Electronic Medication Management

When patients transfer to new health care settings, there is an increased risk of medication errors due to incomplete or inaccurate medication information. To decrease such errors, policymakers such as the Joint Commission have focused on improving the quality of medication list documentation and communication through the process of medication reconciliation. Medication reconciliation employs a systematic approach to reviewing the medications a patient is taking, and comparing them to what has been ordered for the patient in order to identify and resolve medication discrepancies.

In 2008, the New York-Presbyterian (NYP) Healthcare System instituted a structured, electronic process designed to improve medication reconciliation as patients transitioned between ambulatory and hospital care settings. Before adoption, pre-admission and discharge medications were kept as free-form text in the patient's electronic health record (EHR). After adoption, medications were documented using the Outpatient Medication Profile (OMP), a structured, longitudinal electronic medication list shared across NYP's ambulatory and inpatient EHRs. When a patient was admitted to the hospital, the OMP was updated by verifying existing entries and adding new medications that the patient was taking. A medication reconciliation view was created within the EHR that displayed two columns: 1) the list of the current inpatient medication orders; and 2) the list of outpatient medications from the OMP. From this screen, providers review the two lists to identify discrepancies between the lists and update the inpatient orders accordingly. Once finished, the provider attested that medication reconciliation was complete by clicking a checkbox. A medication reconciliation reminder in the inpatient EHR was implemented so that a reminder dialog was displayed when placing orders in the computerized provider order-entry system if attestation of medication reconciliation had not been completed within 6 hours of hospital admission. If the attestation had not been completed within 18 hours after admission to the hospital, a "hard-stop" dialog was displayed and no orders could be placed until attestation was documented.

This study retrospectively evaluated the effectiveness of the electronic medication reconciliation intervention by comparing outcomes pre- and post-implementation in six community-based primary care clinics and two inpatient facilities. Before the electronic medication reconciliation process was adopted, the average number of medications contained in the OMP for a patient at hospital admission was less than two. One year after adoption, the average number had increased to 4.7. Of 253 medications lists reviewed, 181 lists (72 percent) had a discrepancy including at least one medication missing a dose, route, or frequency. Missing information was judged to be potentially harmful in 47 of the 253 lists (19 percent). Before the reminder intervention, the mean duration between hospital admission and attestation of medication reconciliation was 84.5 hours (median= 9.1 hours). However, after the reminder intervention the mean duration between hospital admission and attestation of medication reconciliation was 9.2 hours (median= 5.3 hours). This retrospective study of the medication reconciliation process at NYP can serve as a benchmark for future information technology implementations addressing medication reconciliation.