In medicine, we talk about quality a lot. But most of the time that we are talking about it, we're really not talking about quality at all. You see, quality...
The importance of an accurate medication list for every outpatient cannot be overstated. In theory, the electronic medical record should improve the accuracy of the medication list but in reality, medication lists are very often inaccurate. The act of verifying the medication list is called “medication reconciliation” which sounds so easy on the surface but is so hard in reality.
The Agency for Healthcare Research and Quality (an agency of the U.S. Department of Health and Human Services) says that there should be a single medication list that is the “one source of truth” for the patient and that medical practices should standardize and simplify the medication reconciliation process in order to make the right thing to do the easiest thing to do. But in most outpatient practices, mediation reconciliation is neither standardized, simple, or easy. Pull up any patient’s electronic medical record and if that patient sees more than 1 physician, there is a pretty good chance that the medication list is not accurate. Here are some of the reasons why:
- No stop date on short-term medications. Recently, I opened a patient’s chart and found that the medication list included amoxicillin. I asked the patient who said she wasn’t taking amoxicillin. So I pulled up the medication history and found that she had gotten a 7-day course of amoxicillin in 2009 (8 years ago) but it had never been taken off of her list. With electronic prescribing, a physician can set a duration of therapy (or set a stop date) and after that time, the medication falls off of the medication list. However, even if only 14 pills are prescribed with no refills, if the physician does not set the duration or stop date, then that medication stays on the list in perpetuity. I prescribe a lot of short courses of prednisone and antibiotics and so I have my own prescriptions for these commonly prescribed short-term medications in my “preference list” in our electronic medical record and these include a fixed number of days duration. But many physicians don’t have a preference setting for every antibiotic or other short-term medication that they prescribe and so if they don’t manually enter the stop date every time they write a prescription, that medication will continue to appear to be a long-term maintenance medication forever.
- Restricted hospital formularies. Hospital pharmacies cannot stock every single medication that is on the market. First, it is too expensive to maintain that wide of an inventory. Second, each hospital negotiates with various pharmaceutical companies or medication wholesalers for the least expensive of therapeutically equivalent medications in order to keep their costs down. As a consequence, when, for example, a patient with asthma taking the inhaler Advair gets admitted to a hospital that does not have Advair on the formulary but does have the similar inhaler, Symbicort, then the admitting hospitalist will prescribe Symbicort while the patient is in the hospital. When that patient gets discharged, it is very easy for Symbicort to show up on the discharge medication list but since the patient does not know that Advair and Symbicort are equivalent drugs, that patient will start taking both inhalers. When that patient then sees a primary care physician, the medication list will include Symbicort instead of Advair even though the patient is now taking both drugs.
- “Don’t mess with my medication list”. Frequently, the responsibility for maintaining an accurate medication list falls to the primary care physician and in large, multi-group practices, specialists are often told not to take anything off of the patient’s medication list unless checking with the primary care physician first in order to insure that the list is, in fact, correct. The problem is that nobody has time to check with a patient’s primary care physician every time a patient says that they are not taking a medication that appears on their list so the path of least resistance is for specialist to never delete a medication from the list, only add new medications that they prescribe.
- Leaving medication reconciliation only up to the doctor. Medicare sets the rules for what nurses or medical students can document in the medical record and what the physician has to document. The “past medical history” is a chart component that nurses and medical students are permitted to document. The past medical history is supposed to include the patient’s medication list. Consequently, in many practices, the first time a patient is seen in that practice, the nurse will record the past medical history, including the patient’s allergies, previous surgeries, and current medications. Because it takes a lot of time to enter a long list of medications (including dose, frequency of administration, etc.), it makes sense to have a nurse or medical assistant do all of that documentation, thus freeing the physician’s time up to see more patients. But in many parts of the country, medication reconciliation is considered to be equivalent to prescribing a medication and so physicians are the only ones who can do medication reconciliation which includes taking medications off of the list when a patient reports that he/she is no longer taking them. Thus, the nurses can add to the list but only the physicians can delete from the list. This creates duplicate work and confusing responsibilities and as a consequence, errors occur. In the hospital, deleting a medication from the medication list directly affects the patient’s treatment and should only be done by a physician; however, in the outpatient setting, deleting a medication from the medication list is more justifiably done by a nurse if the patient says that they do not take that medication any longer. It is very important to distinguish the role and responsibility of the nurse in adding/deleting medications from the medication list in the inpatient setting versus the outpatient setting. Your practice has to decide whether maintaining an accurate medication list in the outpatient electronic medical record is part of recording the past medical history or a part of the medication prescription process – if you consider it part of the past medical history, then empower the nurses to do it.
- Medication lists cluttered with non-medication orders. In most electronic medical records, a lot of stuff that gets ordered ends up in the medication list because the EMR doesn’t know what else to do with it. Thus, disability parking placards, the influenza vaccine that the patient received 3 years ago, home oxygen, and wheelchairs will show up in the medication list. This ends up making the list excessively long and more confusing for anyone who is looking at it.
- What is the truth, really? Is the “one true source” a list of what the patient says that he or she is actually taking or what the doctor thinks that they are supposed to be taking? If you ask 100 doctors, 50 of them will say it is what the patient is actually taking and the other 50 will say it is what was actually prescribed. So, if a patient was prescribed a medication for gout, but never filled the prescription because it was too expensive, should that medication be on the patient’s list? One the one hand, it is the medication prescribed to treat the gout so you want to have that as part of your on-going medical record. But on the other hand, if the patient isn’t taking it, then should it keep appearing in the medical record? This is controversial and there is no perfect answer.
- Samples. If you give a patient a sample of a medication in the office, then you want to have documentation of them getting that medication, for example, a small tube of a steroid cream that a dermatologist gives a patient for their poison ivy. But once again, if there is not a stop date when you enter the sample in the medication list, then it stays on the list until someone else takes it off of the list at a later date.
- Bad data from other institutions. Many EMRs have the ability to interrogate other hospital systems that the patient has visited to pull in medications from that hospital system’s medical record. Even if the physicians in your hospital system are tediously compulsive about keeping an accurate medication list, unless the other hospital system’s doctors are equally compulsive, you can pull in errors into the patient’s medication list.
- There just isn’t enough time. When a patient gets admitted to the hospital, usually there is a nurse, a pharmacist, and a physician, all reviewing the patient’s medications. The patient is usually in the hospital for a few days so there is ample time for a thorough review and reconciliation with checks and double checks. But in the outpatient physician office, the responsibility for medication documentation often all falls solely the physician. Even if the office nursing staff participate, the time that the patient is in the office is so short that it is hard to get everything done. A typical physician’s return office visits are scheduled every 15 minutes. That means that in those 15 minutes, the physician has to review the patient’s history and any new test results, take an interval history from the patient, do a physical exam, discuss their findings and recommendations with the patients, order any new tests or medications, document a note, create a letter to the referring physician, enter their billing charges, and do the medication reconciliation. Often, there simply just isn’t enough time to do all of that and frequently the first corner to get cut is to skip the medication reconciliation. Some people would say that the answer is to schedule patients every 20 minutes, rather than every 15 minutes. However, over the course of a full day, that would equate to 25% fewer patients being seen that day and the reduction in revenue associated with 25% fewer patients would put most practices out of business.
- Poorly designed EMR workflows. A physician will naturally go to three windows in the electronic medical record: the progress note window, the test results window, and the orders window. Anything else and they will need a prompt. If the nurses in the office are permitted to mark medications for deletion but are not actually permitted to delete those medications from the medication list, then there has to be a prompt for the physician to go to that medication list window to approve those deletions. Otherwise, they will close that encounter without ever deleting those medications. Either the nurses should be empowered to delete medications that the patient says they are no longer taking or there needs to be a hard-stop to go to the medication list window before the physician can close the encounter.
The good news is that there are some concrete things you can do to reduce the inaccuracy of the medication list. Here are a few:
Be sure that all short-term medications and samples have a stop date in the initial prescription.
Develop an agreed-upon consensus among all of the physicians in the organization about whether they define the medication list as the list of medications prescribed for the patient or what the patient says that they are actually taking.
Develop an institutional policy that all physicians are allowed to delete medications from the list – the primary care physician or any specialist.
Allow office staff to work at the top of their license with respect to adding or deleting medications from the outpatient’s list.
Develop a simple practice to ensure that therapeutic substitutions made for inpatient formulary reasons at the time of admission to the hospital are substituted back to the patient’s normal outpatient equivalent drug.
Create workflows in the office that are consistent so that everyone knows their role in maintenance of the medication list and performs that role on every patient.
Design the electronic medical record so that the physician’s tasks for outpatient medication reconciliation becomes a natural part of the workflow or so that medication reconciliation is required before the encounter can be closed.
Involve the patient by printing a copy of the medication list when the patient arrives to the clinic and having him/her review the list for additions/deletions.
November 6, 2017