EHR and MU

Medication Reconciliation
 Content Developed by:
• Wil Darwin, PharmD, CDE, NCPS
ABQ IHS Area Pharmacist Consultant
ABQ IHS Area RPMS/EHR Consultant

Medication Reconciliation 2
 Objectives
• Recognize that this presentation is an overview of medication
reconciliation.
• Recall the MU requirements for meeting the Medication Reconciliation
Performance Measure.
• Design the necessary components and required documentation for
meeting the Medication Reconciliation Performance Measure.
• Integrate the use of the patient wellness handout in the Medication
Reconciliation process.
• Compare and contrast the outside medications functionality with
outpatient and inpatient medications functionality.
• Explain why outside medications data population is important in
maintaining a complete medication profile.
• Utilize the principles, practices, and techniques for documenting patient
reported medications.

Medication Reconciliation 3
Key Components to Building a Successful
Medication Reconciliation Program
• Building the Foundation: Gaining Leadership Support
within the Organization
• Building the Foundation: Project Teams and Scope
• Developing Change: Designing the Medication
Reconciliation Process
• Developing and Pilot Testing Change: Implementing
the Medication Reconciliation Process
• Education and Training
• Assessment and Process Evaluation

Medication Reconciliation 4
 Points To Consider….
• RPMS-EHR optimization required.
• CAC and Pharmacy Informaticist will need to
configure components:
• EHR GUI template optimization
• RPMS PDM configuration
• Chronic vs. Acute Meds: There is a difference!
• The RPMS Logic of MU Reports.
• Train, train and train staff - follow up/accountability.
• Limit unproven work-a-rounds.

Medication Reconciliation 5
 Points To Consider….
• RPMS-EHR is dynamic and always changing.
• Develop a standardized in-house driven base
procedure.
• Medications can be discontinued when no
longer being taken by patient.
• Medications can become “lost” to providers
due to poor documentation (lack of a
reference point).

Medication Reconciliation 6
 Roadmap for this Presentation
• Review of Medication Reconciliation
Documentation (Patient Education Code)
• Use of Patient Wellness Handout to assist with
Medication Reconciliation Process
• Review of Outside Medication Processes

Medication Reconciliation 7
 Medication Reconciliation
What is It?
What are the Driving Requirements?
• Meeting Accreditation Standards
• Meeting Meaningful Use
• Meeting Best Practice Requirement
• Patient Safety

Medication Reconciliation 8
 Medication Reconciliation
As defined by the APhA and ASHP
• Medication Reconciliation is 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 as 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.

Medication Reconciliation 9
 Introduction
• Medication Reconciliation is a complex
process.
• Medication Reconciliation impacts all patients
who move through a Healthcare System.
• Medication Reconciliation is a comparison of a
patient’s current medication regimen against
the prescriber’s medication orders.

Medication Reconciliation 10
Goals of Medication Reconciliation
• To improve patient safety
• To assist in identifying chronic medications
across the continuum of care
• To encourage patients to become more
involved with their healthcare
• To improve compliance with accreditation
standards regarding medication reconciliation

Medication Reconciliation 11
 Why Perform Medication
Reconciliation?
• Decreases medication errors and reduces
patient harm
• Allows for obtaining, verifying, and
documenting the patient’s current
prescription, OTCs, and herbals when the
patient is seen in clinic
• Allows for considering the patient’s home
medications when medications are being
reviewed in clinic

Medication Reconciliation 12
 Why Perform Medication
Reconciliation?
• Allows for comparing the patient’s home
medications to ordered medications to identify
unintended discrepancies
• Allows for verification of the patient’s home
medications and discussion of unintended
discrepancies with the prescriber for resolution
• Provides an updated medication list and
communicates the importance of managing
medication information to the patient at the end
of the visit
Medication Reconciliation 13
 Literature Review
• Errors that occur in prescribing/ordering
phase are primarily due to lack of drug
knowledge and patient information.1,2
• One study showed that over 70% of drug-
related problems were recognized only via
patient interview.3
• Medication history is often gathered from
sources other than during the patient
interview.4

Medication Reconciliation 14
 Literature Review
• Studies in a variety of clinical settings have
shown substantial discrepancies.4-8
• Up to 27% of all hospital prescribing errors
attributed to incomplete medication history.9
• 33% of patients discharged from the ICU had
one or more chronic medication omissions.10
• 22% of drug discrepancies may have resulted
in patient harm during hospitalization and
59% if continued after discharge.11
Medication Reconciliation 15
 Literature Review
• Reduced rate of errors after implementation
of a medication reconciliation process at
admit, transfer and discharge.12
• Reconciliation by health care providers of
discrepancies in admission medication
histories and orders decrease opportunities
for medication errors and potential harm.13,14

Medication Reconciliation 16
 Medication Reconciliation
• Who is responsible?
• Everyone – patient, nurse, provider, pharmacist
• Process must be clearly delineated:
• Everyone must be trained & trained again
• Consistency is key
• Customize to your facility’s work flow
• Meaningful Use Logic (MU):
• ONLY the M-MR Education Topic counts
• PWH Medication Reconciliation is useful and can be
used to meet other MU measures
Medication Reconciliation 17
 Example:
Outpatient Medication Reconciliation Process
Nurse or Nursing Assistant
1. Call patient into exam room.
2. Screen patient.
3. Enter chief complaint and vitals via EHR.
4. Document health screenings (tobacco,
alcohol, depression, domestic violence).
5. Print/Generate PWH Medication
Reconciliation.
6. Populate M-MR.
Patient
1. Review PWH Medication Reconciliation
while waiting for provider.
2. Assist in record update.
Medication Reconciliation
Provider
1. Review PWH Medication Reconciliation
with patient to determine required
updates (new meds, outside prescriptions,
discontinued meds, OTC, and herbal).
2. Order needed medications.
3. Document updated med list in EHR
progress note.
4. Populate M-MR.
Pharmacist
1. Resolve any discrepancies.
2. Give new PWH Medication Reconciliation
to patient to compare with home
medications.
3. Populate M-MR on PharmEd button.
4. Place new list in chart as a static reference
point.
18
 Example: Urgent Care or ER
Medication Reconciliation Process
Triage Nurse
1. Call patient into exam room.
2. Screen patient.
3. Enter chief complaint and vitals via EHR.
4. Print/Generate PWH Medication
Reconciliation.
5. Populate M-MR.
Medication Reconciliation
Provider or Nurse
1. Review PWH Medication Reconciliation
with patient to determine required
updates (new meds, outside prescriptions,
discontinued meds, OTC, and herbal).
2. Order needed medications.
3. Document updated medication list in EHR
progress note.
4. Populate M-MR.
Pharmacist
1. Resolve any discrepancies.
2. Give new PWH Medication Reconciliation
to patient to compare with home meds.
3. Populate M-MR on PharmEd button.
4. Place new list in chart as a static reference
point.
19
 Example: Inpatient
Medication Reconciliation Process
Nurse Provider
1. Admit patient to floor. 1. Review Pharmacist note.
2. Complete assessments. 2. Order needed medications.
Pharmacist (admit) 3. Document updated medication list
1. Print/Generate PWH Medication in EHR progress note.
Reconciliation. 4. Populate M-MR.
2. Review PWH Medication Pharmacist (Discharge)
Reconciliation with patient to 1. Resolve any discrepancies.
determine required updates (new 2. Give new PWH Medication
meds, outside prescriptions, Reconciliation to patient to
discontinued meds, OTC, and compare with home medications.
herbal).
3. Consult with provider as needed. 3. Populate M-MR on PharmEd
button.
4. Document updated med list in EHR 4. Place new list in chart as a static
progress note. reference point.
5. Populate M-MR.

Medication Reconciliation 20
 Medication Reconciliation
Screening Process
• Medication Reconciliation Management: Two-step
method or process:
• Roll-and-scroll process (pharmacist driven)
• EHR GUI process (provider and pharmacist driven)
• Both disciplines can control the medication list in
RPMS and EHR.
• Both disciplines can use their clinical judgment to
manage, delineate, and execute the medication list.
• This will aid and “stage” a clean medication list for
the provider to view in EHR.
Medication Reconciliation 21
 Roll-n-Scroll Medication Reconciliation
Management (Pharmacist Driven)
• Chronic Med designation: CHRONIC MEDICATION: YES//
• Acute Meds management – develop an in-house policy.
• Pharmacist may need to discontinue duplicates meds.
• Pharmacist may need to discontinue expired meds (protocol based).
• Pharmacist will need to manage Chronic Meds in the RPMS.

------------------------------ACTIVE-----------------------------
1 1899251 ASPIRIN 81MG E.C.TAB 90A 05-19 05-19 3 90
2 1899252 GLIMEPIRIDE 2MG TAB 90A 05-19 05-19 3 90
3 1899253 INSULIN DETEMIR (rDNA) INJ 10ML 10A 05-19 05-19 11 30
4 1899254 LISINOPRIL 5MG TAB 90A 05-19 05-19 3 90
5 1899255 METFORMIN XR 500MG TABS 90A 05-19 05-19 3 90
6 1899256 PIOGLITAZONE 30MG TAB 90A 05-19 05-19 3 90
7 1899257 SIMVASTATIN 5MG TABLETS 90A 05-19 05-19 3 90

Medication Reconciliation 22
 EHR GUI Medication Reconciliation
Management (Provider and Pharmacist Driven)
Managed in the MEDs tab
1. Organize workflow:
• Chronic only
• Greater than six months
• Alphabetize the med list
2. Review med list.
3. Re-designate
“discontinued”
medications and
duplicate medications as
non-chronic.

Medication Reconciliation 23
 Medication Reconciliation
Management
In the EHR GUI:
• Document M-MR
patient education code
in EHR.
• Manage via the Patient
Education component
or with the Pharm Ed
button.

Medication Reconciliation 24
 Patient Wellness Handout Medication
Reconciliation (PWH Medication Reconciliation)

Medication Reconciliation 25
 PWH Medication Reconciliation
• Developed by National IHS OIT team.
• Letter format for the patient, patient friendly.
• PWH Med Rec contains:
• Patient demographics
• Current documented food and drug allergies, and
adverse reactions
• Outpatient Medication profile:
• Active Med
• Outside Med
• Unknown Med

Medication Reconciliation 26
 Health Care Provider Role:
6 Areas to Trigger a MU Credit
• Patient Education:
• M-Medication
Reconciliation
• M-Literature
• Printing PWH:
• PWH (various)
• EHR GUI 3 Buttons:

Medication Reconciliation 27
 Outside Medications
(Non-VA Meds)
• Facilitates Medication Reconciliation processes.
• End-user documents in EHR:
• Provider or nurse driven
• Facilitates with communication
• Not required to be finished in Pharmacy
Package.
• Each medication must be defined in PDM.
• Entries are checked for allergies and drug
interactions (if matched to an NDF in PDM).
Medication Reconciliation 28
 Outside Medications
(Non-VA Meds)
• RPMS configuration:
• Meds are marked as “X” or Non-VA in the PDM drug file

References:
• See power-point presentation on “Non-VA Meds”
• ftp://ftp.ihs.gov/rpms/patches/ehr_0110.06o.pdf (EHR Patch 6 notes)
• ftp://ftp.ihs.gov/rpms/patches/ehr_0110.07o.pdf (EHR Patch 7 notes)

Medication Reconciliation 29
 Unknown Drug Miscellaneous
• “Unknown Drug Miscellaneous” definition name
is built in PDM file and created as an Orderable
Item (Instructions are outlined in EHR Patch 6 notes)
• A Notification can be configured for this
Orderable Item to alert Pharmacy when ordered.
Then the “real” drug can be entered into PDM
• An alternate option is to run a report to capture
data for PDM update

Medication Reconciliation 30
Unknown Drug Miscellaneous (cont.)

Medication Reconciliation 31
 Conclusion
Medication Reconciliation:
• Addresses medication changes at various patient care
events.
• Can reduce medication related events and avoid
negative patient outcomes.
• Requires a multidisciplinary team approach.
• Requires planning and communication systems to be
in place between institutions of care.
• Utilizes the EHR to document the process.
• Vital to ensuring patients are instructed and educated
on optimal medication use.

Medication Reconciliation 32
 Medication Reconciliation is SERIOUS
• Solicit (from patient): Medications (all) and allergies each
encounter.
• Examine: Review at each outpatient and inpatient clinic area; look
for discrepancies.
• Reconcile: Compare home list and list in RPMS-EHR. Make changes
when needed.
• Inform: Inform and educate patient and caregiver about their
medications.
• Optimize: Optimize med doses to target guidelines or to improve
outcome.
• Reduce: Reduce poly pharmacy issues.
• Update: Update med list with appropriate changes.
• Share: Share with patient, caregiver, and all other providers.

Medication Reconciliation 33
 Medication Reconciliation
Components
• Building the Foundation: Gaining leadership support
within the organization
• Building the Foundation: Project Teams and Scope
• Developing Change: Designing the Medication
Reconciliation process
• Developing and Pilot Testing Change: Implementing
the Medication Reconciliation process
• Education and Training
• Assessment and Process Evaluation

Medication Reconciliation 34
 Medication Reconciliation
Meeting the Measure
• Print PWH Med Reconciliation sheet.
• Document M-MR Education Code.
• Remove the “Chronic” flag from a discontinued
medication.
• Enter an “Unknown medication, miscellaneous”
into the Outside Medications List in EHR.
• Set up M-MR education topic on a pick list.

Medication Reconciliation 35
 United South & Eastern Tribes, Inc.
http://www.usetinc.net/ehr/default.aspx

We have found that some measures are

consistently difficult for providers to meet, and
have worked with IHS to develop the following
training videos:
• Medication Reconciliation (3 MB)
http://www.usetinc.net/ehr/EHR%20and%20MU%20
Documents/1/Medication%20Reconciliation.mp4
• Please note that this video may take some time to
download.

Medication Reconciliation 36
 United South & Eastern Tribes, Inc.
http://www.usetinc.net/ehr/default.aspx
• Workflow templates have been developed by the
USET REC clinical consultants in collaboration with
Area CACs and the IHS EHR deployment team. These
templates allow for customization to meet local
needs. Please consider using them as part of your
facility's EHR for MU end user training for either
RPMS EHR or COTS EHR.

Medication Reconciliation 37
United South & Eastern Tribes, Inc.
http://www.usetinc.net/ehr/default.aspx
• Office Visit Workflow:
http://www.usetinc.net/ehr/Workflows/1/Office%20Visit%20Workflow.pdf
• Nursing Workflow:
http://www.usetinc.net/ehr/Workflows/1/Nursing%20Workflow.pdf
• Pharmacy Workflow:
http://www.usetinc.net/ehr/Workflows/1/Pharmacy%20Workflow.pdf
• Lab Workflow:
http://www.usetinc.net/ehr/Workflows/1/Lab%20Workflow.pdf
• Medication Reconciliation Workflow (Ambulatory):
http://www.usetinc.net/ehr/Workflows/1/Ambulatory%20MedRec%20Wor
kflow.pdf

Patient Reminders 38
United South & Eastern Tribes, Inc.
http://www.usetinc.net/ehr/default.aspx
• Consult Workflow Initiated During Office Visit:
http://www.usetinc.net/ehr/Workflows/1/Consults%20With%20Office%2
0Visit%20Workflow.pdf
• Consult Workflow Initiated During Chart Review:
http://www.usetinc.net/ehr/Workflows/1/Consults%20Non-
Office%20Visit%20Workflow.pdf
• Outside Referral Workflow During Office Visit:
http://www.usetinc.net/ehr/Workflows/1/Referral%20Office%20Visit%20
Workflow.pdf
• Outside Referral Workflow Not Associated with Office Visit:
http://www.usetinc.net/ehr/Workflows/1/Referral%20Chart%20Review%
20Workflow.pdf

Patient Reminders 39
 Medication Reconciliation
Hands-On Session
• Record M-MR – Education Component
• Record M-MR – PharmEd button
• Review Medication tab:
• Chronic vs. Acute Medications
• Outpatient Medications and Outside Medications
• Review documentation process for New Allergies
and No Known Allergies

Medication Reconciliation 40
Questions and Discussions

Medication Reconciliation 41