Moving From Paper To Electronic Medication Reconciliation: November 12, 2013

Moving from Paper to Electronic
Medication Reconciliation
November 12, 2013
www.saferhealthcarenow.ca
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Next Webinar: December 10, 2013 at 12 noon ET
MedRec Quality Audit Month Results
2235 1906 Acute Care

patients 329 Long Term Care
99 28% Met all 5 quality

criteria
Organizations
3 - 4 met quality
40% criteria
Join us to hear about the results and how your

organization should be involved.
Call Overview
Introduce the toolkit to support healthcare providers in making a safe and effective
transition from paper MedRec to eMedRec.
1. Discuss the results of the pan-Canadian survey of existing

practices with respect to the use of technology to support
Medication Reconciliation (MedRec)
2. Describe the steps and considerations for transitioning to
electronic MedRec (eMedRec)
3. Identify factors that support and impede successful migration of
paper MedRec to eMedRec.
4. Discuss the lessons learned from research and other organizations.
Todays Speakers
Dr. Elizabeth Borycki
Dr. Borycki is an Associate Professor at the University of Victoria, Victoria,
British Columbia Canada.
Dr. Borycki has worked in numerous roles among them as a Clinical
Informatics Specialist, Disease Management Specialist, Consultant and
Researcher. Elizabeth teaches organizational behaviour and change
management, systems evaluation, quality improvement,
information/information technology management and research methods in
the undergraduate and graduate programs in the School of Health
Information Science.
Elizabeth has co-authored many health informatics articles. More recently,
she has edited two books: The Human, Social and Organizational Aspects of
Health Information Systems and Comprehensive Management of Chronic
Obstructive Pulmonary Disease. She was the Academic Representative for
Canadas Health Informatics Association (COACH) to the International
Medical Informatics Association (IMIA).
Todays Speakers
Dr. Andre Kushniruk
Dr. Kushniruk is a Professor of the School of Health Information Science at the University of
Victoria and he previously served as the Director of the School of Health Information Science
at the University of Victoria.
Dr. Kushniruk conducts research in a number of areas including evaluation of the effects of
technology, human-computer interaction in health care and other domains as well as usability
engineering. His work is known internationally and he has published widely in the area of
health informatics and testing of healthcare IT (including work in the area of decision support
for medication reconciliation).
He focuses on developing new methods for the design and evaluation of information
technology and studying human-computer interaction in health care and he has been a key
researcher on a number of national and international collaborative projects. His work includes
the development of novel methods for conducting video analysis of computer users.
Dr. Kushniruk has held academic positions at a number of Canadian universities. He was
elected as a Fellow of the American Medical Information Association (FACMI) in 2009 and
also served on the COACH (Canada's Organization for Health Informatics) board of directors.
He holds undergraduate degrees in Psychology and Biology, as well as a M.Sc. in Computer
Science from McMaster University and a Ph.D. in Cognitive Psychology from McGill
University.
Please complete our poll
8 www.saferhealthcarenow.ca
Moving from Paper to
Electronic Medication
Reconciliation (eMedRec)
Moving from Paper to Electronic
Medication Reconciliation
(eMedRec)
Andre Kushniruk
Elizabeth Borycki
Helen Monkman
Alex Kuo
University of Victoria
Margaret Colquhoun
Alice Watt
ISMP Canada
Marie Owen
CPSI
Medication Reconciliation (MedRec)
A process in which providers work with

patients and other providers to ensure
accurate medication information is
communicated across transitions of care
Admission, transfer, discharge
Intended to prevent harm from

ineffective communication
Is challenging!
What is eMedRec?
Electronic MedRec (eMedRec) uses Health
Information Systems (HIS) to access and
integrate electronically stored patient
medication data
To support the development of the electronic

Best Possible Medication History (eBPMH) and
the detection and resolution of discrepancies
Can be integrated with other systems such as

computerized provider order entry (CPOE)
eMedRec: Two Unreconciled
Medication Lists for Comparison
(adapted from Markowitz, 2011)
eMedRec: Matching Two Medication Lists
eMedRec: Final Reconciled Medication Record
eMedRec Process Flow Map
Idealized Overview of eMedRec
What is the Current State of eMedRec?
eMedRec: A Review of the Literature
Conducted a literature review

searched PubMed and CINAHL for the term medication
reconciliation.
218 unique articles, published between 2003 and
October 2012
reviewed by title, abstract (where possible) and/or full article
to exclude studies that did not include original research (e.g.,
editorials) or that lacked reference to MedRec.
139 articles remained that met the inclusion criteria

The following characteristics were also recorded:
Type of MedRec
Points of care
Outcome Measures www.saferhealthcarenow.ca
Type of MedRec
Processes ranged from:
Entirely paper-based
hybrid (i.e. combination of paper and electronic)
entirely electronic MedRec (eMedRec).
The numbers of studies for each type of medication

reconciliation were similar:
paper (35 studies)
hybrid (40 studies)
electronic (44 studies)
some of the papers did not explicitly state or describe what type of MedRec was used and
therefore could not be included.
Key Findings: Points of Care
The articles collected dealt with MedRec as it occurs at different
points of care.
most of the articles focused on hybrid processes

few articles looked at eMedRec processes across different points of
care
Key Findings: MedRec Investigations
at Different Points of Care
Quantitative Measures of Medication Reconciliation
Key Findings: Information Technology
(IT) and eMedRec
Information technology has been used in the
eMedRec process to do the following:
Generate the best possible medication lists

(BPMHs)
Electronically support human MedRec processes
providing electronic sources of data
providing electronic tools for comparing lists and
detecting and resolving medication discrepancies
Examples of eMedRec Studies
Boockvar et. al (2011). Medication Reconciliation: Barriers
and Facilitators from Perspectives of Resident Physicians and
Pharmacists (J. of Hospital Medicine)
Focus groups and observation of VA eMedRec tool
Participants agreed about central goal of eMedRec to prevent
errors, but disagreed if it achieved goal
Participants varied in how they sequenced the task using the
tool
When time was limited, physicians considered other
responsibilities higher priority
Barriers included: competing tasks, unreliable sources of
information and need for education
Schnipper et al. (2009). Effect of an Electronic
Medication Reconciliation Application and Process
Redesign on Potential Adverse Drug Events (Arch
Int Med)
Performed a controlled randomized trial
Intervention was an eMedRec tool and process redesign
involving physicians, nurses and pharmacists
Main outcome was unintended discrepancies between
preadmission meds and admission or discharge meds that had
potential for harm (PADEs)
Found that the eMedRec tool and process redesign was
associated with a significant decrease in PADEs
Kushniruk et al. (2011). Cognitive Analysis of a
Medication Reconciliation Tool
conducted think aloud usability tests and clinical
simulations of use of an eMedRec tool
Both artificial cases and real cases observed
Found
Pharmacists and physicians approached cognitive process of
using eMedRec tool differently
Significant differences found in accuracy of task and time
spent by pharmacists as compared to physicians
Led to implications for redesign, customization and training
What is the Current State of eMedRec in
Canada?
eMedRec in Canada
There is a move from paper to eMedRec
to improve efficiency and safety
to integrate MedRec with information
systems
Paper Based MedRec Hybrid MedRec eMedRec

+
eMedRec in Canada
We conducted an online survey of eMedRec practices
in Canada to assess the current state of eMedRec
Method:
online survey
conducted in spring 2013
Participants:
2799 people were invited to participate
212 people responded
included physicians, nurses, pharmacists, administrators, QI
professionals, and health IT professionals
Where is eMedRec Implemented
in Canada?
Type of eMedRec in Canada
Perceived Success of eMedRec in Canada
Ranked Reported Motivators for eMedRec
Factors that Led to Successful eMedRec
Implementation
eMedRec in Canada
eMedRec functionality was highly

variable, with not all functions used
Most respondents indicated no additional

resources (e.g., human, financial) were
allocated to sustaining eMedRec (61%)
What are the Advantages of eMedRec?
Potential Advantages of eMedRec include:
Improved standardization of documentation
Improved legibility of information
Improved communication between providers
Improved accessibility of documentation
Potentially improved eMedRec compliance through

implementing:
Soft stops - reminders that eMedRec needs to be completed for
a patient)
Hard stops - orders cannot be placed until eMedRec is
completed
What are the Advantages of eMedRec?
Decision support tools
assist in comparing medication lists
identifying discrepancies
providing warnings for drug interactions or allergies
Integration with computerized provider order entry

(CPOE) to facilitate improved ordering processes
Improved efficiency of many medication-related

processes in health care organizations (Poon et al.,
2006).
Key Aspects of Implementing eMedRec
Senior leadership support is important
The transition to eMedRec will require sustained
resources, perseverance, clear accountability,
preparation and dedication to achieve success
Understand the current state of an organizations HIS

is critical to implementing eMedRec
Example: In planning to implement CPOE, it is
valuable to pair eMedRec implementation with
CPOE implementation because efficacy is improved
when they are implemented together
Assessment of Organizational Readiness
Before implementation, organizations should determine the
following:
What HIS they currently have in their organization
What they plan to implement in terms of eMedRec tools
The HIS inputs and outputs eMedRec
All involved must be aware of the type of HIS already in place

(e.g., electronic health records)
Have a common understanding of the definition of eMedRec and

the components of eMedRec
Workflow Standardization, Organizational
Policy and Procedures
Implementing eMedRec usually requires changes in
workflow
Important to communicate critical aspects of the
process such as:
The overall plan for implementing and sustaining eMedRec
across the organization
Health professional roles and responsibilities for each task
Clear time expectations for tasks to be completed
How the changes will affect all health professional tasks and
roles.
Changes in organizational policies and procedures
Workflow Standardization, Organizational Policy and
Procedures
Observation of workflow and clinical simulations
are increasingly being used around the world to assess the impact of
new information systems upon workflow
best undertaken in a setting similar to, or in the actual setting where
eMedRec takes place.
Observation and clinical simulations can be used to:

diagram workflows,
Assess the impact of the technology upon care processes
Identify potential sources of technology-induced errors
Design the eMedRec interface
Design policies, procedures and training
Address cumbersome workflows and potential pitfalls of workflows
prior to implementation
Selection and Procurement of eMedRec
Solutions
Organizations must carefully weigh a number of considerations related

to the selection and procurement of eMedRec technology:
What information technology is currently available in the

organization?
What features and functions of an eMedRec solution will be:

mandatory for an implementation
nice to have (but not required)
will be implemented at a later date
Selection of eMedRec Solutions
Ideally the features and functions of eMedRec allow for
the following:
Display of current medications and eBPMH lists side-by-side.
Complete information on: current, previous, active and
discontinued medications, to facilitate comparison
Flagging of discrepancies in medications
Medication display on a timeline so that the user understands
what medication is to be/was given and when
Modification of medications from the same screen
e.g. continue, discontinue, hold, or change
Integration with CPOE (if applicable) so that new medications
can be easily prescribed
System Reliability
Assessment of system reliability and the creation of
reliability targets is an essential aspect of
implementing eMedRec.
A back-up plan if eMedRec fails or goes down

i.e., downtime policies and procedures
Electronic or paper back- up available in the event that

there are technical difficulties that prevent MedRec
from being done electronically
Usability
A usable eMedRec system will lead to:
Higher rates of compliance
Fewer workarounds
Less training
More efficient eMedRec processes
Fewer technology-induced errors
be better for infrequent users or users with lower
levels of computer literacy
Cost
For any implementation to be a success it is important
to identify project and long term maintenance costs.
Ensure commitment and support of senior management through
an executive sponsor dedicated to this project
Ensure that sufficient financial resources are available to
implement and sustain eMedRec
Determine the impacts of using new eMedRec processes upon
physicians, nurses and pharmacists
Ensure that there is sufficient staff with enough time to be able
to conduct eMedRec on an ongoing basis
Conduct periodic evaluations to ensure that all health
professionals are complying with eMedRec processes
Budget for evaluation and follow-up
Safety
eMedRec has the potential to:
reduce errors
introduce errors into the MedRec process.
To fully benefit from eMedRecs ability to decrease errors:

Ensure that health professionals are educated in and aware of their
role in all aspects of eMedRec processes
Encourage health professionals and patients to report near misses
and errors that arise, in order to refine eMedRec processes to
ensure system reliability and maximize the benefits of eMedRec
Ensure a well defined evaluation plan is in place to track the
compliance with and outcomes of implementing eMedRec
Issues and Challenges in Moving to eMedRec
From Survey and Literature
Inadvertently increasing workload by

requiring electronic entry of
medications
Integration issues
Changing the way users communicate
Resistance to adopting new technology
Recommendations
Understand current workflow before
implementing
Understand how eMedRec can integrate
with existing and planned health
information system infrastructure
Obtain management and financial support
(including ongoing for sustainability)
Need to carefully stage eMedRec
implementation
Need for Evaluation Throughout the
Implementation Process
Workflow evaluation and usability testing
Integration with existing infrastructure
Adequacy of training
Evaluation of Error and Performance
Number and % of patients reconciled
accuracy of reconciliation
frequency of use
Development of a New Paper to eMedRec
Toolkit
To support managers and health care professionals
who are considering or moving to eMedRec
Funded by Canada Health Infoway
Work conducted by AE Informatics, University of
Victoria professors, ISMP Canada and CPSI
Will be made available through ISMP Canada and

CPSI
Toolkit: Table of Contents
What is the current state of eMedRec?
What are the stages in implementing eMedRec?
What should be considered after eMedRec is
implemented?
How should eMedRec be evaluated?
Lessons Learned
Checklists
Ideal features
procurement and pre-implementation
Evaluation
Toolkit: Checklists and Tips
Conclusions
eMedRec can be an important tool for safety and
lead to a range of benefits
There are number of factors that influence
success of eMedRec implementations
Work based on national survey, literature review
and interviews has lead to development of the:
Electronic MedRec Implementation

Planning Kit
Further information: andrek@uvic.ca

Thank-you!
Upcoming MedRec Webinars
Dec 10, 2013 Canadian Quality Audit Month Results
Jan 14, 2014 The Marquis Project - Dr. Jeffrey Schnipper
Feb 11, 2014 Engaging Patients in MedRec
March 25, 2014 MedRec in Home Care
Please complete our poll

Moving From Paper To Electronic Medication Reconciliation: November 12, 2013

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Moving from Paper to Electronic

November 12, 2013

Bienvenue nos participants

Pour accder aux diapositives

-Cliquez sur l'onglet "FRENCH"

Suivre la bote Chat pour les

2235 1906 Acute Care

99 28% Met all 5 quality

Join us to hear about the results and how your

1. Discuss the results of the pan-Canadian survey of existing

A process in which providers work with

Intended to prevent harm from

To support the development of the electronic

Can be integrated with other systems such as

Conducted a literature review

139 articles remained that met the inclusion criteria

The numbers of studies for each type of medication

most of the articles focused on hybrid processes

Quantitative Measures of Medication Reconciliation

Generate the best possible medication lists

eMedRec functionality was highly

Most respondents indicated no additional

Potentially improved eMedRec compliance through

Integration with computerized provider order entry

Improved efficiency of many medication-related

Understand the current state of an organizations HIS

All involved must be aware of the type of HIS already in place

Have a common understanding of the definition of eMedRec and

Observation and clinical simulations can be used to:

Organizations must carefully weigh a number of considerations related

What information technology is currently available in the

What features and functions of an eMedRec solution will be:

A back-up plan if eMedRec fails or goes down

Electronic or paper back- up available in the event that

To fully benefit from eMedRecs ability to decrease errors:

Inadvertently increasing workload by

Will be made available through ISMP Canada and

Electronic MedRec Implementation

Further information: andrek@uvic.ca

Dec 10, 2013 Canadian Quality Audit Month Results

Jan 14, 2014 The Marquis Project - Dr. Jeffrey Schnipper

Feb 11, 2014 Engaging Patients in MedRec

March 25, 2014 MedRec in Home Care

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