One of the most bedeviling arenas for improvement in hospital care is called "medication reconciliation." As I have noted below, part of this standard means that we are supposed to discuss with all patients the medications they are taking before entering the hospital, and review their medications again upon discharge.
Here's part of problem. Many people do not know or do not remember what medicines that are taking, so a doctor who asks these questions while doing the patient's medical history will not get accurate information.
One way to work through this problem would be if we could get access to the records of pharmacies and get the list of medicines that have been prescribed and dispensed to patients.
The good news here in Massachusetts is that we are the #1 user of e-prescribing. Under this system, when you need a medication, the doctor sends the order electronically to your pharmacy of choice, and you pick it up there. No more scripts, no more handwriting.
The program involved lots of folks, with support from Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, and Tufts Health Plan, and is done in cooperation with Surescripts, an organization founded by the pharmacy industry in 2001.
BIDMC is one of the first hospitals in the country to use this advanced technology. We've been live with Surescripts routing on our web-based online medical record system since last year. Now, the plan is to use the capability in reverse -- to be able to query the Surescripts system and other stakeholders with pharmacy databases (e.g., Rxhub, which connects mail order pharmacies). So, when you showed up for surgery or another visit, we would be able to download a list of your current medications from the database of pharmacies. Even if you lived in Nevada and showed up at our emergency room in Boston, we would have access to this national database and make sure we were not giving you a medication that interacted badly with one you are taking.
We are hoping to go live with this by September 15 and, of course, will share our experience with all others in the region and beyond.
This approach does not solve all the issues around medication reconciliation, but it is an example of where the creative use of information technology can help enhance patient safety.
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14 comments:
This sounds like a good approach as long as all pharmacies and PBM's contribute their information to the database. Lots of people get their drugs from more than one pharmacy, depending on which one has the best price for a particular drug, plus a PBM for chronic scripts by mail.
Yes, we are trying to make it as inclusive as possible, e.g., inclusion of Rxhub for mail order folks.
I've been reading a lot of blogs from ER nurses and ambulance drivers lately, and your post gives me hope that someday one aspect of their jobs will be less stressful. At least 50% of the posts I read involve drug-seeking behaviors on the part of patients using the ambulance services or ER. If a patient's pharmaceutical history were available via computer, false claims of "my regular doctor gives me...." and real drug allergies and so on would be available. ER staff are wonderful, but the burn-out on such patients is too high for practitioners to successfully triage them to rehab or other services. I think that giving them a tool to combat addiction rather than a need for over-caution would be really empowering.
<sarcasm>What about HIPAA?</sarcasm>
I'm glad this is finally happening. I think it's only a matter of time, though, before some idiot cries foul over HIPAA and patient privacy.
I hope that this being able to check patient script histories is available to pharmacies, too, in the near future. Drug seekers are particularly troublesome, especially when they're paying out-of-pocket.
Sorry for using the "comment" feature, but I didn't see any other contact for you. I figured the moderation would catch it before it posts in the wrong place.
I'd be interested in any comments you have about the article in today's NY Times regarding a ninety-day post surgical "warranty." I was interested in the self-imposed financial incentive to get things right the first time.
/Rick Narad
Professor, Health Services Admin.
California State University, Chico
Thanks, Rick. I saw that, too. Let me mull it over.
Correct me if I'm wrong, but I believe that all the care given by the surgeon (pre-op, intra-op, post-op) is covered by the "global surgical fee" that is paid to him/her by the insurance company, which pretty much amounts to a "warranty" in that if the patient requires re-operation or other care after surgery, the surgeon is not paid again. (The hospital and any other necessary consultants are, however, paid, which is only fair. . .) I don't know if this extends a full 90 days, but it might.
This is the best idea I've heard yet for tackling the med rec issue.
In Northern California all of our hospitals are working on how to do med reconcilliation, since we don't have the electronic solution you are trying. We'll be watching your results closely. I wish we were closer to e-perscribing because without it, it is very difficult!
Hi Paul,
Do you think obtaining a list of medications from pharmacies will satisfy your med reconciliation requirements (from JCAHO). Is there anything else that your hospital does, or needs to do in order to be fully compliant? Is there a complete list of 'to do's for a hospital that BI might have researched for meeting this requirement. I would be grateful if you can share it.
And yes, I would be very interested in knowing your views on the 90-day heart surgery warranty issue. Geisinger has taken the lead! Will BI be far behind..i don't think so!
Thanks,
Pintoo
hi anon 8:41,
you need to take a leaf out of MA. There's a huge collaborative effort, of which BIDMC is a part, which is building a shared, community approach to eprescribing.
For more information on the community solution, go to http://www.mahealthdata.org/ma-share/projects/e-prescribinggateway.html
I hope the electronic data is used in conjunction with patient self-reporting, rather than as a de facto replacement.
There are a huge number of ways in which a patient can have access to prescription drugs that would not be in the electronic data: samples given out by a doctor, prescriptions that were written for a family member or friend, drugs obtained in other countries where they are over the counter, drugs obtained in convenience stores (there was a long Globe story about this recently), and more. Dosages taken can also be quite different from dosages prescribed.
A good solution should involve both electronic records and self-reporting. Points where those differ are worth exploring, but I wouldn't rely on the electronic records as complete or accurate.
Based on the ideas presented in this blog, I just sent an email to my "Rx-by-mail" provider (used by my insurer) inquiring why they are not part of RxHub.
I recently ran into absurd situation whereby my PCP's office and mailorder Rx service were pointing fingers at each other, saying there was no way to refill my (non controlled substance, common use) Rx either over the phone OR by FAX. End result, I had to drive to MD office, pay to park, pick up Rx in person and snail mail it.
With the technology and encryption of today, this seems like bronze age way to do things.
Incidentally, my PCP is with HCA and my records ARE online through Patient Site and BIDMC.
I hope my insurer and HCA can get it together.
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