Electronic checklists help reduce mistakes, study shows, but key to effective medication reconciliation lies in health information exchanges.
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When hospital workers use an electronic medication checklist to record a patient's current medications, there are likely to be fewer medication errors than when they handwrite medication histories, a new study finds.
While the study did not include a large number of patients, it contributes to the evolving understanding of medication reconciliation--a requirement in Meaningful Use Stage 2 of the government's EHR incentive program.
Medication reconciliation is the process of comparing new orders to the medications a patient is already taking. Discrepancies between the two can result in medication errors. The checklist study, published in Perspectives in Population Health Management, points out that because medication histories are often difficult to gather, 25% of prescriptions in use are not recorded in hospital records and 61% of patients are taking one or more drugs that are not recorded.
According to the Agency for Healthcare Research & Quality (AHRQ), studies have shown that unintended medication discrepancies occur in nearly one-third of patients at admission, a similar proportion at the time of transfer from one site of care within a hospital, and in 14% of patients at hospital discharge. Many of these discrepancies occur because clinicians are unaware of a patient's current medications and typically have to rely on the patient to provide the names of those drugs when they are admitted.
While a number of studies have been done on the use of IT tools to improve medication reconciliation, AHRQ points out that their effect on clinical outcomes remains unclear. The checklist study is an effort to fill that gap.
The study focused on elderly patients admitted to a large Texas hospital. The 64 patients selected for the study were age 65 or older, were taking five or more medications, and had spent at least one week in the hospital. The patients' inpatient medications were all recorded in the hospital EHR as a baseline. Nurses interviewed the patients about their medications, documenting their answers at different times manually and in an electronic checklist in the EHR.
The study showed that electronic documentation reduced medication errors, mainly because of alerts that helped the nurses correct their entries. "The findings of this study suggest that implementing electronic health record systems with decision support for identifying inaccurate doses and frequencies of prescribed medicines will increase the accuracy of patients’ medication histories," the authors concluded.
Jordan Battani, a principal with consulting firm CSC, told InformationWeek Healthcare that the checklist study underlines the weak link in medication reconciliation: the current reliance of hospitals on patients' and caregivers' recollections of their medications. "In most settings right now at admission to the hospital, that's likely to be the primary data source, and it's the weakest link," she pointed out.
Electronic checklists can be useful in improving documentation of what patients say, correcting their mistakes, and eliminating errors related to poor handwriting, she said. But the best way to improve medication reconciliation, she noted, is to increase the use of health information exchanges. "The standalone EHR will help some, but the big thing that will really change the game is effective information exchange across the continuum."
While hospitals wait for effective health information exchanges to spring up in their communities, Battani added, they might consider taking advantage of the ambulatory-care medication histories--based on prescriptions filled at pharmacies and mail order houses--that are available through Surescripts. "The pharmacies have really good information about what prescriptions are filled and when."
However, she noted, "Today we don't have effective mechanisms in place for bringing that [pharmacy fill] information into the EHR in hospitals." Also, she added, the data doesn't include prescriptions filled in hospital pharmacies.
Ken Kleinberg, a consultant with The Advisory Board Co., suggested another method to improve the accuracy of medication histories in hospitals. About half of U.S. hospitals, he said, are already doing bar-coded medication administration at the bedside. They could use the same technology, he said, to scan the bar codes on pill bottles that patients bring in. That would identify which medications patients were taking and could also show potential drug interactions.
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