Table 2).
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Table 2. Discrepancies by medication category Medication category Prescription/OTC pain Prescription/OTC GI Prescription/OTC topical Supplement/herbal Prescription/OTC vitamin Inhaler/nebulizer Antihypertensive Prescription/OTC allergy/cough/cold Antidepressant Antidiabetic
% 11.4 9.9 7.1 7.0 6.9 6.5 6.5 5.8 5.3 4.6
Abbreviations used: GI, gastrointestinal; OTC, over the counter.
Prescription medications were implicated in 68.8% of the discrepancies. Individual medications also were tracked, and they varied greatly, with the most common medication causing discrepancies (albuterol) accounting for only 3.1% of all discrepancies. Medication reconciliation proved to be an effective method to identify patients for CMM, as CMM was performed in 48.3% of patients. CMM did not affect the resolution of medication discrepancies.
Discussion In this study, medication reconciliation by clinical pharmacists in an outpatient family medicine clinic identified and resolved 2,164 medication discrepancies in 1 year. Because approximately one-half of these dis-
1,200 Short term 1,000
Patient Specialist provider
800
Bethesda physician 600 400 200 0
Current Not taking medication not medication on on list list
Dosage differs
Frequency differs
Figure 1. Medication discrepancies by category and cause Journal of the American Pharmacists Association
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crepancies were thought to be clinically important, this intervention is likely to have affected patient care positively. With 6.6 ± 4.5 discrepancies per patient, EHR medication list discrepancies clearly were prevalent. Compared with another pharmacist-led ambulatory care medication reconciliation study by Stewart and Lynch,14 our study had more patients (327 vs. 219) and found more discrepancies (2,164 vs. 499) in a greater percentage of patients (98.5% vs. 74%) and in a shorter amount of time (12 vs. 13 months). In our study, discrepancies also were reported regardless of whether they were clinically important. Our study found an average of 6.6 ± 4.5 discrepancies per patient, but Stewart and Lynch did not report this information. Our study may have identified more discrepancies in more patients for a number of reasons. Our study required patients to be taking 10 or more medications, whereas Stewart and Lynch14 did not have such a requirement. Patients in our study had many more medications on their medication lists before medication reconciliation (15.4 ± 6.1 vs. 4.4 [mean]). As pharmacists cost more to employ than other clinic staff who can perform medication reconciliation, resources should be focused on patients most likely to benefit from medication reconciliation by pharmacists, such as those taking at least 10 medications. In addition, the practice setting in the study of Stewart and Lynch was very different from ours. Their study included both primary care and specialty services; therefore, perhaps their patients were seeing fewer outside providers. In addition, the clinic in the study of Stewart and Lynch was a free clinic serving indigent patients and providing free medications or using manufacturer prescription assistance programs. Our patients almost exclusively obtained their medications from a pharmacy, usually paying a copay. The patients in Stewart and Lynch may have been more likely to take their medications when they were being provided for free with no copay, therefore reducing the number of possible discrepancies. The source of medication discrepancies found in this study highlights the need for pharmacists in PCMHs. Approximately 20% of the discrepancies came from specialty care providers. When pharmacists are a consistent part of PCMHs, these discrepancies can be caught and addressed when patients are seen by their primary care provider. The NCQA PCMH standard 3D assesses medical homes on medication management, including medication reconciliation at care transitions and at least yearly; assesses patient understanding of and response to medications; and documents OTC and herbal therapies.4 This is especially relevant as both this study and the study by Stewart and Lynch14 found that a high percentage of discrepancies were caused by OTCs being left off medication lists. Some of the discrepancies identified in this study could have been easily prevented. For example, ap186 JAPhA | 5 4 :2 | M AR/AP R 2014
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proximately 13% of discrepancies were caused by short-term medications remaining on the EHR medication list, which could have been prevented by adding an end date to the electronic prescription, thereby automatically removing the medications from the medication list when the course of therapy was complete. An education campaign launched at a family medicine clinic to educate providers on adding end dates to EHR prescriptions showed some success.17 However, these discrepancies usually are not clinically important. Predicting discrepancies would be ideal, but unfortunately, based on data reported here, it would be difficult. Given that the most common medication implicated in discrepancies (albuterol) only garnered 3.1% of all discrepancies, it would not be feasible to try to identify “high-risk” medications that may indicate the presence of discrepancies. This also would hold true for trying to identify potential discrepancies by categories of medications. In addition, more than one-half of the discrepancies occurred outside of the control of the primary care clinic, as they were caused by specialist physicians or patients. Considering that patients averaged three clinically important discrepancies, the lack of ability to predict discrepancies highlights the importance of regular medication reconciliation in the outpatient setting. This study was the first to quantify the frequency of CMM performed as a direct result of medication reconciliation (48.3%). Patients identified as those who would benefit from medication reconciliation based on polypharmacy also would benefit from CMM. As CMM is a billable service, medication reconciliation by a pharmacist, which leads to CMM, may help sustain a clinical pharmacist position.
Limitations The limitations of this study included the subjective nature of some of the data points collected (i.e., patient knowledge status, clinical importance of discrepancy), potential lack of interreliability resulting from two clinical pharmacists conducting medication reconciliation, and not knowing the percentage of eligible patients who were seen. In addition, the time spent conducting medication reconciliation and CMM were not recorded. A strength of this study was the high number of patients who were seen, resulting in a large number of discrepancies and the ability to categorize discrepancies.
Conclusion This study shows that EHR medication list discrepancies are prevalent in the outpatient setting and that onehalf may be clinically important. Clinical pharmacists can play an important role in identifying and resolving medication discrepancies by performing medication reconciliation in outpatient clinics, which can affect patient care positively. Pharmacists require more fiJournal of the American Pharmacists Association
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nancial resources than some other health professionals (e.g., nurses); therefore, focusing efforts of pharmacistconducted medication reconciliation in patients taking 10 or more medications may be prudent. Conducting medication reconciliation in these patients also may be an effective means of identifying patients for CMM.
8. Steurbaut S, Leemans L, Leysen T, et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010;44(10):1596–603.
References
10. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441–7.
1. American Pharmacists Association, American Society of HealthSystem Pharmacists. Improving care transitions: optimizing medication reconciliation. www.ashp.org/DocLibrary/Policy/PatientSafety/ Optimizing-Med-Reconciliation.aspx. Accessed April 9, 2013. 2.
The Joint Commission. The Joint Commission Accreditation Program: Hospital National Patient Safety Goals. www.jointcommission.org/ assets/1/6/2011_NPSGs_HAP.pdf. Accessed November 27, 2012.
3. The Joint Commission. National Patient Safety Goals effective January 1, 2013: Ambulatory Health Care Accreditation Program. www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_AHC.pdf. Accessed April 9, 2013. 4. National Committee for Quality Assurance (NCQA). Patient-centered medical home (PCMH) 2011 standards. https://inetshop01.pub.ncqa. org/Publications/deptCate.asp?dept_id=2&cateID=300&sortOrder=7 96&mscssid=#300796. Accessed June 26, 2013. 5. Centers for Medicare & Medicaid Services. Accountable care organization 2013 program analysis: quality performance standards narrative measure specifications. www.cms.gov/Medicare/MedicareFee-for-Service-Payment/sharedsavingsprogram/Downloads/ACONarrativeMeasures-Specs.pdf. Accessed May 6, 2013. 6. Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523–6. 7. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory care setting. JAMA. 2003;289(9):1107–16.
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9. Corrigan MA, Atkinson KM, Sha BE, Crank CW. Evaluation of pharmacy-implemented medication reconciliation directed at antiretroviral therapy in hospitalized HIV/AIDS patients. Ann Pharmacother. 2010;44(1):222–3.
11. Boockvar KS, Blum S, Kugler A, et al. Effect of admission medication reconciliation on adverse drug events from admission medication changes. Arch Intern Med. 2011;171(9):860–1. 12. De Winter S, Spriet I, Indevuyst C, et al. Pharmacist- versus physicianacquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010;19(5):371–5. 13. 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(8):850–4. 14. Stewart AL, Lynch KL. Identifying discrepancies in electronic medical records through pharmacist medication reconciliation. J Am Pharm Assoc. 2012;52(1):59–66. 15. Patient-Centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. http://www.pcpcc.org/sites/default/files/ media/medmanagement.pdf. Accessed December 5, 2013. 16. Minnesota Department of Human Services. Medication therapy management services (MTMS). www.dhs.state.mn.us/main/ idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelecti onMethod=LatestReleased&dDocName=dhs16_136889. Accessed July 9, 2013. 17. Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14(7):626–31.
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Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic Anna S. Milone, Ann M. Philbrick, Ila M. Harris, and Christopher J. Fallert
Received November 27, 2012, and in revised form July 11, 2013. Accepted for publication September 15, 2013.
Abstract Objectives: To evaluate the incidence of medication discrepancies in electronic health record (EHR) medication lists in an outpatient family medicine clinic where clinical pharmacists perform medication reconciliation, to classify and resolve the discrepancies, to identify the most common medication classes involved, and to assess the clinical importance of the discrepancies. Methods: This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, with data collected from February 2009 to February 2010. To be included, patients had to be 18 years or older and have at least 10 medications listed in the EHR. The clinical pharmacist saw each patient before the physician, reviewed the medication list with the patient, and made corrections to the EHR medication list. When possible, comprehensive medication management (CMM) also was conducted. Results: During 1 year, 327 patients were seen for medication reconciliation. A total of 2,167 discrepancies were identified and resolved, with a mean (±SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies per patient. The range of total discrepancies per patient was 0 to 26. The most common discrepancy category was “patient not taking medication on list” (54.1%). Overall, the source of the discrepancy usually was the patient, but it varied according to discrepancy category. The most common medication classes involved were pain medications, gastrointestinal medications, and topical medications. Of the 2,167 discrepancies, 51.1% were determined to be clinically important by the pharmacist. The pharmacist conducted CMM in 48% of patients.
Anna S. Milone, PharmD, is Professional Education Teaching Specialist; and Ann M. Philbrick, PharmD, BCPS, is Assistant Professor, College of Pharmacy, University of Minnesota, Twin Cities, Minneapolis. Ila M. Harris, PharmD, FCCP, BCPS, is Associate Professor; and Christopher J. Fallert, MD, is Assistant Professor, Medical School, University of Minnesota, Twin Cities, Minneapolis. Correspondence: Ann M. Philbrick, PharmD, BCPS, Bethesda Family Medicine Clinic, 580 Rice St., Saint Paul, MN 55103. Fax: 651-665-0684. Email: [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. Published online ahead of print at www. japha.org on February 11, 2014.
Conclusion: Outpatient medication reconciliation by a pharmacist identified and resolved a large number of medication discrepancies and improved the accuracy of EHR medication lists. Because more than 50% of the discrepancies were thought to be clinically important, improving the accuracy of medication lists could affect patient care. Keywords: Medication reconciliation, outpatient setting, pharmacists. J Am Pharm Assoc. 2014;54:181–187. doi: 10.1331/JAPhA.2014.12230
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edication reconciliation is a frequently discussed topic in pharmaceutical care. In 2007, the American Pharmacists Association and the American Society of Health-System Pharmacists collaborated to provide the following definition for medication reconciliation: “the comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well to observe compliance and adherence patterns. This process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are rewritten or adjusted, or if the patient has added nonprescription medications to (his or her) self-care.”1 The use of medication reconciliation has been promoted by many national organizations, including The Joint Commission, as a means to reduce medication er-
At a Glance Synopsis: Medication reconciliation by clinical pharmacists in an outpatient family medicine clinic identified and resolved 2,164 medication discrepancies in 1 year, resulting in improved accuracy of electronic health record (EHR) medication lists. The most common discrepancy category was “patient not taking medication on list” (54.1%). Overall, patients typically were the source of medication discrepancies, but this varied according to discrepancy category. More than 50% of the discrepancies were thought to be clinically important; therefore, improving the accuracy of medication lists could have a positive effect on patient care. Analysis: Some of the discrepancies identified in this study could have been easily prevented. For example, approximately 13% of discrepancies were caused by short-term medications remaining on the EHR medication list, which could have been prevented by adding an end date to the electronic prescription, thereby automatically removing the medications from the medication list when the course of therapy was complete. Although predicting discrepancies would be ideal, these data demonstrate the difficulty of such a possibility. Given that the most common medication implicated in discrepancies (albuterol) only garnered 3.1% of all discrepancies, identifying high-risk medications that may indicate the presence of discrepancies would not be feasible. Considering that patients averaged three clinically important discrepancies, the lack of ability to predict discrepancies highlights the importance of regular medication reconciliation in the outpatient setting.
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rors and prevent adverse drug events (ADEs). Medication reconciliation first came to the forefront of health care initiatives in 2005 when National Patient Safety Goal (NPSG) 8 was introduced; it sought to “accurately and completely reconcile medications across the continuum of care.”2 This goal, originally aimed at improving medication errors in the hospital setting, has since been expanded to ambulatory care. Effective January 1, 2013, The Joint Commission introduced NPSG 03.06.01: “Maintain and communicate patient medication information.”3 This safety goal stresses five areas of success: (1) obtaining and/or updating information on the medications that patients are currently taking, (2) defining the types of medication information to be collected (i.e., name, dose, strength, frequency, purpose), (3) comparing the medication information the patient brought with the medications ordered to identify and resolve discrepancies, (4) providing patients with written information on the medications that they should be taking following completion of the care episode, and (5) explaining the importance of managing medication information to patients at the end of care episode.3 The National Committee for Quality Assurance (NCQA) stressed medication management and specifically medication reconciliation in its 2011 standards for patient-centered medical homes (PCMHs).4 In addition, medication reconciliation is a core measurement in the Centers for Medicare and Medicaid ServicesGuidelines for Accountable Care Organizations (ACOs). ACOs are measured based on the percentage of patients 65 years or older discharged from any inpatient facility who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record.5 Although much of the information surrounding medication reconciliation is based in the hospital setting, ADEs also are a major problem in ambulatory care. Approximately one-third of ADEs happen in the ambulatory setting.6 The rate of ADEs in older patients in the ambulatory care setting has been reported as 50.1 per 1,000 person-years, with 38% of ADEs categorized as serious and 27.6% considered preventable.7 Pharmacists can play a major role in managing patient medications and decreasing ADEs. Many studies have shown decreased medication errors and decreased ADEs when pharmacists perform medication reconciliation in an inpatient setting.8–13 However, studies are just beginning to show the benefit of pharmacistled medication reconciliation in the ambulatory care setting. Thus far, only one study has been published regarding pharmacist-led medication reconciliation in an outpatient setting. Stewart and Lynch14 studied medication discrepancies through pharmacist-conducted medication reconciliation in a free ambulatory care clinic with several specialty services for indigent, uninsured patients. Their study objectives included describing discrepanJournal of the American Pharmacists Association
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cies and identifying patient characteristics related to the presence of discrepancies. There was no requirement for the minimum number of medications patients were taking. Data were collected over 13 months and included a total of 219 patients, among whom 499 medication discrepancies were found. The most common type of discrepancy found was medication reported by patients not listed on the electronic health record (EHR; 51.5%). Stewart and Lynch also found that the presence of at least one discrepancy was associated with taking three or more medications.
Objectives The primary objective of the current work was to evaluate the incidence of medication discrepancies in EHR medication lists. The secondary objectives were to classify discrepancies, identify the most common medication classes involved, estimate the clinical importance of the discrepancies, and determine whether medication reconciliation was an effective means to identify patients in whom comprehensive medication management (CMM) should be conducted. Previous studies have not looked at whether medication reconciliation is an effective method to identify patients for CMM. This is applicable to pharmacy practice structures and viability because CMM is a billable service, whereas medication reconciliation alone in an ambulatory setting is not billable. The overall goal of this process improvement was to improve accuracy of patient medication lists and increase collaboration between physicians and pharmacists through pharmacist-performed medication reconciliation.
Methods This research was conducted at Bethesda Family Medicine Clinic in St. Paul, MN, and data were collected from February 2009 to February 2010. Bethesda Family Medicine Clinic is a training site for University of Minnesota Family Medicine residents and serves as a rotation site for advanced practice experiences of medical students and student pharmacists. It serves a low-income population, and the majority of patients have medication insurance from the State of Minnesota, which provides medications for a low copay. St. Paul is a U.S. designated resettlement city, so Bethesda Family Medicine Clinic has a large population of refugees from Southeast Asia. Bethesda Family Medicine Clinic is now a statedesignated health care home, though it was not at the time of this study. Two clinical pharmacists each spend 2 days per week at the clinic, providing 4 days per week of clinical pharmacy services. One of the clinical pharmacists is funded by the college of pharmacy, and one is funded by the medical school/clinic site. Practice obligations include conducting CMM, serving as consultants to physicians, and educating medical residents and student pharmacists. Pharmacists perform CMM Journal of the American Pharmacists Association
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and provide pharmacist-managed anticoagulation and smoking cessation services. This study was given exempt status by the Institutional Review Board at the University of Minnesota, Twin Cities. Eligibility criteria were age 18 years or older, scheduled for an appointment with a physician, and 10 or more medications listed in the EHR. This number was used because it indicated polypharmacy and was an easily identified number of medications on our rooming notes by patient care staff. Although polypharmacy commonly is defined in the literature as five or more drugs, the number of patients meeting this criteria in a clinic day would far exceed the acceptable number of patients that one clinical pharmacist could see. Although medication reconciliation was performed for patients every 6 months, after transitions of care, or as requested by the primary physician, only the data from the first medication reconciliation were included in this study. Process Patient care staff identified eligible patients based on the EHR medication list as part of the rooming process and paged the clinical pharmacist to the exam room. The clinical pharmacist saw the patient for medication reconciliation immediately before the physician visit. Because the clinical pharmacist has many clinical duties other than medication reconciliation and approximately 96 patients are seen daily in the clinic, only a portion of eligible patients could be seen. When a clinical pharmacist was unable to see a patient, it was the provider’s responsibility to ensure that the medication list was accurate. For patients taking fewer than 10 medications, the patient care staff performed medication reconciliation. During medication reconciliation, the clinical pharmacist reviewed the medication list with the patient and/or caregiver and made corrections to the EHR medication list. The final medication list was updated to reflect what the patient was actually taking. If the patient was not knowledgeable about their medications and did not have their medications or a written medication list with them, their pharmacy was called and dispensing records were reviewed. The clinical pharmacist verbally communicated any important omissions, changes, and/or drug therapy recommendations to the provider when possible. When verbal comments were not possible, a written note was left at the provider’s workstation. At the end of the visit, the patient was provided with an updated printed medication list. Each visit was documented in the EHR using a standard template (Appendix 1 in the electronic version of this article, available online at www.japha.org). Demographic information and a subjective assessment of patient knowledge of medications were collected. Patients were determined to be knowledgeable if they could j apha.org
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name and describe how they were taking most of their medications, somewhat knowledgeable if they required prompting by the pharmacist, and not knowledgeable if they were unable to state the medications they were taking, even after prompting by the pharmacist. Medication discrepancies were recorded and classified in the categories “current medication not on list,” “patient no longer taking medication on list,” “dosage listed differently than how patient is taking,” “frequency listed differently than how patient is taking,” and “duplicate medication on list.” From there, they were further classified into subcategories, by who was responsible for the discrepancy: a provider at the clinic, a provider outside of the clinic (labeled as specialty provider), or the patient. When a hospital discharge or home health/ nursing home medication list was involved, discrepancies between that list and the clinic EHR medication list also were recorded. Finally, the actual medications involved in each discrepancy were recorded for each patient. If time permitted, CMM was performed. The definition of CMM was from the Patient-Centered Primary Care Collaborative and was defined as the standard of care that ensures that all of a patient’s medications are appropriate, effective, safe, and able to be taken by the patient as directed. It includes a care plan to achieve goals of therapy and a follow-up plan.15 Pharmacists had scheduled CMM visits during the day but also performed CMM as needed in response to medication reconciliation. The pharmacists purposefully do not have a fully scheduled day of patient visits because they also need to be available for physician consults, anticoagulation management, and seeing patients per physician request. Although clinical pharmacists cannot bill for medication reconciliation, medication management by pharmacists in a clinical setting is a billable service in Minnesota for medical assistance recipients, even when the patient also is seeing a physician on the same day. The codes used are 99605, 99606, and 99607, and the level of service is dependent on the number of medications, medical conditions, and drug therapy problems identified.16 The number of patients seen for medication reconciliation who then received CMM was documented to determine whether medication reconciliation was an effective method to identify appropriate patients for CMM. The clinical importance of each discrepancy was determined based on the pharmacist’s clinical judgment, but each clinical pharmacist followed general guidelines. For example, discrepancies from short-term medications still on the list (e.g., antibiotics) and overthe-counter (OTC) medications (e.g., multivitamins, docusate) generally were not considered clinically important. Dose discrepancies of important prescription medications (e.g., patient’s metoprolol dose was increased by cardiologist), the omission of physician184 JAPhA | 5 4 :2 | M AR/AP R 2014
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Table 1. Characteristics of patients receiving medication reconciliation at the clinic Characteristic n Age (years), mean ± SD Gender Women Men Race/ethnicity White Black Hmong Other Asian Somali Hispanic Other Interpreter needed Had medications with them Had medication list Has a home health nurse Has a patient care assistant
% 327 55.9 ± 14.9 67.3 32.7 45.3 35.2 10.1 4.0 3.1 1.5 0.9 15.5 23.2 25.4 16.5 10.1
prescribed medications (e.g., new medication started in hospital), and prescribed medications discontinued by the patient (e.g., patient stopped metformin because of adverse effects but did not inform their physician) were deemed clinically important. The clinical pharmacists may have deviated from the categories based on clinical judgment. For example, OTC medications may have been considered clinically important if a patient on warfarin was taking OTC aspirin or ibuprofen. Likewise, a prescribed medication discontinued by the patient may not have been clinically important (e.g., discontinuation of seasonal allergy medication that was no longer needed). Data collection and analysis Each patient was assigned an anonymous identifier. A spreadsheet linking patient identifiers with actual patients was maintained on a password-protected computer by the clinical pharmacists. After each visit, the EHR documentation note was printed with all patient identifiers removed. The anonymous identifier was recorded on the printed note. These notes were collected for data entry and analysis by the primary investigator. Descriptive statistics were used to report the results.
Results Medication reconciliation was performed for a total of 327 patients during a 1-year period. Patient characteristics are summarized in Table 1 and reflect the population seen at the clinic. At least one discrepancy was found in 322 (98.5%) patients. A total of 2,164 discrepancies were identified, with more than one-half (51.1%) Journal of the American Pharmacists Association
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considered clinically important. All medication discrepancies were resolved, and all medication lists in the EHR were updated to reflect the medications that the patient was actually taking. Means (± SD) of 6.6 ± 4.5 total discrepancies and 3.4 ± 3.2 clinically important discrepancies were found per patient. The range of total discrepancies per patient was 0 to 26. Overall, medication reconciliation shortened patients’ total number of medications (15.4 ± 6.1 before the visit, 12.5 ± 5.6 after medication reconciliation). Overall, 59.3% of patients were considered knowledgeable, 24.2% somewhat knowledgeable, and 16.5% not knowledgeable. Regarding medication discrepancies, the category of discrepancy type with the highest frequency of discrepancies was “patient no longer taking medication on list” (54.1%) and, overall, a majority of discrepancies resulted from patients making changes to their medications (Figure 1). However, when discrepancies were evaluated within individual categories, the cause varied. For example, in the categories “current medication not on list” and “dosage listed differently than how patient is taking,” almost one-half of the discrepancies occurred because a specialist prescribed or changed the medication. However, in the categories “frequency listed differently than how patient is taking” and “patient no longer taking medication on list,” the patient was the source of approximately one-half of the discrepancies. Medication discrepancies also were organized by medication category. Among the top three were pain medications (11.4%), gastrointestinal medications (9.9%), and topical preparations (7.1%; Table 2).
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Table 2. Discrepancies by medication category Medication category Prescription/OTC pain Prescription/OTC GI Prescription/OTC topical Supplement/herbal Prescription/OTC vitamin Inhaler/nebulizer Antihypertensive Prescription/OTC allergy/cough/cold Antidepressant Antidiabetic
% 11.4 9.9 7.1 7.0 6.9 6.5 6.5 5.8 5.3 4.6
Abbreviations used: GI, gastrointestinal; OTC, over the counter.
Prescription medications were implicated in 68.8% of the discrepancies. Individual medications also were tracked, and they varied greatly, with the most common medication causing discrepancies (albuterol) accounting for only 3.1% of all discrepancies. Medication reconciliation proved to be an effective method to identify patients for CMM, as CMM was performed in 48.3% of patients. CMM did not affect the resolution of medication discrepancies.
Discussion In this study, medication reconciliation by clinical pharmacists in an outpatient family medicine clinic identified and resolved 2,164 medication discrepancies in 1 year. Because approximately one-half of these dis-
1,200 Short term 1,000
Patient Specialist provider
800
Bethesda physician 600 400 200 0
Current Not taking medication not medication on on list list
Dosage differs
Frequency differs
Figure 1. Medication discrepancies by category and cause Journal of the American Pharmacists Association
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crepancies were thought to be clinically important, this intervention is likely to have affected patient care positively. With 6.6 ± 4.5 discrepancies per patient, EHR medication list discrepancies clearly were prevalent. Compared with another pharmacist-led ambulatory care medication reconciliation study by Stewart and Lynch,14 our study had more patients (327 vs. 219) and found more discrepancies (2,164 vs. 499) in a greater percentage of patients (98.5% vs. 74%) and in a shorter amount of time (12 vs. 13 months). In our study, discrepancies also were reported regardless of whether they were clinically important. Our study found an average of 6.6 ± 4.5 discrepancies per patient, but Stewart and Lynch did not report this information. Our study may have identified more discrepancies in more patients for a number of reasons. Our study required patients to be taking 10 or more medications, whereas Stewart and Lynch14 did not have such a requirement. Patients in our study had many more medications on their medication lists before medication reconciliation (15.4 ± 6.1 vs. 4.4 [mean]). As pharmacists cost more to employ than other clinic staff who can perform medication reconciliation, resources should be focused on patients most likely to benefit from medication reconciliation by pharmacists, such as those taking at least 10 medications. In addition, the practice setting in the study of Stewart and Lynch was very different from ours. Their study included both primary care and specialty services; therefore, perhaps their patients were seeing fewer outside providers. In addition, the clinic in the study of Stewart and Lynch was a free clinic serving indigent patients and providing free medications or using manufacturer prescription assistance programs. Our patients almost exclusively obtained their medications from a pharmacy, usually paying a copay. The patients in Stewart and Lynch may have been more likely to take their medications when they were being provided for free with no copay, therefore reducing the number of possible discrepancies. The source of medication discrepancies found in this study highlights the need for pharmacists in PCMHs. Approximately 20% of the discrepancies came from specialty care providers. When pharmacists are a consistent part of PCMHs, these discrepancies can be caught and addressed when patients are seen by their primary care provider. The NCQA PCMH standard 3D assesses medical homes on medication management, including medication reconciliation at care transitions and at least yearly; assesses patient understanding of and response to medications; and documents OTC and herbal therapies.4 This is especially relevant as both this study and the study by Stewart and Lynch14 found that a high percentage of discrepancies were caused by OTCs being left off medication lists. Some of the discrepancies identified in this study could have been easily prevented. For example, ap186 JAPhA | 5 4 :2 | M AR/AP R 2014
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proximately 13% of discrepancies were caused by short-term medications remaining on the EHR medication list, which could have been prevented by adding an end date to the electronic prescription, thereby automatically removing the medications from the medication list when the course of therapy was complete. An education campaign launched at a family medicine clinic to educate providers on adding end dates to EHR prescriptions showed some success.17 However, these discrepancies usually are not clinically important. Predicting discrepancies would be ideal, but unfortunately, based on data reported here, it would be difficult. Given that the most common medication implicated in discrepancies (albuterol) only garnered 3.1% of all discrepancies, it would not be feasible to try to identify “high-risk” medications that may indicate the presence of discrepancies. This also would hold true for trying to identify potential discrepancies by categories of medications. In addition, more than one-half of the discrepancies occurred outside of the control of the primary care clinic, as they were caused by specialist physicians or patients. Considering that patients averaged three clinically important discrepancies, the lack of ability to predict discrepancies highlights the importance of regular medication reconciliation in the outpatient setting. This study was the first to quantify the frequency of CMM performed as a direct result of medication reconciliation (48.3%). Patients identified as those who would benefit from medication reconciliation based on polypharmacy also would benefit from CMM. As CMM is a billable service, medication reconciliation by a pharmacist, which leads to CMM, may help sustain a clinical pharmacist position.
Limitations The limitations of this study included the subjective nature of some of the data points collected (i.e., patient knowledge status, clinical importance of discrepancy), potential lack of interreliability resulting from two clinical pharmacists conducting medication reconciliation, and not knowing the percentage of eligible patients who were seen. In addition, the time spent conducting medication reconciliation and CMM were not recorded. A strength of this study was the high number of patients who were seen, resulting in a large number of discrepancies and the ability to categorize discrepancies.
Conclusion This study shows that EHR medication list discrepancies are prevalent in the outpatient setting and that onehalf may be clinically important. Clinical pharmacists can play an important role in identifying and resolving medication discrepancies by performing medication reconciliation in outpatient clinics, which can affect patient care positively. Pharmacists require more fiJournal of the American Pharmacists Association
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nancial resources than some other health professionals (e.g., nurses); therefore, focusing efforts of pharmacistconducted medication reconciliation in patients taking 10 or more medications may be prudent. Conducting medication reconciliation in these patients also may be an effective means of identifying patients for CMM.
8. Steurbaut S, Leemans L, Leysen T, et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010;44(10):1596–603.
References
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3. The Joint Commission. National Patient Safety Goals effective January 1, 2013: Ambulatory Health Care Accreditation Program. www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_AHC.pdf. Accessed April 9, 2013. 4. National Committee for Quality Assurance (NCQA). Patient-centered medical home (PCMH) 2011 standards. https://inetshop01.pub.ncqa. org/Publications/deptCate.asp?dept_id=2&cateID=300&sortOrder=7 96&mscssid=#300796. Accessed June 26, 2013. 5. Centers for Medicare & Medicaid Services. Accountable care organization 2013 program analysis: quality performance standards narrative measure specifications. www.cms.gov/Medicare/MedicareFee-for-Service-Payment/sharedsavingsprogram/Downloads/ACONarrativeMeasures-Specs.pdf. Accessed May 6, 2013. 6. Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med. 2007;22(11):1523–6. 7. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory care setting. JAMA. 2003;289(9):1107–16.
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9. Corrigan MA, Atkinson KM, Sha BE, Crank CW. Evaluation of pharmacy-implemented medication reconciliation directed at antiretroviral therapy in hospitalized HIV/AIDS patients. Ann Pharmacother. 2010;44(1):222–3.
11. Boockvar KS, Blum S, Kugler A, et al. Effect of admission medication reconciliation on adverse drug events from admission medication changes. Arch Intern Med. 2011;171(9):860–1. 12. De Winter S, Spriet I, Indevuyst C, et al. Pharmacist- versus physicianacquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010;19(5):371–5. 13. 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(8):850–4. 14. Stewart AL, Lynch KL. Identifying discrepancies in electronic medical records through pharmacist medication reconciliation. J Am Pharm Assoc. 2012;52(1):59–66. 15. Patient-Centered Primary Care Collaborative. The patient-centered medical home: integrating comprehensive medication management to optimize patient outcomes. http://www.pcpcc.org/sites/default/files/ media/medmanagement.pdf. Accessed December 5, 2013. 16. Minnesota Department of Human Services. Medication therapy management services (MTMS). www.dhs.state.mn.us/main/ idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelecti onMethod=LatestReleased&dDocName=dhs16_136889. Accessed July 9, 2013. 17. Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient medication use. J Manag Care Pharm. 2008;14(7):626–31.
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